Public Health: Moving Forward

Colleen Moran, MPH MS
Wisconsin Population Health Service Fellow
Wisconsin Division of Public Health
Madison, WI




Public Health is cool, right? Well, I suppose it depends upon whom you ask. This became a topic of discussion the other day - how do we "rebrand" public health? How do we communicate what it is and how cool it is? Most of the time when I tell people I work in public health, they ask me something regarding primary care, something clinical. I have to gently let them know that I'm not in, "that kind of health," that, "I work in prevention - I try to change the environments we live, work, learn and play in, and incorporate health into policies, to make the healthy choice the easy choice, so that fewer people have to visit the clinic," I'm usually met with a blank stare and the inevitable followup question: "so what is it exactly that you do?"


That question, a good one I might add, is what I dedicate my blog post to today. I'd like to answer that question of "what is it that I do" and in the process, try to explain just how amazingly cool public health really is. So in recognition of National Public Health Week, this blog post is dedicated to celebrating the great successes public health has accomplished so far, while also focusing on where the future lies for the world of public health. And hopefully along the way I'll answer that nagging question.

How Far We've Come . . .

First, let's take a moment to remember how far we've come. Back in the early days of public health, contaminated water was causing disease outbreaks such as cholera (remember Dr. Jon Snow and the Broad St. pump?), overcrowding was leading to transmission of infectious diseases, workplaces were unsafe, and family planning was unheard of. Just a few generations ago mothers and father worried about their children contracting polio, measles and mumps, and many did with devastating effects. 

We've come a very long way. Listed below are 10 of the greatest public health achievements of the 20th century. To many, the achievements listed below are so basic that they virtually go unnoticed. However, I think it's time to pause and recognize how far we've come, thanks to public health.

Ten Great Public Health Achievements in the 20th Century

1. Immunizations*
2. Motor-Vehicle Safety
3. Workplace Safety
4. Control of Infectious Diseases
5. Declines in Deaths from Heart Disease and Stroke
6. Safer and Healthier Foods
7. Healthier Mothers and Babies
8. Family Planning*
9. Fluoridation of Drinking Water*
10. Tobacco as a Health Hazard

While  most of us take these advances for granted, there a few of the achievements on the list that create controversy and I would feel remiss if I did not make note of that (the * above denote these controversial public health practices). However, I do not want to spend time refuting the arguments people make against these public health achievements. Rather, I would like to use this blog post to acknowledge the fact that we've largely moved from the focus of the 20th century on infectious diseases and injury prevention to a 21st century focus on chronic diseases and the environments, systems and policies that must be changed to create a healthier world. There is so much more to be done in public health. It's time to move forward. 

So What IS Public Health . . . ?

So what do we mean when we say "environmental, systems and policy level changes"? Well, think about your daily routine: 

• How do you get to work? 
• How do your kids get to school and are they safe and happy there?
• Where do you purchase your groceries? 
• Where do your kids play outside?  
  

http://healthsciences.curtin.edu.au/teaching/soph_whatis.cfm

If you said you drive to work, is this because there is no public transportation? The research demonstrates that if you use public transportation you get more exercise simply getting to and from the transit stop than if you drove yourself, thereby helping you reach your recommended levels of physical activity. Not to mention the environmental benefits of using public transit which lead to improved respiratory health outcomes from cleaner air. We must change your environment so that you can access public transit but this must be done at a systems and policy level. This is public health. 

https://www.safeschoolscoalition.org/
RG-posters.html

If you said, "I drive my kids to school because it's too far for them to walk," or, "I don't feel safe letting my kids take the bus," that is public health. If you said, "my child is bullied at school," or,"the lunch they are fed is not healthful" - that too is public health. Where we site our schools, if our kids can incorporate physical activity into their daily routine by walking to and from school, if you feel that the neighborhood is safe enough for your children to walk in - this is your environment and changes to the systems and policies that create this environment must be made. This is public health. 

https://www.flickr.com/photos/35586421@N03/
3331755112/in/pool-683857@N21

If you said, "I drive 30 minutes to the nearest full service grocery store to purchase my groceries," this is a public health issue. What about the folks that don't have access to a grocery store because they don't have a car, can't drive, and/or there is no public transportation? How do we feed ourselves healthy foods if we can't access them, can't afford them, or have to spend hours per week simply in transport to retrieve them? What type of zoning we create, where we site our grocery stores, and what types of foods we sell in them create our environment and at the systems and policy level, we must make changes. This is public health. 




http://www1.ochca.com/ochealthinfo.com/docs/newsletters/whatsup/2013/13-04.htm

If you said, "my kids don't play outside," why is this? Is there no park in your neighborhood? Are there no sidewalks for your children to walk, bike or play on? Is there a  park but you don't feel safe sending your children there? Do the cars drive too fast to allow you to feel safe letting your kids walk anywhere? This is your environment and we can make systems and policy level changes to make it healthier. We can change the zoning regulations to allow for urban agriculture in empty lots and front yards, we can create "road diets" to slow down traffic, we can increase the pedestrian and biking infrastructure, plant shade trees, and create community centers. This is public health. 

So Where Do We Go From Here?

The new face of public health focuses on these upstream social determinants of health. Where you live, work, learn and play are the biggest factors in your health and well being. An example of such public health work in action is an op ed recently posted by my friend and fellow Fellow, Carly Hood, on How to improve the health of Wisconsin families.


County Health Rankings Model
University of Wisconsin Population Health Institute
County Health Rankings and Roadmaps 2014. www.countyhealthrankings.org

"In short, when people don't have access to education, healthy food options, safe and active living environments or transportation to and from a decent-paying job, their health suffers."


In short, EVERYTHING is public health. As public health professionals today, we work to create healthier environments in which to live, work, learn and play tomorrow.

Moving Beyond #72

Moving Beyond #72:  Improving Health in Menominee County

Lauren Lamers, MPH
Wisconsin Population Health Service Fellow
Menominee Tribal Clinic
Shawano-Menominee Counties Health Department
Keshena, WI 

On March 26, the Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute released the 2014 County Health Rankings.  Within each state in the U.S., the Rankings rank counties from most to least healthy based on heath outcomes as well as the environmental, clinical, social, and behavioral factors that influence health.  For many counties, the release of the Rankings is an opportunity to see how their community’s health measures up to other counties in their state, identify successes in improving community health, and hone in on areas that still need improvement.  For Menominee County, however, the Rankings tend to be all too predictable. 

County Health Rankings Model
University of Wisconsin Population Health Institute. 
County Health Rankings and Roadmaps 2014.  www.countyhealthrankings.org

Every year since the Rankings have been released nationally, Menominee County has ranked 72^nd of Wisconsin’s 72 counties for both health outcomes and the factors that influence health.  Perusing the data behind Menominee County’s ranking, several factors driving the low ranking quickly become apparent: unemployment and child poverty rates more than double the state average, high rates of teen pregnancy, and a high prevalence of health risks such as smoking and obesity just to name a few.  Furthermore, considering the wide disparities in health outcomes and health determinants between Menominee County and other counties in Wisconsin, the #72 ranking is unlikely to change any time soon.

Although consistently being ranked last in the Health Rankings can paint a rather grim and defeating picture, when I began my fellowship with the Menominee Tribal Clinic I quickly realized how much the Health Rankings, while not necessarily inaccurate, do not capture.  In many ways, it is the factors that the Rankings cannot directly measure that tell a much richer and more inspiring story about the health of this community.

First, there are a host of historical factors not directly captured in the County Health Rankings that nonetheless underlie the Rankings’ measures of heath outcomes and health determinants.  As a predominantly Native American community, the historical trauma experienced by the Menominee Tribe, including forced relocation to the present reservation, boarding school educational policies intended to destroy Menominee culture, and termination of the Menominees’ status as a federally recognized tribe in the mid-twentieth century, continues to dramatically affect the health of the community.  Many of the indicators captured in the Rankings, such as high rates of poverty, substance abuse, and premature death, are direct reflections of this legacy of historical trauma.

Many efforts are currently underway, however, to address and move beyond this trauma and improve the physical, social, emotional, and spiritual wellbeing of the Menominee people.  Through Fostering Futures, an initiative to promote trauma-informed care across tribal and county agencies, community leaders have joined together to discuss the impact of historical and intergenerational trauma and discuss how to build resilience among families and children.  Additionally, in response to the county’s health ranking, a Community Engagement Workgroup of stakeholders across a variety of sectors has been meeting for several years to implement initiatives aimed at reducing youth obesity and teen pregnancy and improving school readiness.  Other local coalitions and programs are actively addressing issues such as substance abuse and are promoting healthy youth development through the teaching of the Menominee language and traditional cultural practices.  Through this work, community members have identified how a variety of social, environmental, and behavioral factors interact to influence health, and their collaboration has enabled them to take a multifaceted approach to improving community wellbeing.

While the engagement, collaboration, and resilience of the Menominee community are not necessarily quantifiable factors that can be incorporated to a Health Rankings model, they are crucial for eventually making changes to improve community health.  It will take years for small improvements in health to be manifest in the overall health ranking, but there are already some indicators of the fantastic work that this community is doing.  For instance, in the 2010 Rankings, the percentage of Menominee County ninth grade students who graduated in four years was 68% – the lowest in Wisconsin.  In the 2014 Rankings, that number has increased to 93% - above state average.  Violent crime has decreased, and Menominee County is currently ranked 45^th for clinical care and 15^th for environmental factors. 

According to the Robert Wood Johnson Foundation and UW Population Health Institute, the County Health Rankings are intended to “serve as a call to action for communities to understand the health problems in their community, get more people involved in improving the health of communities, and recognize that factors outside medical care influence health.”¹  The community members in Menominee County have certainly embraced this call to action wholeheartedly.  While it may not be reflected in the #72 health ranking, their fantastic work to improve health and wellbeing is an exemplary model for other communities to follow.

 

1.  County Health Rankings and Roadmaps.  Frequently Asked Questions.  http://www.countyhealthrankings.org/faq-page#t82n12072       

A Major Achievement: The Healthiest Wisconsin 2020 Baseline and Health Disparities Report

                                     

 
  e.shor, MPH and Christina R. Hanna, MPH
  Population Health Service Fellows
  HIV/AIDS Program, Division of Public Health
  Madison, Wisconsin

Over the past few years, many Fellows and staff at the Wisconsin Department of Health Services (DHS) have been working to put together the Healthiest Wisconsin 2020 Baseline and Health Disparities Report. The report serves both as a baseline report for Healthiest Wisconsin (HW) 2020, Wisconsin's state health plan, and as a report on health disparities in Wisconsin. Users can orient themselves to this large report by reviewing the text on the web page and the Executive Summary.

The report is organized into health focus areas, an infrastructure focus area focusing on access to high-quality health services, and data summaries by population. The health focus areas include:

• Alcohol and other drug use
• Chronic disease prevention and management
• Communicable disease prevention and control
• Environmental and occupational health
• Healthy growth and development
• Injury and violence
• Mental health
• Nutrition
• Oral health
• Physical activity
• Reproductive and sexual health
• Tobacco use and exposure

The data summaries by population highlight demographic and socioeconomic data for each population and emphasizes health risk behaviors and outcomes where that population experiences disparities compared to other groups. The populations highlighted in this report include:

• Blacks/African Americans
• American Indians
• Asians
• Hispanics/Latinos
• Lower socioeconomic status populations
• People with disabilities
• Lesbian, gay, bisexual, transgender populations
• Geography (rural, suburban, urban)

Fellows worked on many pieces of the report including writing SAS codes, running data, analyzing data, putting together the PowerPoint, and writing some of the chapters, editing, and evaluation. It was truly a team effort with over 60 contributors. The current and former Fellows that have contributed to this important report include Akbar Husain, Anneke Mohr, Erica LeCounte, Christina Hanna, Carly Hood, Lindsay Menard, Melissa Olson, Kelli Stader, and e.shor.

This report is unique is that it brings together a rich set of data on a diverse range of populations. Within the Wisconsin Division of Public Health, program areas have epidemiologists that collect, analyze, and present data specific to that area. For example, the HIV Program has staff members who collect and compile data and publish reports on HIV in Wisconsin. There is no one epidemiologist that is charged to compile data about racial and ethnic populations, LGBT people, and other marginalized communities and the health disparities that these communities face. A large number of people stepped out of their usual responsibilities to help put this report together. Another unique aspect of this report is that it highlights communities that are often left behind and do not get enough attention, especially given the extreme health disparities in Wisconsin. All of these factors make it incredibly important to get this report out to people working on these issues and working in these communities. If you think of someone who could benefit from the information in this report please send them the link and do your part in getting the word out!