In this opinion-editorial, Ron Haskins writes about some little known evidence-based social programs that the Obama administration has funded and supported for many years. Unfortunately, many studies find that approximately 75 percent of programs to improve school and work outcomes do not work very well. For example, D.A.R.E has been widely supported in schools throughout the country to prevent substance abuse, but evaluations typically show disappointing results. Therefore, the author uses this op-ed to argue that congress must be able to identify which programs work and continue funding many of the Obama administration’s evidence-based social programs.
As part of the article, the author also shares a few examples of model social programs that appear to work. For instance, the Wyman’s Teen Outreach program in Florida aims to teach ninth graders “healthy behaviors, life skills, and a sense of purpose,” and evidence suggests that it reduces teen pregnancy and school suspension rates. As another example, the Nurse-Family Partnership in Pennsylvania funds nurses to visit low-income first-time mothers starting before birth and lasting until the child is two years old. Evaluation results show that children continue benefitting from the program until they are at least fifteen years old. Mothers participating in the program are more likely to have a job and are less likely to abuse their children while their children are healthier and more prepared for school.
The article ends by noting why rigorous evaluations are often unpopular among all political parties; we would likely find that many popular, widespread, and expensive programs are ineffective if we evaluated them. Therefore, the author argues that successful programs must continue receiving money. After all, “social policy is too important to be left to guesswork.”
Relevance: This opinion-editorial discusses an important issue for individuals interested in reducing health disparities starting with some of the root causes: social programs and policies. It also reminds us that although a program may be targeting a social problem known to be associated with health disparities (e.g., poverty), this does not mean that the program itself is effective. This article is also a reminder of how our social policies (both good and bad) can influence the health and overall well-being of individuals.
Source: Haskins, R. (2014, December 31). Social programs that work. The New York Times. Retrieved from http://www.nytimes.com/2015/01/01/opinion/social-programs-that-work.html?ref=us&_r=0
New! Re: Social Programs that Work: Op-Ed by Ron Haskins in the New York Times
After class today, I reflected more about this op-ed and how it applies to our class discussion. As someone training to be a researcher, many of the points about evidence-based interventions rang true. However, it also made me think about community-based participatory research (CBPR). When we look to implement effective social programs, very few of them likely include true CBPR methods. Although there are techniques for tailoring an intervention to different cultures and communities, this is quite different from giving the community the true power to define the problem and approach to solving it. If we start with a problem and turn to the literature to find an evidence-based intervention, we will likely arrive in the community with a prepackaged solution. Although there may be some flexibility in the intervention, it makes me wonder how we can best balance the need to use our limited resources on evidence-based interventions with our goals of CBPR. What if the community wants to go in a direction that is not evidence-based?
Additionally, I thought this piece also tied to many of our discussions about the influence of politics in public health. Often effective and successful programs are cut due to funding constraints while others (which may or may not be working) continue receiving funds. This issue made me reflect on our discussion about the agendas and goals of individuals who have the power to make decisions or to influence decision-makers.
New! Precis: Summary of the Major Findings of the Evans County Cardiovascular Study by John Cassel MD, MPH
"Summary of the Major Findings of the Evans County Cardiovascular Study" by John Cassel MD, MPH, highlights knowledge gained as a result of a collaboration between Dr. Cassel (an academic epidemiologist) and Dr. Hames (a primary care physician in Evans County, Ga). The idea began when Dr. Hames observed in his clinic and community that (1) he rarely saw "black patients, particularly black men, with any manifestaton of coronary hear disease (CHD) despite the fact that levels of blood pressure in many of their patients were markedly elevated" and (2) coronary disease was a very common manifestation in his white patients."
They designed a prevalence study in which every community member over 40 years old and a smaller sample of individuals 15-39 years old had medical examinations and laboratory tests completed. The participation rate was 92% (3,102 people). The study showed:
(1) "all manifestations of [CHD] occurred very rarely in black men"
(2) among white men men in higher social class had higher rates than men in lower social class
(3) white men in lower social class and black men had similar rates.
Interestingly, while none of these differences could be explained by other measured risk factors variations in how physically demanding the mens occupations were seemed to be partly responsible for differences between white men of higher social class and the other men studied.
The prevalence study was followed by an incidence study to determine outcomes (stroke and CHD) for those who did not have CHD in the original study. They obtained follow up information for 98.8% of the original participants. Findings showed;
(1) lower class white men had rates closer to higher class white men than previously observed
(2) black men continued to have lower rates even though they responded to risk factors the same way white men did
(3) when black and white men were both sharecroppers, white men had similarly low rates
Again, the differences were not explained by risk factors.
Provocatively, Cassel explains why measures of statistical signficance were not calculated or necessary and provides data for the "interested reader [to] compute these tests himself."
(1) Collaborative work between public health and clinical medicine allows us to identify a situation affecting a populations health and study it to answer the question "Why?"
(2) Good rapport between investigators and the community members builds relationships and creates a greater willingness to participate
(3) Clinical significance and statistical significance are not synonymous!
I wanted to take the opportunity to write briefly about Dr. Jones and her gardener's tale allegory that we briefly discussed in class on Thursday. The most interesting part of the article/story to me is the question of who is the gardener? The article states that in the United States, the gardener is our government, but I would venture to state that the gardener is anyone who knowingly or unknowingly perpetuates systematic racism in our society, including us! Last semester I was introduced to this concept of "gatekeeping" by the Racial Equity Institute. I believe that as young researchers we are trained to identify and populations that need health interventions and learn the methods to conduct research that is considered evidence based. After our training is complete many of us will go on to work on improving health and reducing health disparities, but under the wing of a larger organization and restricted by funding and other external factors. This was just a quick thought, but the more I hear the story the more I think about who exactly is the gardener in the story today and where do we start when it comes to working towards health equity.
New! Precis: Out in the Rural: A health center in Mississippi
Last Edited By Dolly Penn (pennd) on Feb 9, 2015 7:00 PM
In Out in the Rural: A health center in Mississippi the story of the Tufts-Delta Health Center in North Bolivar County in Mississippi is shared. In the documentary Jack Geiger, Helen B. Barnes, LC Dorsey along with residents and other involved people talk about the comprehensive health center and all of its programs.
There were 14,000 black people living the 500 square mile area of North Bolivar County. The median family income was $900 per year. Most people were functionally illiterate with an average of 4 years of schooling. The median age was 15 years and the median age of the male heads of household was 57 years. 50% of the people had no onsite water and 65-70% of housing in the area would be considered un-inhabitable for humans. According to the documentary, "women are the hardest hit because the men just leave." Unsurprisingly, given the aforementioned social descriptors, this county had a high infant mortality rate (70 deaths/1000 births).
In this setting, Dr. Geiger developed a comprehensive community health center which included a physician, laboratory, pharmacy and home health visits because he recognized the need for social change and the role health services could play in being a "route of entry" for social change. He introduced a concept called community health action in which the "concept of health is to make social change, to build institutions that can make social change, and keep it going."
In addition to the health center, the community members were organized into a health council and health association to assess the needs of the community and act in the interest of the "overall community not just health." Members of the community were trained to make necessary environmental changes (ie sanitation and housing). The community members also started a farm cooperative for internal consumption and for export for revenue.
Other community programs included: transportation system, supplemental food, legal assistance, low cost housing, head start, youth career guidance, in service training for health center staff, college preparatory courses and a county bookstore and cultural center focusing on black history.
Relevance: Sustainable disease prevention and healing results from integration of traditional medicine to address health concerns and community leadership to facilitate social change since in many cases, disease is a manifestation of social ills.
New! Precis: Interview of Jack Geiger, L.C. Dorsey, John Hatch Tape 1
Last Edited By Dolly Penn (pennd) on Feb 18, 2015 10:23 AM
Tape 1 of the interview of Jack Geiger, L.C. Dorsey, and John Hatch focused on their reflections on what worked to transform the community in Mound Bayou, Mississippi and how they saw the community change over time.
Regarding what worked, Jack Geiger said; "There is not one thing that worked." Each time period has a set of problems and solutions for those problems. Even if the problems are the same over time, the solutions change based on the community. However, solutions that transcend time are "educating and training" the community because these investments benefit the entire community. "Institution building" is another investment that empowers the local community. The focus of community building is not only the current generation but the effects for future generations.
Hatchet opined many of the improvements of the past are not respected by the present generation. He said the younger generation seems lost and have "no dream or hope of betterment." This difference in attitude and motivation compared to past generations is manifested in an unwillingness to work hard and study for improvement. The black church, in his opinion, must take the lead in "changing the activities of the youth and the communities."
The sense of community as was seen in the past no longer exists. An important reason for this shift is lack of employment opportunities in the area since 1965 caused by decrease in the labor economy and increased opportunities for employment in other states. This migration of labor produced broken families (without fathers in the home for long periods of time), a more segregated community, and wealth "stratification within the black community." Interestingly, Hatchet mentioned he "traveled to Europe and found the level of living for the lower third abroad" was better "than citizens in Durham. NC." L.C. Dorsey said, "the real problem in the US is economic but people are seeing it as a people problem."
Despite the current state, there was still belief that the problems can be overcome with investment in the community and empowerment through education and skills training so that the community is self-sustainable.
Relevance: Community empowerment for positive change must start within the community and focus on investing in people and institutions to improve current conditions and prepare for the future. In Geiger's words; we must "build institutions, invest in the people, and continually define the problem in current terms so that you get a response from the community."
At the annual Preventive Medicine conference, I attended a session focused on health disparities where one of the speakers, Dr. Linda Rae Murray had a dynamic presentation that made many of the audience members uncomfortable and made me smile because I have heard Dr. Jenkins say many of the things she mentioned, most notably, that “race does not exist.” She also talked about wealth and community health.
Dr. Murray talked about how people do not like to talk about racism. She described disparities as “observed differences” and inequities as “ethical judgments about differences.” According to her, we cannot discuss inequities without discussing values. She mentioned that the WHO Commission on social determinants of health uses the word “discrimination” where it should use “racism” because people are afraid to talk about racism. She said “if we cannot talk about racism and discrimination, we will continue to have problems.” In her opinion, the “white” race exists only in the united states of America and is a direct result of individuals wanting to be something different than those they thought less of (ie African Americans and Indian Americans).
From the global perspective, she talked about how the Institute of Medicine’s US Health in International Perspective showed rich white Americans are sicker than rich Europeans. She then opined “if white people continue to be brainwashed that white is a race, they will continue to do poorly compared to their peers.” Next, she talked about wealth in a way that enlightened me.
Dr. Murray showed a graph which displayed the differences in wealth by “race” (white >$100,000, black $6,000, Hispanic $8000). Interestingly, when home equity was removed from the equation wealth was noticeably reduced (white <$35,000, black $2,000, Hispanic $4,000). She used the change in wealth die to home equity to make the point that there is a misconception of wealth in the US. “Everyone thinks they are a part of the middle class, which is epidemiologically impossible.” In reality, we are ALL poor!
Finally, she addressed the importance of community oriented health services. Like Geiger, Dorsey and Hatch, she believes “care to address health cannot just be within the exam room.” We have to go into the community.
Relevance: There are a few scholars talking about health disparities, racism, wealth, and community oriented health care from a perspective that is not widely accepted. WE must be the scholars to continue this conversation with our generation and to teach it to the next generation so that the conversation continues and so that we are moved to action which precipitates change.
New! Precis: Solo Interview with Jack Geiger - Tape 1
The first tape of this solo interview with Jack Geiger cover’s his early life, education, and early career. This interview charts Dr. Geiger’s path from his childhood in New York City to the community health center in Mount Bayou, Mississippi.
The interview, much like our first EPID 799 class, focuses on the importance of a person’s background and how that influences their perspective and their work. Dr. Geiger grew up in New York City, the son of a doctor and a microbiologist. He graduated from high school at age 14 and, with his parents’ blessing, moved in with the actor and activist Canada Lee after meeting him at a theatre adaptation of “Native Son”. Jack lived in Harlem for a year before heading to the University of Wisconsin where he got involved in civil rights; while working for the school newspaper he discovered that the University had a list of “approved off campus housing” that was not open to people of color. They tackled the issue of segregated University housing. He and some colleagues then started the second branch of CORE in Madison.
Jack also enlisted in the Merchant Marine. He chose this branch over others because it wasn’t segregated. When he would return to NY he would hang out with Canada Lee and other intellectual leaders of the black community. At the University, an older group of black students informally taught Jack how to organize people. He was involved in the first threatened march on Washington which was aimed at desegregating defense industry jobs. A lot of his subsequent experience in the Merchant Marine and as a pre-med student at the University of Chicago had an activist bent – he and others would put on their dress blues and take an integrated group to buy train tickets at the “whites only” ticket counter, document hospital discrimination, and pressured the University to accept Black medical students.
By 1954 he was getting bored with journalism and went to medical school. While there, he “discovered” social medicine only to learn that it had been invented about 100 years prior. He saw a lot of social medicine in the British literature but the American literature was “fuzzy, liberal, tender loving care” and talked about social medicine as an attitude rather than a thing that you did. He then tells a great story about how he ended up in South Africa that I cannot do justice to by summarizing.
In South Africa at that time, there was a lack of activism to change the political scene – doctors mostly provided “palliative” care that didn’t address social structures. He came back to the U.S. and then ended up in Mound Bayou, Mississippi – I assume he discusses his work there in more detail on the second tape.
Relevance: Jack Geiger is a seminal figure in the history of social medicine in the United States. The process by which he came to see this need, and develop a community approach to a solution, in the United States is fascinating. We have talked a lot in this class about the importance of understanding how your own history, and the history of others, shapes individual perspectives; this interview is a comprehensive overview of Dr. Geiger’s history and how it led to his work in Mound Bayou. He is also a good storyteller and I found that listening to him speak was enjoyable.
New! Precis: Applying the TM Technique to Address Autism-Spectrum Disorders, ADHD, and Other Neuropsychological Disorders of Adolescence and Young Adulthood
This webinar features two speakers: Dr. Fred Travis from the Maharishi University of Management and Dr. William Stixrud from the George Washington University School of Medicine. During his portion of the webinar, Dr. Travis presents research (much of it his own) that provides evidence that Transcendental Meditation produces significant neurological effects in the brain. He displays slides featuring EEGs and other brain scans that illustrate neurological markers that support these findings.
The webinar then presents a video produced by David Lynch (an advocate for TM) that shows a case study of a young man with a diagnosis of Asperger’s who experienced social and academic improvements after learning TM.
Dr. Stixrud speaks about the prevalence of stress in society and its effects on the developing brain. He states that reducing stress can improve outcomes for children with ADHD and references Dr. Travis’ data that suggests that TM is effective at improving school behavior, reducing anxiety, improving mood, sleep, and emotion regulation, among other things. Dr. Stixrud states that children with autism often experience high levels of stress and anxiety that may be reduced by engaging in TM. Dr. Stixrud also presents some information on the Quiet Time program which is being implemented in some schools and that includes two fifteen minute periods of TM per day (more information is available at www.davidlynchfoundation.org).
Relevance: Dr. Travis provides a brief overview of some research on TM and Dr. Stixrud provides some anecdotes about the efficacy of TM in practice. This webinar provides some more information about the use of TM and may be a useful resource for those who wish to learn more about the practice. One note: much of the information presented in this webinar is anecdotal and/or does not establish a causal link between TM and the myriad health outcomes that are mentioned.
New! Precis: When Affirmative Action Was White - An Untold History of Racial Inequality in Twentieth-Century America
We often talk about affirmative action in the United States as method for increasing opportunities for African Americans; those who oppose affirmative action frequently argue that these types of programs is no longer necessary because Blacks are no longer at a relative disadvantage – racism is largely a non-issue. What we never talk about is that the plethora of opportunities and programs that have benefited European Americans for centuries are essentially a historical program of affirmative action for whites that continue to contribute to inequality in this country.
In his book, When Affirmative Action Was White, Ira Katznelson provides a detailed description of the litany of public policies that were enacted throughout the 20th century that deliberately benefited White Americans at the expense of African Americans. He describes how the post-civil war southern states had inordinate sway over the New Deal because they flooded the Senate not just with conservative Republicans, but also with conservative Democrats that undermined the numerical Democratic majorities in Congress by uniting with southern Republicans to form a “Conservative Coalition”. In order to pass his New Deal policies, FDR was forced to make concessions in the legislation for this group. As a result, “farmworkers and domestics” were left out of the New Deal; the vast majority of these workers were African American.
Dr. Katznelson then explains how Black veterans were largely unable to enjoy the benefits of the GI bill since there were fewer colleges that would accept them. He describes how the process of redlining dramatically restricted African-American access to affordable home loans and prevented Black families from moving into neighborhoods with rising home values, thus limiting their ability to accumulate wealth. Throughout, Dr. Katznelson exposes the inherent racism in Federal policies and highlights how this bias was exacerbated through the state-level implementation of laws, particularly in the south.
Relevance: Anyone with an interest in how our government has systematically maintained economic, educational, occupational, health, and overall quality of life disparities across color lines could learn a great deal from this book. Dr. Katznelson provides a compelling historical framework for the creation and maintenance of these inequities and makes clear the lengths that we have gone to hide their source and to ignore them.
New! Precis: Youth Justice, Youth of Color, and Health Policy Implications
This webinar was presented by James Bell J.D., the Founder and Executive Director of the W. Haywood Burns Institute in Oakland California and was presented by the National Partnership for Action to End Health Disparities as part of their “Equity in All Policies” webinar series. (The webinar is available here.)
Mr. Bell presents a number of studies that suggest that Black young people are treated very differently than White young people in our justice, mental health, school, and child welfare systems. He is careful to state that these systems are performing their intended function, but that in doing so they produce different outcomes for children of color than for White children. Some of the data presented by Mr. Bell suggest that the justice system is disproportionately used to manage the behavior of children of color (rather than to punish violent crimes), that police officers tend to perceive Black youth as four to six years older than they actually are, and that when experiencing a mental health disorder, White youth are often referred to treatment while Black youth are more likely to be referred to a correctional placement.
The thrust of Mr. Bell’s talk is that the justice, mental health, school, and child welfare systems, need to fully understand how critically interconnected they are – there is opportunity for data sharing and collaboration that could allow these systems to better serve youth, particularly youth of color who are disproportionately impacted by each of them. The justice system is designed primarily to protect public safety – perhaps this system is not the one that should be handling the misbehavior of children because we know that detention is not an effective behavior change method; the youth justice system is “transactional, not transformational”, it is processing young people, not helping them.
Relevance: Mr. Bell’s succinct and data-driven presentation provides compelling evidence for how institutions, through a lack of coordination or despite it, contribute to disproportionate negative outcomes across the life course for people of color compared to European Americans. If one seeks to create change, one must have an understanding of how the system is structured and how it functions.