Ichiro Kawachi, MD, PhD

IchiroTrained in both internal medicine and epidemiology, Ichiro Kawachi, has been a pioneer in the field of social epidemiology. Dr. Kawachi’s first foray into public health began as a doctoral student in New Zealand in the 1980’s, when he published a paper quantifying the estimated annual deaths due to second-hand smoke. This paper stoked the ire of the tobacco industry but ultimately led to the passage of historic legislation in New Zealand limiting cigarette smoking and tobacco use. Currently the chair of the Department of Social and Behavioral Sciences at the Harvard School of Public Health, Dr. Kawachi is a professor in social epidemiology and has taught for over 20 years. He has published over 500 articles on social determinants of population health. His books include the Health of Nations with Bruce Kennedy, Social Epidemiology with Lisa Berkman (Oxford University Press, 2000; Completely revised 2nd edition forthcoming in summer of 2014); and Globalization and Health and Social Capital and Health co-edited with S.V. Subramanian and Daniel Kim.

Career in Profile

  • 1985 – Received M.D. from Otago University, New Zealand
  • 1991 – Received Ph.D. from Otago University, New Zealand
  • 1993-NOW – Professor, Harvard School of Public Health, Department of Social and Behavioral Sciences

You have several titles: professor, department chair, social epidemiologist, and more recently, behavioral economist/scientist. Tell me a little about your work in each of these roles and which one is consuming the most of your time these days.

I spend about 75% of my time on research, 20% on teaching, and the remainder on administration. I’ve been very conscientious of trying to protect research time. I have a lab – the Society and Health Lab – that currently has a dozen postdoctoral fellows from all over the world. I try to prioritize research including a NIH-funded R01 project on the aftermath of the tsunami and earthquake in Japan. We’re in the field right now, trying to trace the people who were affected by the tsunami.

I’m still very passionate about teaching. I spend at least twenty percent of my time teaching. My classes are Health and Society, which I’ve been teaching here for over 20 years. I do that twice a year in the summer and the fall. I teach about 400 students altogether each year. Recently, I recorded Health and Society for edX. Thirty-two thousand students registered for it. It was really amazing to see this because as you follow the online chat in the classroom, you can see that the very time if you drop a pin from where one of these comments came from, within a day or so, you quickly draw a map of the world. I also teach Behavioral Economics, which started out small and has done the equivalent of going viral in the classroom because we are in the largest lecture theater now at the Harvard School of Public Health. The chair’s duties are administrative, shepherding academic and strategic concerns of the department. I try to keep it to a tenth of my time.

You were trained in medicine, became an epidemiologist, and have been a leader in the field of social epidemiology. You co-wrote the book on social epidemiology. How did you come to do this work?

I trained as a physician in New Zealand. I switched to epidemiology when I got fed up with doing downstream medicine day after day. It wasn’t what I expected. What I had underestimated was the sheer repetitiveness of day-to-day clinical medicine. I trained in internal medicine. I’d say that 80% of my patients had heart attacks, strokes, congestive heart failure, or chronic respiratory disease. If you take those four diagnoses, they comprise about 80% of internal medicine, at least it was when I was practicing. The bread and butter of medicine are these common things.

What do these things have in common? A lifetime of poor behavior, smoking, stress, bad diet, lack of exercise. So I started to realize that there must be a better way to go upstream and try and prevent these people from ever getting any illness. So, that was my initial stimulus to go from clinical medicine to doing something upstream, such as tobacco control.

I became very active in the New Zealand Public Health Association at that time. I was elected as the National Secretary. Just at that time, the Health Minister of New Zealand was Helen Clark, who later became the longest serving prime minister of New Zealand, and who is currently the head of the United Nations Development Program in New York. Under her leadership, she decided to pass legislation to ban all forms of tobacco advertising in New Zealand and to restrict smoking in workplaces. She was way ahead of the curve. She started thinking about this in 1989 and it finally passed in 1991. This was right at the time when I decided to make the switch to public health. So I became very excited by this.

I spent a lot of time lobbying for the passage of this legislation. That’s how I got interested in public health. Through my interest in tobacco control I then did a PhD in Epidemiology and then came to Harvard, now over 20 years ago. My initial reason for coming here was to study the benefits of stopping smoking in large cohort studies. While I was here, I met Sol Levine, who was one of the founding chairs of my current department. I got exposed to this idea of health inequality. I suddenly realized that the problem of tobacco control is actually one of health inequality. I suddenly realized that unless you tackle inequality, you aren’t going to really tackle tobacco control. People smoke because it is one of the cheapest pleasures, it is one of the few things that someone can have for himself/herself in a life that is full of stress and chaos and few options. That got me interested in social epidemiology.

Twenty years ago, when I was recruited into this department, I wanted to use the term social epidemiology to distinguish what I was doing from what I had been doing before, which was chronic disease epidemiology. At HSPH the students have to declare a major field of study for their thesis. One of the first things I did, when I took on one of my earliest doctoral students [was to suggest] that he declare social epidemiology as his field. Much to my annoyance, this was rejected by the school’s Committee on Admission and Degrees. In 24 hours it had come back and the chair of the Committee had said that there is no such field. That got me sufficiently riled and I decided to work on a textbook. Lisa Berkman also had the same idea and already we got a book contract from Oxford University Press. So we decided to write the textbook together and we declared the arrival of this field. These days, no one questions that there is a field of social epidemiology. Len Syme had been doing similar work for years but I guess he never used the term social epidemiology. The same with Sir Michael Marmot. They were doing it. But they hadn’t declared it an academic discipline. The past twenty years can be seen as an effort to build a training program in social epidemiology, which is what we say that we have at Harvard.

Describe your interests and focus in behavioral economics. What are the implications of this field on public health practitioners and policy? Does it represent a fundamental shift in how we are approaching research and interventions?

I became interested in behavioral economics when, five years ago, I became chair of the Department of Society, Human Development and Health. We are now called the Department of Social and Behavioral Sciences. Being a chair of a behavioral sciences department, I decided to review the curriculum. What are we teaching our students about behavior? Much to my amazement, it turned out that there was nothing in our curriculum about behavioral economics, which has been in the background of economics and psychology for the last thirty years, as it really started in 1980.

I was amazed by this gap because on the one hand you have those behavioral economists and psychologists who don’t speak to public health people, yet all of their examples concern health behavior. They’re practicing public health without a license! On the other hand, when I looked at our curriculum, we are the behavioral science department at the School and there wasn’t a single course listed on our whole department roster that taught behavioral health. So I decided that we better quickly fill this gap.

I think behavioral economics is very interesting because it does seem to me a remarkable confluence of ideas – in disparate fields from psychology to neuroscience to economics and public health – to more fully understand the basis of human behavior. I don’t think that by any means it’s a panacea, but it’s something new that we haven’t done. I think if we do it right, it has the potential at least to reduce inequalities as well. Because we know that all the things we speak about in behavioral economics – the heuristics, the biases, and the problems of delayed gratification – all of these things are even more acute in populations that face poverty and scarcity. To the extent that we can address these things, it has the promise of reducing inequalities and boosting the effectiveness of health behavior interventions.

What is a career success or highlight that you are particularly proud of?

My most efficacious paper to this date remains my 1987 article published in the New Zealand Medical Journal, which I wrote when I was a doctoral student. I always tell this to my students, because much as I try to work toward writing elegant papers in high-profile journals, the one that really had public impact is still the one that I wrote as a doctoral student in epidemiology. Back in 1987, the New Zealand Parliament was starting to debate whether or not they should pass legislation to restrict second-hand smoking. I had this idea to calculate how many deaths second-hand smoking in New Zealand causes. I used the technique of Population Attributable Risk, which I had learned in my epidemiology courses. I got some numbers and did a calculation. I discovered that nearly (an estimated) 300 Kiwis (New Zealand residents) were killed every year by inhaling second-hand smoke in the workplace and the home. Three hundred deaths each year might not seem like large numbers, but in New Zealand, that’s roughly two-thirds of the annual death toll from traffic accidents.

My point was that the New Zealand Traffic Ministry spent millions of dollars in anti-drunk driving campaigns, so why didn’t New Zealand government take passive smoking just as seriously. I published in the New Zealand Medical Journal and it had enormous impact. It was picked up by local anti-smoking organizations that held a demonstration in front of Parliament where 300 of them got dressed in crosses and laid down in front of Parliament. Politicians started to cite it in their speeches to Parliament. The next thing I know, I got a letter attacking the paper. Someone submitted a letter attacking the paper and it was written by none other than Nathan Mantel, who every public health student knows because of the Mantel-Haenszel odds ratio. This world famous statistician turned out to be a consultant for the tobacco industry.

When I saw that letter, I knew that I had made an impact. I had sufficiently disturbed the tobacco companies that they had paid this world famous statistician to attack my paper in the New Zealand Medical Journal (which I doubt he had ever read before my article appeared). To this day, I contend that that was the most important, directly policy-relevant paper I’ve written. It just shows that I peaked early. Students can still do really important work. I’ve never had that kind of success since then.

What is a challenge that you’ve faced or continue to face in your career?

A challenge in behavioral economics and social epidemiology is the massive disparity in power between “us” versus “them”. In this country, at least, economic power has become so concentrated in the last 30–40 years, it’s becoming harder and harder to make an impact through the mechanism of democracy. If you want to make some point of view, it is hard to get it represented through the ordinary channels of media.

It’s exactly like Joseph Stiglitz described in The Price of Equality. He articulated what I always wanted to say about income inequality’s corrosive effects on the body politic. His argument is that the concentration of wealth in the top one percent is distorting political decision-making in a functioning democracy. It is distorting media, the rules of the game by which the economy is run, and I think this is a huge challenge both inside and outside of public health.

To get something done within public health, you have to influence institutions, the laws, and regulation. Developing evidence is the initial step. We also say that lots of policies get made on the basis of no evidence. If there is a will to do it, they’ll do it. If you want something to be passed, at least on our side, you have to have evidence. What researchers at the School of Public Health are doing is providing the knowledge base. As has been said before, that is only one of the ingredients. You have to have the political and popular will to do something and you have to have an appropriate strategy to translate that evidence into policy. Unless those things come together, you won’t get change. The problem with growing polarization is that you can produce lots of evidence but the political will is stuck.

Is there a persistent public health problem that still concerns you today?

I have to say that it is health disparities, persisting inequality between rich and poor countries, and persisting inequality within rich countries. The field of social epidemiology is really an attempt to focus attention on that problem.

It is not enough that the average gets dragged up. You have to lift everybody. There is a lot of attention on global health but basically, you don’t need to go that far. Look in our backyard. You will see disparities in life expectancy that span the entire globe. A man born in a New Orleans’ parish has a life expectancy in his ‘50’s, compared to an Asian-American woman born in a rich Bergen County, NJ, who has a life expectancy of 90. A forty-year difference in life expectancy pretty much spans the average differences in the countries of the globe. I tell young, idealistic youth who want to make a contribution to global health that you don’t have to go all the way to Malawi. You can do something in rural Mississippi. Health centers like the one in Mound Bayou, MS, because basically it’s the model of physician responsibility. The primary care doctors basically said that it’s not enough to provide primary care, you’ve got to invest in educating the people, making them leaders, and make it self-sustaining (Editor’s note: Mound Bayou was the first community health center in the country).

This feature was interviewed, transcribed and partially edited by our guest editor, Ted Henson. The photo was provided by Maki Miyashita.

Tom Bodenheimer, MD, MPH

BodenheimerAfter graduating from Harvard Medical School, Dr. Tom Bodenheimer spent time as a Peace Corps physician in Costa Rica, where he learned about the political economy and health infrastructure of rural Latin America.   This led him to wonder how the US might adapt successful public health models from the developing world, such as promotores, or community health promoters.  Upon his return, he practiced primary care for 32 years in San Francisco’s Mission District, a primarily low-income, Latino community.  He has written and co-authored several books on health policy, including Understanding Health Policy and Improving Primary Care. Dr. Bodenheimer has spent the past 11 years of his career in the University of California San Francisco’s (UCSF) Department of Family and Community Medicine, where with his colleagues, he works with primary care providers to improve health care service delivery.

Career in Profile

  • 1961- Graduated from Harvard College
  • 1965- Graduated from Harvard Medical School
  • 1965-1966- Interned at Boston City Hospital, Harvard Medical Service
  • 1966-1967- Worked as a Research Assistant in Neuro-Anatomy, National Institutes of Health
  • 1967- Served as a Peace Corps Physician in Costa Rica
  • 1967-1968– Consulted for US Department of Health Education and Welfare
  • 1968-1969– Served as a Urban Coalition Fellow in Community Medicine at the San Francisco General Hospital
  • 1969– Completed MPH at University of California, Berkeley
  • 1969-1971– Resident in Internal Medicine at University of California, San Francisco
  • 1972-1975– Physician at the South of Market Health Center
  • 1974-1976– Researched at the Health Policy Advisory Center
  • 1975–1979– Physician at Mission Neighborhood Health Center
  • 1980–2002– Physician at BayWest Family Health Care
  • 1991-1996- Associate Clinical Professor, Department of Family and Community Medicine, University of California, San Francisco
  • 1995-96– Worked as the Hospital Utilization Manager at BayCare Medical Group
  • 1996–2002- Clinical Professor, Department of Family and Community Medicine, University of California, San Francisco
  • 1998–2000- National Correspondent, New England Journal of Medicine
  • NOW – Adjunct Professor in the Department of Family and Community Medicine and Co, Director of the Center for Excellence in Primary Care, University of California, San Francisco

Can you talk about your decision to transition from practicing primary care to influencing health policy through your position at the University of California-San Francisco?

In primary care, there was this total divorce between primary care and populations. In primary care, we thought about who’s coming in today or tomorrow. People didn’t even know who their population was or who was on their panel of patients. Even though I have a Master’s in Public Health [MPH], I turned off that way of thinking for a long time due to the pressures of private practice, but now I’m getting interested in it again. I was always really interested in health policy, even during my 1-year MPH program at the University of California-Berkeley. Even while I worked as a primary care physician, I itched to keep my hand in health policy, so Kevin Grumbach and I co-wrote Understanding Health Policy. I did some writing as a physician, and I kept my interest in health policy throughout my career as a practicing physician, but didn’t have much opportunity to do much with it until I left the practice. I like to write. It’s fun.

My health policy work had to get pretty truncated while I worked in primary care, but being in a private practice really teaches you how the health system works, from the bottom up. Not from the very bottom, which sadly is where patients are, but primary care is close to the bottom. This was during the time when Health Maintenance Organizations [HMO] came into being, so we had HMO contracts and PPO Preferred Provider Organization [PPO] contracts and we were in different independent physician associations and we had to worry about different managed care issues … We learned a lot about health policy just by trying to keep our practice working in the crazy world of California in the 1980s and 1990s.

You’ve done a number of things in your career, so what are one or two highlights?

When people ask, what do you think you did with your life? I say, “I tried to take care of a lot of low-income, mostly Latina patients, and tried to do the best I could to make their lives better”. To me, that’s the best thing I’ve done.

In terms of highlights? When I left the practice, I had no idea what I was going to do. I realized, “I have to go…I’m too burned out to do this any longer”. I went to a conference up in Seattle that Ed Wagner’s group [GroupHealth Research Institute] was running, and I met people that I’d never met before – Ed Wagner, Kate Lorig – and I realized, “I want to work on patient self-management”. I know that if patients aren’t part of what happens, it’s not going to work.

So my main focus at UCSF has been patient self-management, mostly through health coaching. Health coaching works with people with chronic conditions to help them understand their disease, and gain the knowledge, skills, and confidence that they need to care for themselves as best they can. For example, if a patient with asthma doesn’t know how to use the inhaler, then the inhaler isn’t going to do any good. Using an inhaler is a skill. So a doctor gives patients a prescription for an inhaler and nobody will show them how to use it, they’ll use it incorrectly or they’ll use the wrong one, and it’s useless.
Virtually every chronic condition has some skills associated with managing it. Behavior change is a big component of chronic disease and preventive care, and we have a method for dealing with behavior change that is called ‘action plans’. Rather than saying: “you have to lose 10 pounds”, you ask: “What would you like to do to make your health better?” Let the patient give you their long-term goals. Then you say, “Well, how can we implement an action plan to get you there?” Baby step by baby step – that’s what the action plan is. The action plan might be: instead of eating a pint of ice cream each night, I’ll eat half a pint. Whatever they’re confident they can succeed in.

Medication adherence is a big issue in primary care, and health coaching helps patients overcome their numerous barriers to taking their meds, whether it’s cost barriers, not believing it’s important to take their meds, not remembering – whatever the barrier might be. So the summary of health coaching is helping people to be engaged in their own health.

There’s a part of public health that’s health education, and then there’s primary care, and health coaching is a space where the two meet. So it strikes me that health coaching is a way that health education can operate within primary care, by working with patients to manage their chronic conditions.

Let me push health coaching a little farther. A colleague of mine and I co-wrote a paper. We ask people to create action plans to change their behavior, but we don’t change the community in which they live. So a lot of times people live in a poor neighborhood where there are a lot of fast food outlets, and we ask them to create an action plan to improve their eating. Fast food is cheap! We haven’t done the “upstream” work so that our patients can achieve their action plans, because the environment around them doesn’t support their action plan.

We wrote a paper where we coined the phrase “evidence-based health.” Evidence-based health has 3 parts. First, evidence-based medicine – so the care team does all the things that have been shown to work. Second is health coaching, helping patients to incorporate the evidence into their lives. The third component of evidence-based health is community health, or all those upstream factors that make it difficult for patients to fulfill their action plans. This takes guideline-driven medicine, adds on the self-management piece to help people implement the guidelines themselves, but also recognizes the toxic environment in which many of us live. It’s like housing and asthma. You can do all the action planning you want with patients with asthma, but if you don’t deal with the mold in the walls, it’s not going to make much of a difference.

So it’s primary care engaging with the patient, and also looking at the broader context in which the patient lives or works?

Exactly. It’s where primary care and public health need to come together. And of course, that’s the big divide that nobody’s been able to figure out. Because primary care folks are too busy to deal with public health, and I think a lot of public health people care about primary care but they’re in a different world. The two worlds need to be in one world.

I often think of public health and primary care on a continuum, community to individual, but we’re often not talking to each other.

JAMA just had a 50-year issue on the progress on reducing smoking to improve population health. It was a wonderful issue, and they pointed out that most of the effective interventions have been public health interventions – the cigarette taxes that increase cost, smoke-free zones and mass media campaigns. Our counseling hasn’t made nearly as much of a difference as the public health measures. One author pointed out that most people who stopped smoking just did it by themselves. By now, thanks to public health messaging campaigns, almost everybody who smokes knows that it’s bad for them, it’s just hard to quit. So it’s pretty clear that with regards to smoking, which is still the biggest killer in the US, public health has been enormously successful, way more than medical care.

On that note, you also do work in health policy. Can you talk about that?

There’s the macrosystem and the microsystem. For example, how much primary care providers get paid. Because they get paid a lot less than specialists, most medical students don’t want to go into primary care and it’s harder work. So that’s a macrosystem health policy issue. The microsystem, in contrast, is what happens at the level of the individual practice or clinic.

Our group at UCSF is called the Center for Excellence in Primary Care. Most of the work we’ve done is microsystem work. We try to figure out how can we help practices work better. How can we help them use data to drive quality improvement? How can we help primary care teams work together? See more patients? Primary care doesn’t have enough capacity to see all the patients who need primary care. We’ve also developed models for providing intensive health coaching for complex patients – the 10% of patients who incur 70% of costs. All of those things are microsystem improvements that desperately need to be done, because a lot of primary care clinics don’t work well at all.
This relates back to the macrosystem, because if medical students train in primary care clinics that don’t work well, or all the doctors are unhappy and burned out, then the students say, “I don’t want to go into this!” So the two are related.

Can you illustrate what that looks like?

One of the practices we’re working with is a pediatric practice. One of their goals was to improve cycle time. Low-income families come in, it’s a teaching clinic, so they see a resident. The resident then goes to the attending to get precepted, the patient’s sitting there with kids bouncing off the wall. Finally the resident comes back, maybe with the preceptor. Then the kids haven’t gotten their immunizations yet because the preceptor has to approve the immunization order, so then the families have to wait even longer for the LVN [licensed vocational nurse] to get everything ready. So families are waiting a long time, and it’s really hard for patients with small kids to wait so long. Our analyses showed that roughly 50% of the cycle time – which was 2 hours – was waste and 50% was value-added.
We had to figure out how to reduce the waste, and a lot of it had to do with the workflow for immunizations. If we could get the immunizations approved earlier and done while parents were waiting for residents to come back, we could maybe reduce the cycle time by half an hour. That’s an example of the kinds of things we try to do with clinics. Sometimes we fail and sometimes we succeed.

When you think about public health or primary care, what do you see as a persistent challenge?

I think it’s where the dollars go. It’s something like 3% of the total health budget, which is about $2.25 trillion, goes into public health, and about 6% goes to primary care. A lot of it goes to specialists and hospitals and to interventions that aren’t evidence-based and that patients don’t even need or want. Some of it is end-of-life, unnecessary surgeries, unnecessary tests. There’s a whole movement called “Avoiding Avoidable Care”. To avoid care that’s unnecessary, and thus drive down costs.
We need to completely redistribute the health budget so that way more goes into public health and primary care. There is plenty of money in the healthcare system, and it is maddening to see the priorities of where that money is spent. It’s the paradox of excess and deprivation.
There are so many people who have so much care that they don’t even want, and a lot of this is driven by fee-for-service payment. And then there are a lot of people at the other end – the uninsured, minorities, vulnerable populations – who don’t get care. It’s a huge challenge and it won’t be easily solved. So much money goes into the far downstream care of people who didn’t get the upstream prevention and primary care that they need.

What might it take to solve this problem?

Well, I know what the healthcare budget would look like – channel the money that’s being wasted on unnecessary care in specialty and unneeded hospital admissions, etc., and redirect it into primary care and public health. How to get there is political.

The will to do the right thing in this country seems to have waned in the last 50 years, and I don’t know if we’ll get it back. So people can see what the solution should look like, but I cannot see how we’re going to get there. I can give you a bunch of platitudes about how we have to elect Don Berwick as Massachusetts’ governor (former head of the Centers for Medicare and Medicaid Services, and former President and CEO of the Institute for Health Improvement) – but it’s much deeper than that. It’s a deep-seated problem and I don’t know how we’re going to solve it. Other countries have solved it because they have political systems that are more rational, I think, and also more humane.
10% of a person’s health is determined by healthcare, and 60% is determined by self-management issues, community issues, education, class, race, anything but healthcare. There’s so much potential for people to live long, wonderful, healthy lives in the 21st Century. People should have the opportunity to do it and the opportunity should be evenly distributed among society, and it’s not. It’s sad to see that the potential of humanity is so variable depending on where you come from, your income, what family you were born into, issues like that. I think that’s, to me, the biggest issue. People call it “disparities.” I think it’s about allowing everybody to have the opportunity to have a long, healthy, happy life, as much as it’s possible.