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.

Sandra Witt, DrPH

Sandra Witt - for collageIntroduction

Dr. Sandra Witt spent 14 years at the Alameda County Public Health Department, where she played an integral role in pioneering health equity practice. She worked on programs and policies responsive to public health issues affecting County residents with the goal of eliminating health disparities.  This work, along with her leadership in health surveillance, monitoring, and technical assistance, won her an Outstanding Manager of the Year award.  Sandra is currently the Program Director of Healthy Communities (Northern Region) at the California Endowment, where she, along with the Senior VP of Healthy Communities and her counterpart in the Southern Region, oversees the implementation of a place-based initiative to strengthen some of California’s most vulnerable communities.  Her commitment to achieving social justice in public health, plus her insights and experiences in transforming public health practice to achieve health equity, make her an obvious public health hero.

Career in Profile

  • 1977 – Obtained BA in Sociology and Health from McGill University
  • 1983 –  Obtained MA in Latin American Studies/Anthropology from University of Florida, Gainesville
  • 1985 – 1990 –  Health and Development Officer, International Development Research Centre, Ottawa.
  • 1991 – Obtained MPH from UC Berkeley
  • 1997 – Public Health Consultant, International Health Programs of the Western Consortium for Public Health
  • 1998 – Completed Dr.PH in Maternal and Child Health, UC Berkeley School of Public Health
  • 1998 – 1999 – Epidemiologist, Alameda County Public Health Department
  • 2000 – 2010 – Director of Community Assessment, Planning, Education and Evaluation, Alameda County Public Health Department
  • 2007 – 2010 – Deputy Director of Planning, Policy and Health Equity, Alameda County Public Health Department
  • 2011 – present – Director, Healthy Communities (North Region), The California Endowment

You’ve worked on health equity practice from two different perspectives, a local health department and a foundation.  Can you tell us a little about your work in each?

During my time at the Alameda County Health Department, we recognized that we could continue to provide needed services – and the community certainly needed services – but it was also important to figure out how we could change the social conditions that created the need for services and entrenched health inequities to begin with.  We felt that the real focus of health equity is not just health disparities – the outcomes in health status – but rather the root causes that create those disparities.  Today it is widely recognized that there are huge differences in life expectancy based on where you live.  Your zip code matters.  When we were starting this work we invested resources to get people to understand that the opportunities in place have a lot to do with how long and how well you live.

Currently I work at the California Endowment, where I’m the Director of Healthy Communities (Northern Region).  We have a $1 billion, 10-year initiative that focuses on building healthy communities where children are healthy, ready to learn, and safe.   The initiative selected 14 places across the state that had 1) poor health outcomes and social inequities, and 2) experience and interest in working together to solve community problems.  We started with a planning process that created a space for community voice to shape community priorities.  Each site came up with a community plan, which  guides the Endowment’s grantmaking on strategies that support efforts that meet the community’s priorities to improve health.

Moving to the foundation was an opportunity to further the work we’d started at the health department to figure out how to support efforts, which change the social conditions that create poor health outcomes.  The Endowment has an incredibly bold and big vision of what change can look like, which is exciting.

Often times, the residents that are most marginalized in our society are not included at the  decision-making table or processes that directly impact their lives. They need to be included in shaping the solution.  So equity and inclusion are core elements of how we think about this work.  A key piece is recognizing which issues are important to our communities – especially ones that disproportionately affect low-income communities of color – and then raising the profile of these issues within our communities.  Another piece is creating opportunities to educate policymakers about how these issues affect our communities and the health of our communities. Another key component of our work  is focused on power-building — building the leadership capacity of adults and youth to advocate on their own behalf. We also foster collaboration so that people from different perspectives can come together to develop policy solutions.

For example, in Fresno the young people raised the issue of school suspension and expulsion.  They felt that these disproportionately impacted young men of color and we know that suspensions and expulsions can contribute to a trajectory into the criminal justice system.  So we supported organizing to bring attention to these issues within their communities.  The Endowment’s statewide policy branch also realized that these concerns could be addressed through statewide policy.  State and local advocates worked together to identify positive school discipline practices and policies. One of those practices is implementing restorative justice, which can bring down suspension rates quite quickly.  After a lot of organizing by our local and state partners a number of state bills passed that addressed suspensions and expulsions in schools.

If you only think about health in the context of the doctor’s office, you miss opportunities to affect the many other factors that impact a community’s trajectory to good health, like school discipline policies and practices.

 I’ve heard you speak about “health equity practice.”  Can you tell us more about that?

Public health departments, as they stand now, are not really set up to focus on broader social conditions.  So when we think about transforming public health practice to address health inequities – what we call a health equity practice – we have two grounding principles.  First, in all the work that we do, we should think through how policies or practices impact health inequities.  This helps us think through where to focus first.  Second, we ask if there are processes for the people who are most impacted by these decisions, to have the opportunity to participate in shaping the solution.  Those perspectives and lived experiences are key to the conversation.  You need to think about both if you want to engage in practices to address health inequities.

Health equity practice is part of a broader public health move to change the social conditions that impact health.  Poor health outcomes often concentrate in particular places.  Place is where you live, work and play and shape the opportunities you have to be healthy and productive.  This analysis was key in leading us  to recognize we have to focus on changing the social conditions that create these inequities.  In health equity practice, we’re looking for ways to change policies and practices in institutions that work in education, housing, transportation, economic development, etc. so that everyone’s health can be improved. A core component of health equity practice has to be focused on creating and institutionalizing mechanisms for the most marginalized to participate in decision making on issues that impact their health and well-being.

Let’s say I’m working in a health department and want to widen my health equity practice, do you have any suggestions for how we might go about doing that?

I can share how we did it at Alameda County.  At the health department, we were very intentional about working directly with residents and community organizations in areas that had the lowest life expectancy.  These communities identified their priorities, and we partnered with them to bring in other partners to address  those issues.  So that’s one place to start.  In our work at the Endowment, as well, we’ve started with what communities, residents, and community based organizations identify as the priorities.

There’s an internal piece of this work and then there’s an external part of the work.  A big piece of equity and inclusion is understanding the historical legacy of racism and how that impacts our communities.  The health department invested in the development of a curriculum for all staff to understand these topics.  We covered: What is public health? What is the broader environmental and political context within which health is produced? And why do certain neighborhoods look the way they look?  What are the historical reasons or policies and practices that we, as a society, put in place, which created the opportunities for some and disadvantages for others?

This built a shared understanding within the health department. At the same time we worked with communities and learned from those experiences as well. If we don’t look at what we do as an institution and identify how we create barriers to inclusion and perpetuate inequities, we cannot reach our goal of achieving health equity. You don’t end up working with the community.  You think you’re doing things for the community, but really you’re doing things to the community.

I don’t want to underestimate the importance of this step.  It requires leadership and willingness for honest self-examination.  It also requires a willingness to understand how our processes have impacted our populations.  It helps the organization understand hurdles to the work and what it means to build authentic relationships with the community and residents.

For the external work, when figuring out how to begin engaging residents and community organizations, one step we took was to tap into the assets of our own staff.  At the health department, our staff came from all over, including many from these very communities. We created opportunities in-house for staff to talk to us about what was going on in their neighborhoods.  We showed them the data, but we also wanted their reflections about : What’s going on?  If you were going to talk to somebody, who would that be? Are there organized groups there? Are there CBOs we should link with?

Honestly, I think we sometimes forget our staff and our internal resources.  For example, community outreach workers are in many communities, and they became essential for putting us in contact with folks whose houses they regularly visited.  Through those kinds of connections we could begin to go out, meet people, create opportunities, and pull people together for community meetings.  In many of our communities, particularly our most marginalized, historically things have not changed.  There’s a lot of distrust of systems– appropriately so as there has been a history of broken promises.  Part of the process is developing a relationship with residents and getting a better understanding about what the realities are.

We also wanted to think about the assets of local communities.  So we visited a lot of churches, for example.  In one of our communities, we reached out to a school principal to coordinate efforts around fielding a community survey to identify priorities.  Every year, the principal asks her teachers to go out and meet her students’ parents because she wants her teachers to understand the community that her students live in.  We wanted to do a community survey.  We already had a group of residents who shaped the questions in our survey.  So she teamed her teachers with our health department staff and community folks to administer the door-to-door surveys together.  That was a powerful partnership – with residents and between public health and the educational system.

This work is really big and can sometimes feel overwhelming. I think it’s important to break it down and figure out where to start.  The truth of the matter is that there are multiple entry points into this work depending on where your health department is and where the communities are.

Bob Prentice, MA, PhD

Bob photo 2When Dr. Bob Prentice, PhD, finished his graduate work in Sociology at Michigan State, he packed up his van and drove to San Francisco. Eventually, he landed in the San Francisco Department of Public Health, where he worked for eighteen years, including a five-year tenure as the Director of the Public Health Division. From there, he co-founded and became the Director of the Bay Area Regional Health Inequities Initiative (BARHII), a collaboration of eleven local health departments in the San Francisco Bay Area and beyond. He also served as Senior Associate for Public Health Policy & Practice at the Public Health Institute. Dr. Prentice’s commitment to re-envisioning public health within a social justice context, including his groundbreaking work expanding public health partnerships into fields like land use, air quality management, and transportation policy, make him a noteworthy public health hero.

Career in Profile

  • 1967 – Completed BA in Social Science, Michigan State University
  • 1972 – Completed MA in Sociology, Michigan State University
  • 1982 – Completed PhD in Sociology, Michigan State University
  • 1988-1991 – Coordinator of Homeless Programs, City and County of San Francisco, Mayor’s Office
  • 1982-1996 – Multiple positions with San Francisco Department of Public Health (Health Program Planner, Director of Indigent Programs, Director of Homeless Programs, Director of Community-oriented Primary Care)
  • 1994-1999 – Director, Public Health Division, San Francisco Department of Public Health
  • 1999-2011 – Senior Associate for Public Health Policy & Practice, Public Health Institute
  • 2005-2011 – Director, Bay Area Regional Health Inequities Initiative (BARHII)

 

Can you talk about a career or success or highlight?

The Bay Area Regional Health Inequities Initiative (BARHII) is a regional collaborative in the San Francisco Bay Area with a mission to transform public health practice to eliminate health inequities and create healthy communities. We started out as a series of conversations between the Public Health Officers and Public Health Directors of three counties (San Francisco, Alameda, and Contra Costa). Back then, we didn’t have the granular data that we have now – I couldn’t have told you that people in Bayiew/Hunters Point (a low-income San Francisco neighborhood) have a 14 year lower life expectancy than people in Russian Hill (an affluent San Francisco neighborhood). But we knew that there wasn’t just a randomness to that, it was tied to other things about those neighborhoods. We were all 60’s activists as well as public health professionals and this was not acceptable.

We now know that 10-15% of that disparity comes from health care. So what accounts for the rest of it? That question opens up the possibility of public health involvement outside the traditional realm of public health programs. BARHII partnered with environmental justice groups to push for improved policies in land use, air quality and public transportation. Those agencies were so used to hearing from the environmental justice groups that their meetings almost felt predictable. But BARHII changed the dynamics because we could argue for changes in public transportation policy by saying, “Unless we do something differently, 1 out of 3 babies born in 2000 will develop diabetes in some point in their life – and closer to 1 out of 2 for African Americans and Latinos.”

Environmental justice and public health both argued for improved public transportation and more stringent air quality targets, but we had different approaches to advancing our positions, which were worked out together prior to public testimony. Because we reframed the debate to include public health, the public officials heard these arguments differently. The air quality management district hadn’t always been sympathetic to environmental justice concerns, but as advocates for public health, they’ve come around.

A decade later, it’s pretty well established that public health has an important role in land use. But that’s just a starting point for all the factors that go into making a neighborhood like Bayview/Hunters Point. What about employment, gentrification, the tax code, public housing? Those are large scale changes over a long period of time, but I think that’s where the field has to go. We’re just getting started here.

What is a persistent challenge that you see in the field?

Ever since the Reagan administration, a strong political current is that our nation’s collective purpose is to minimize the role of government in every aspect of life. Well, except for the military and sex. That’s made it incredibly difficult to work in a public health department. It’s not just the budget. It’s the ability, as a public agency, to move aggressively in a social or political realm. If public opinion wants to minimize the role of government, how do you do that? Take the idea of regulating sugar-sweetened beverages. It’s not just about fast food and obesity, it’s about the fact that a public agency dares to interfere with people’s lives. Tax and regulate sodas? That’s the nanny state!

Unfortunately, that’s the environment we’re working in. My vision of public health means the field needs to be more aggressive about going into new territory, and it’s not even clear that we have permission to do what we’re doing right now. At least in many people’s minds. The real dilemma is that most factors that really influence health are beyond the purview of health departments. We have to learn to work in other people’s territory, and often, we are not welcome. We have to learn how to deal with that strategically!

Do you have any thoughts on what it will take to address this?

We need to have a strong relationship with the community. We need to work with them as allies in a strategic relationship: they contribute their insights from living in the communities, we contribute data or scientific evidence and public health perspectives. We talk to each other. We weigh in with our respective credibility when major decisions come up. We need partners within the community and other departments who can create the opening for public health participation. Whereas if public health tried to walk in on its own, we might not be welcome.

Regional collaboratives like BARHII are also useful. In BARHII, we used to say: if one health department does it, you’ve established a precedent. We understood local political constraints might mean that Alameda County could do certain things that Solano County or San Mateo County couldn’t do – yet – but eventually, we could leverage the regional precedents to establish a new standard of practice. Our perspective was: Go for it! Take it as far as you can! Let us look in on your work, applaud it, and then use your precedent to help all of us claim legitimacy. For example, Alameda County was one of the first health departments to hire community organizers, but that idea is being embraced in other jurisdictions as well. So regional groupings help move beyond local political constraints. They help all participating health departments think strategically about these structural issues.

BARHII’s influence is not just regional. Other jurisdictions, such as Minnesota and West Virginia, are also embracing health equity, so there is a basis for communication on a national scale. Of course, we had a lot of difficulties, it wasn’t a uniform success. But we wanted to influence the field. Not out of organizational egoism, but the longer we’re outliers, the longer it’s difficult to do the work. If more places engaged in similar work, that established legitimacy to our efforts. It’s like that idea of local health departments establishing precedents within BARHII, but on a national scale. More people doing this work means we can push the field even farther.

Jim Bloyd, MPH

JB 1As an undergraduate at San Francisco State University, Jim discovered public health through a Sociology of Medicine course.  His interest further blossomed as a volunteer in San Francisco General Hospital’s Emergency Room, where he observed that the health problems he witnessed were not rooted in biomedicine, but in social factors like hunger and malnutrition.  He switched career paths from medicine to public health.  Currently with the Cook County Department of Public Health in Chicago, Jim has been heavily involved in Place Matters, a national initiative to address the social, economic and environmental factors that influence health inequities.  Jim’s experiences highlight the challenges and opportunities of working within a local health department, as well as the need to maintain social justice as a central tenet of public health.

Career in Profile:

  • 1988 :  Studied Spanish and Health at San Francisco State University, California
  • 1990:  Studied Behavioral Sciences and Health Education at University of California Los Angeles, School of Public Health
  • 1990-1991: Implemented tobacco use prevention programs in East Los Angeles as a Health Educator for the County Department of Public Health, California
  • 1991-1993:  Worked as a Health Educator at the Lake County Health Department, Illinois
  • 1993- NOW Leads community health improvement planning activities and assists in fulfillment of agency strategic goals as the Regional Health Officer for the Cook County Department of Public Health, Illinois
  • 2007- NOW:  Studying at the University of Illinois at Chicago, School of Public Health as a DrPH Candidate

What is a career highlight for you?

In Chicago, we recently hosted a Place Matters action lab that succeeded in several ways.  Our Place Matters for Health -report in Cook County showed that folks who live in Census tracts where the median household income is $55,000 lived 14 years longer than people who lived where the median income was $12,000 or less.  This underlines the point that the solution is not just to educate people from poorer neighborhoods. There is a whole constellation of living conditions and stresses that follow income lines.  That’s the real issue.

Related to that, in the metropolitan Chicago area, structural racism shows up as patterns of residential segregation. We found that quality of education and educational attainment are stratified by race.  We found that opportunities are also segregated, so that 80-90% of Blacks and Latinos live in low opportunity neighborhoods in metro Chicago.  Public health relates to life expectancy inequities, chronic illness inequities, and we need to work with individuals to increase their collective power.  We need to find ways for individuals and communities to change policies, which will create healthier places for them to live.  Ultimately, we need to wrestle with privilege and segregation and unfair distribution of resources of all kinds.

The report is an example of issues I hold dear, and it was given a very strong vote of approval by our agency’s leadership.  It was a team effort.  There were many people, locally and nationwide, who were working on this national initiative.  It was fun, exciting moment at the end of a lot of hard work.

What’s a challenge that you’ve experienced in your career so far?

Trying to see the work in public health as process. Trying to be patient.  Trying to listen to other people more, and trying to understand that other people are coming from other perspectives, and to feel okay about challenging perspectives that I need to disagree with, and find a way to disagree that is still effective.  I think a challenge is to try and understand my personal responsibility for challenging racism and privilege, especially in the area of race, but in other areas as well.  I may not have played a role creating these systems of privilege, but I can feel good about taking responsibility for challenging and opposing these systems of privilege.

Especially in large, local health departments, it’s a challenge to work in a bureaucracy. You may have more resources, but I can’t say that we’re as flexible, or that we operate as quickly, as I would like.  However, many community leaders and residents welcome discussions on the social determinants and injustices as a way to explain their daily experiences.  They want to know what we, as a health department, can offer them beyond behavior change trainings and education.  Folks have setbacks in their careers, but I’m learning to say, “OK, this is just one day or one battle.  Or maybe there’s a battle I choose not to fight, and I’m gonna choose to work on this.   I’m learning to avoid burnout by not spreading myself to thin.”  This is a time of diminishing resources, so it’s a challenge to keep that perspective in order to keep being effective, keep generating resources for social justice and public health.

When it comes to public health what matters to you and why?

It’s important to make social justice more apparent in the work that we do, and it’s always a challenge.  When it comes to the big picture, health inequities are the most important part of public health.  I try to take an explicitly anti-racist, community engagement, social determinants approach to addressing health inequities.

What is a persistent public health problem that concerns you?

On a practical level, I’m concerned with cutbacks to public health infrastructure, staff and budgets.  It hampers our ability to do our job and to inform the public about the data we collect.  It’s even a challenge to inform the public about health inequities!  Despite the fact that the U.S. ranks among the wealthiest countries in the world, our political priorities mean that that public health is not highly valued.  Building a public constituency is challenging.  People fought for the creation of local health departments, and the public health workforce should not be afraid to take on the politics of informing folks. We don’t have a profit motive, we are accountable to the taxpayers, and I think that’s a very valuable thing.

If we don’t exist … people are paying for that now!  You see it in the widening inequities, premature deaths, chronic diseases, and this is especially true for people of color and low income folks.  We’re still approaching epidemiology through a biomedical risk factor lens.  We need to be evidence- or science-based, which requires a theory of change that can be tested and researched.  For those of us in the practice world, we need to reflect on our theories of change.  Nancy Krieger’s Epidemiology and the Peoples’ Health outlines non-biomedical risk factor-oriented theories.  These theories should guide our work.  Rudolph Virchow recommended that people need freedom from homelessness, illness and poverty.  Awareness of theories can – and should – affect our practice.  It challenges us to question our status quo positions, like our focus on individual behavior change that tends to blame the victim. This puts us in difficult positions, and I think that’s why people don’t think too hard about these alternatives.

What’s your ideal solution to this public health problem?

We have a lot to learn from community organizing and political analysis to understand power.  Who has power and who does not?  I would hire community organizers to challenge unequal or balancing relationships of power, which is called for by the World Health Organization.  A successful community organizer challenges the status quo.

At a practical level, community-based organizations like the Restaurant Opportunity Center (ROC) build power among marginalized people, low-wage earners and communities of color. They address racism and unearned white privilege. We need to build strong relationships with the ROCs and other labor-organizing efforts.  Local health departments can – and are – getting involved with foreclosure and anti-eviction movements, big box retail store and labor, even the 99% movement, equity, and Wall Street.  Public health can make connections to movements that move us towards social justice.  Social justice will lead to health equity, which allows everyone’s health potential to be fully realized.

Reflective: Looking Back On Volumes 4-6

Every four months we pause from conversations with public health leaders to reflect on lessons learned from their varied careers, and insights into persistent and emerging public health challenges.

We are Public Health has been honored to feature conversations with several groundbreaking, widely respected pioneers in the field.  The last three volumes highlighted Dr. Len Syme, father of social epidemiology, and Dr. Jack Geiger, a pioneer of the community health center movement in the US.  As Dr. Geiger acknowledged in his interview, “we all stand on the shoulders of others.”  The ripple effect of their unique contributions to our field is evident in the work of other featured practitioners such as Jim Bloyd, Dr. Sandra Witt and Dr. Bob Prentice, who are all working to operationalize Dr. Syme’s and others’ social determinants of health framework in communities and within government institutions.  Similarly, we see Dr. Geiger’s strategy of engaging, organizing and empowering community members to create their own solutions and successfully address public health challenges reflected in Emma Rodgers’ coalition-driven work in the Bronx, Laura Sanders’ advocacy for immigrants’ rights in Southeastern Michigan, Arnell Hinkle’s efforts to create youth-led and culturally appropriate nutrition and physical activity resources, Dr. Joe Zanoni’s work to improve the health and safety of immigrant day laborers, and finally in Dr. Joseph West’s community research on diabetes in Chicago’s North Lawndale network.

Drs. Syme and Geiger’s legacies extend beyond these amazing public health workers who continue to “stand on their shoulders”.  Their impact is also evident in current public health work and policies. These days, it is rare for public health students to graduate from any school of public health without a working knowledge of the social determinants of health. In the field, the determinants are widely considered just as critical to supporting and improving the health of communities and reducing health inequities as the delivery of clinical services. Additionally, community health centers are rapidly becoming the go-to places for many Americans to seek health care and community resources.  In the age of the Affordable Care Act, also known as Obamacare, these centers play a central role as the medical homes of low-income residents across the nation, and a growing number are finding creative ways to integrate the social determinants into primary care.

When we started this website we hoped that we would be able to feature public health’s well respected and renown pioneers. We are delighted to also see the connections between their groundbreaking work, and the current efforts of a diverse set of public health practitioners.  It is truly inspiring to witness the evolution of their audacious visions.

We are so excited about where the next three volumes will take us!  We look forward to reflecting on more trends in these public health histories.

Len Syme, PhD

Len Syme, PhDDr. S. Leonard Syme has been pioneering research on the social determinants of health since the 1950s.  He is regarded as the “father of social epidemiology” for both his ground-breaking work and his mentorship of numerous leaders in the field, including Sir Michael Marmot, Dr. Lisa Berkman, and Dr. Nancy Krieger.  His body of work has focused on child health, job stress, social support, poverty, and social inequities on health.  He joined the faculty at the UC Berkeley School of Public Health in 1968, where he is now an Emeritus Professor and Co-Director of the Health Research for Action Center.  Dr. Syme was elected into the Institute of Medicine and has won numerous awards, including the Lilienfeld Award for Excellence in Teaching by the American Public Health Association and the JD Bruce Award for Distinguished Contributions in Preventive Medicine from the American College of Physicians.  His pioneering work on the social determinants of health, and his commitment to translating this research into successful interventions, make him a clear choice to profile as a public health hero.

Career in Profile:

  • 1953: Completed BA in Anthropology and Sociology from UCLA
  • 1955: Completed MA in Sociology from UCLA
  • 1957: Completed PhD in Medical Sociology from Yale
  • 1957 – 1960: Sociologist, Heart Disease Control Program, US Public Health Service
  • 1960 – 1962: Executive Secretary, Human Ecology Study Section, NIH
  • 1962 – 1965: Sociologist and Assistant Chief, Field and Training Station, Heart Disease Control Program, US Public Health Service in San Francisco
  • 1966 – 1968: Chief, Field and Training Station, Heart Disease Control Program, US Public Health Service in San Francisco
  • 1968 – 1993: Professor of Epidemiology, UC Berkeley School of Public Health
  • 1975 – 1980: Chairman, Department of Biomedical and Environmental Health Sciences, UC  Berkeley School of Public Health
  • 1993 – Present: Professor of Epidemiology and Community Health (Emeritus) and Professor in the Graduate School of Public Health, UC Berkeley

 

You are often called “the father of social epidemiology.” How did you get into this work?

In graduate school, I came across Emile Durkheim’s work on suicide.  He observed that the causes of suicide are thought to reside within individuals, but certain groups have consistently high or low rates of suicide.  If individuals come and go in a community, then why do group rates stay high or stay low?  He proposed that there must be something in the community that increases the rate of suicide, even though it doesn’t predict which individuals will succumb.  I said, Whoa.  It’s like the symphony orchestra.  You can study the violin or the trumpet or the drums to become an expert on the individual instruments, but that won’t help you understand symphonic music.  That’s when I began to get into community stuff.

My early work focused on social class as a determinant of health.  Michael Marmot’s work with the British Civil Servants was the breakthrough.  The Civil Service is divided into different Steps (with higher pay grades associated with more prestigious steps), which means you’ve got a cross-section of socioeconomic strata right within the Civil Service.  Marmot’s initial research focused on heart disease, and he showed that the Ministers at the very top of the Civil Service hierarchy at Step 1 have half the rate of heart disease as those who in Step 2 – Professionals and Executives – doctors and lawyers – just one level down.  This gradient existed throughout the Civil Service.  The lower the Step, the higher the rate of heart disease!  But the higher rates are not just among people at the bottom.  They exist from top to bottom.

When I was with Marmot in London, we decided to look at all diseases.  It turns out this gradient exists for all diseases in the Civil Service.  When I got back to Berkeley we reviewed the world literature, and we found that the gradient exists for all diseases, in every industrialized country.  We controlled for blood pressure and cholesterol, smoking and physical activity, but there’s still a three-fold difference.  If you don’t control for social class, it overwhelms everything.  So we control for social class so that we can study other things, but that means that the elephant in the room – the most important determinant of health – sits bright and unexamined.

So then let’s just get rid of social class and everything will be fine!  That’s not going to happen tomorrow.  In fact, there’s evidence that it’s impossible to get rid of social class.  In the 1930s the Israeli kibbutz tried to eliminate social class, but that failed.  We have evidence that social class divisions begin in nursery school.  But what is it about social class that really matters?  Is it low income or low education?  Is it poor medical care, poor housing, poor jobs?  It’s a whole list of things associated with low social class, and they’re so hopelessly intertwined that you can’t tease them apart.  Many of us – Marmot and others – hypothesize that the most important factor is whether or not you have control over your destiny.  We now know there are biological changes in immune function when people have less control.

Health Research for Action is devoted to helping people have more control over their lives.  We have guides for new mothers, we have guides to help older people avoid falls, we have a guide for disability.  None of these guides deal directly with diseases or risk factors, but they do help people deal with the problems that they face in their daily life.  Our theory is that when people have more ability to influence the events in their life, better health will follow.  So that’s what the center is about.  Our evaluations show that people keep the guides and refer to them, they share them with their friends, and they’ve changed the way they think about life.  But you can’t show a change in health because we’re talking about a change in immune functioning, so we’re talking long-term.  This is not the type of work we do in public health.  It’s very hard to get outcomes information, and it’s very hard to get a grant that is not focused on one disease or another.

Translating research to practice is really, really hard.  First of all, we “authorities” always pick the wrong topic to focus on, because we never pick the topics that people care about.  We rarely think about health literacy.  Almost all of our interventions have failed.  We’ve done two things well.  Smoking rates have declined, and seat belts have saved lives.  Most of those successes are due to changes in laws and policies, tobacco price increases, and limitations on where you can smoke and how you can drive.  Rarely has our brilliant statistical work on risk factors translated into successful interventions by itself.

What’s been a challenge in your career?

A major flaw in our field is our focus on diseases.  We’re really talking about psychosocial risk factors and compromised immune functioning, and while these don’t cause one disease, they increase the risk of all diseases.  Once you pick a disease, you’ve lost the power of the approach.  But where would you send a grant to study discrimination diseases?  Or hopelessness diseases?  We don’t have a way to do that, because all the money is focused on clinical outcomes and risk factors.

Awhile ago, the CDC offered a grant to study kids in fifth grade.  The CDC was interested in violence, smoking or drugs, inappropriate sexual behavior, school performance, things like that.  We submitted a proposal to study “hope.”  Our prior work with fifth graders in Richmond, CA – a very poor community – showed that many of them didn’t think they would live beyond the age of 20.  If you don’t think you have a future, smoking and drugs and school performance don’t matter that much.  So we wanted to see if we could help these fifth graders achieve a goal they’d set for themselves.  We thought improvements in smoking and violence would follow from that.   I’m really amazed, but the CDC made ours the #1 rated grant in their program.  So that was very nice.  We did that for 3 years, and we really did a good job.

We used Photo Voice, where we gave out cameras and asked the students to take pictures of the things they cared about, and that started the conversation.  For example, one group was embarrassed by graffiti in their school.  We worked with them on removing the graffiti, because you don’t just go out and buy paint brushes and cover the graffiti, you have to get permission from the principal and the school board, you have to get money for paint brushes, it’s a whole thing.  That was just one group.  We had a lot of groups, and they all had their own thing.  At the end of 3 years, we talked to the students and it was clear their lives had changed.  I’d like to follow them and find out what difference it made, but where do I get money?  The CDC did “hope” once, but what foundation is interested in hope?  It’s one of the most fundamental risk factors, but it isn’t diabetes or obesity, so it’s very hard to get money.  I’m sitting out here in the wilderness concerned about things like hope, and my field is not with me.

What has been a career success for you?

The students that I’ve worked with.  I do medium research.  I do medium teaching.  But I’m really fortunate to mentor a group of the world’s best people, like Michael Marmot, Lisa Berkman, Nancy Krieger, George Kaplan.  They’re just a group of outstanding students who are now leaders in the field.  Everybody attributes their success to me and that’s just not true.  They’re all fabulous people, and I was just fortunate enough to be involved in their work.

The fact that Michael Marmot is knighted is a reflection of the fact that his work with the British Civil Servants has changed everything!  He’s now the most famous public health person in the world, and he’s changing the agenda everywhere.  Or the work of Lisa Berkman – these people are changing everything.  And I just get to sit back and watch.

What’s a persistent public health problem that you see?

Inequalities in health.  Inequalities are not just devastating to the people involved, they’re devastating to the entire country and society.  It’s also a toxic issue for all of us.  When some of us don’t thrive, none of us thrive.  That keeps me up at night.  When 1% of society has 50% or 60% of resources, this is not a good society.  We really need to pay attention to income inequality.  If you think you can get away with being the winner and not caring about other people … you’ve seen our statistics! The U.S. has a fancy, expensive medical care system but we still rank 37th or 38th in the world.  We’re behind Slovenia!  We need to study all levels of social class, because all of us still have higher rates of obesity and diabetes than other countries.  We need to refocus to wellness.  We’ve got to get our country back.  It’s not a question of being nice to poor people.  It’s good for all of us.  Being on a losing team is not good for any of us.

What is your ideal solution to this problem?

I would study kids, from birth to age five.  What happens in the early years doesn’t necessarily track into adulthood – you’re not necessarily doomed – but birth to five is tremendously influential.  By studying kids, you would discover the important early life risk factors.  You’d also have a fighting chance with your interventions, because parents care about kids!  The problem with studying children is that they don’t have enough disease.  But we now have a whole slew of biological markers that measure adult immune function – like interleukin – and I’d try to understand if those are appropriate markers in young people.  Or I’d look for a series of new biological markers that show up in early childhood.  They wouldn’t be diseases, but they would be things that lead to diseases.  I’d investigate what really matters to children, so that we can intervene early in life.

Reflective: Looking Back On Volumes 1-3

Every four months we pause from interviews with public health leaders and true heroes to reflect on lessons learned from their varied careers, and insights into persistent and emerging public health challenges.

Our first set of interviews included late career reflections from pioneers who expanded the field, including Dr. Len Syme, the “father of social epidemiology” (later referred to as the social determinants), and Dr. Quentin Young, activist physician, who pushed for the field of health to embrace the principles of social justice and human rights.  Other interviewees shed light on the critical importance of community partnerships and grass-roots efforts, in order to improve the conditions in which communities live, work, pray, and play.  Dr. Renee Canady integrates health equity into her leadership role for the Ingham County Department of Public Health; In her career, Susan Avila brought deep commitment to her role as public health nurse in inner-city Chicago; Angela Reyes addresses youth violence and other issues affecting Latinos in Detroit; and Causandra Gaines has worked in partnership with other community leaders and residents to improve the health of Detroit residents.  Finally, a trio of public health leaders mused on the importance of institutional, state, and national policies and priorities in improving the public’s health and reducing and eventually eliminating health inequities.  These include Dr. Linda Murray, Chief Medical Officer of the Cook County Department of Public Health; Dr. Georges Benjamin, Director of the American Public Health Association; and Dr. Anthony Iton, Senior Vice President of Health Communities at the California Endowment.

A common theme across all interviews is the need to address the root causes of health inequities that affect marginalized populations throughout the US.  Poverty, violence, racism, segregation, oppression, a lack of hope and power all negatively affect the health of communities.  So does outright disenfranchisement, whether it occurs along social, political, or economic lines.  Current political debates attempt to police marginalized groups.  They do this by denying them pathways to citizenship, a living wage, quality educational opportunities, social safety nets, equal marriage, among others.  However, as our public health heroes point out, often it is community members, and not necessarily policy makers, who are intimately familiar with both the issues and the potential solutions.  As such, we need to create a way for the community to participate in the decision-making process surrounding the policies that affect their communities.  Furthermore, our heroes highlighted the need for action at the community, state, and national levels.  To do so requires the political will do live in a more just society.

The issues highlighted in this volume – poverty, violence, racism, segregation, oppression – are not new issues for the field of public health.  While the face of the forces that have created, perpetuated, and re-perpetuated these inequities may have evolved over time, these root causes remain.  And while the nature of the problems may have evolved over time – from the explosion of HIV/AIDS in the 1990s to chronic disease epidemic of the 2000s, the populations most severely affected by these public health problems remain the same.  The health problems may have shifted, but the structural processes affecting health remain largely unchanged.  Despite this, we find reason for optimism in innovative, creative, passionate collaborations currently underway at the community and state level, and applaud these heroes for their persistence and conviction in the face of so many obstacles.

Given the forces working to undermine our public health, how do we, in Dr. Iton’s words, counterbalance strong political and economic forces that overshadow the needs of disenfranchised groups? How can we ‘organize people and marshall their collective power, within these democratic processes, to advocate for a different set of priorities and a different approach to sharing these resources”?

We invite you into a discussion in the comments.  Please also like our Facebook Page and follow us on Twitter as we continue this conversation.  Stay tuned next month for a next volume of We are Public Health!