Joe Zanoni, PhD

imageFolio_jz_final - for websiteDr. Joe Zanoni, like many others, considers himself an accidental public health practitioner.  He started his career as an early childhood/special education teacher in the 1980s.  After he was laid off he returned to school, and entered a labor relations program in hopes that it would prepare him to provide training and education for businesses.  This led him to work with labor unions, which in turn prepared him to work with various populations, from teaching health care workers about blood protections at dawn of the HIV/AIDS crisis, to his current focus on the safety and health of immigrant day laborers.  Dr. Zanoni has drawn upon these experiences and the educational philosophy of Paolo Frèire and others, to promote the importance of peer-led education.  He is particularly proud of his research with workers’ centers.  This work has shown how empowering immigrant workers – whose voices are often unheard and whose labor is markedly unregulated – can reduce their rates of death and injury on the job.  We are pleased to profile Dr. Zanoni as one of our public health heroes.

Career in Profile:

  • 1980: Completed his Bachelors of Science in Education, Disabilities at the University of Wisconsin
  • 1980 – 1983: Special Education Teacher at the Madison Metropolitan School District, Madison, WI
  • 1984 – 1986: Infant Care Provider at the Kunkle Center, University of Wisconsin-Milwaukee
  • 1986: Completed his Master of Industrial and Labor Relations at the University of Wisconsin
  • 1987 – 1991: Research and Legislative Coordinator, Service Employees International Union, Local 150, Milwaukee, WI
  • 1991 – 1997: International Senior Representative for Health and Safety, Service Employees International Union (SEIU) in Chicago
  • 1998: Program Manager, Great Lakes Center for Occupational and Environmental Safety and Health, University of Illinois at Chicago, School of Public Health, Chicago, IL
  • 1998 – 2010: Associate Director of Continuing Education and Outreach, Illinois Occupational and Environmental Education and Research Center (IOEERC), University of Illinois at Chicago, School of Public Health, Chicago, IL
  • 2007 – 2010: Instructor at the Division of Environmental and Occupational Health Sciences (EOHS), SPH-UIC
  • 2010 – Completed his PhD in Education: Curriculum Studies at the University of Illinois at Chicago
  • 2010 – NOW: Research Assistant Professor, EOHS, University of Illinois at Chicago, School of Public Health
  • 2011 – NOW: Director of Continuing Education and Outreach at the IOEERC, preparing masters and doctoral graduates to serve as occupational and environmental health professionals in the areas of industrial hygiene, nursing, medicine, safety and epidemiology

Can you tell us about a career highlight?

I’m really proud of the work that I’m doing with workers’ centers because there are so many things that are part of it. I’m most proud of my dissertation, and also the Charla work.  Charla means “to converse, talk or chat” in Spanish.  It’s a social learning process.  I worked on a pilot study through the University of Illinois School of Public Health, where I learned about workers centers.  These centers are community-based groups, and this brought our focus from unions to immigrant groups.  We went to workers’ centers in Chicago and asked, “How do you like to learn?”  Instead of offering them training, we wanted to know, “How can this be part of what you are doing?”

They said, “We don’t really want to come to a training session, we don’t want to be lectured at, we’d like to learn in some kind of informal chat…like a charla!”  “What would that be like?” “Like sitting around doing different things, and then all of sudden we start talking about something.”

I thought “Wow, why don’t we delve into this?”  So I worked with three different workers’ centers to create a team of people that set up Charlas that invite people to talk about health and safety on the job.  The twist is that we’d do it in a communal setting.  I found a Spanish-speaking, culturally relevant colleague and trained him to facilitate three sessions at each workers’ center.

We’ve since continued this work with another research project. We trained peer educators to lead trainings at worker centers.  We had to have authorized trainers in the room, but they co-lead with the peer educators in a small group workshop format.  We have lots of workers employed in these types of jobs, where many immigrant workers die on the job for a variety of different reasons.

We started in Chicago, and when we heard about other Midwest workers centers we created a train-the-trainer program.  In our third year, we expanded to the Southwest.  We’ve also performed assessments to see how we were doing.  We want to know, “What did they learn?  What is the social context of the training? How are the workers’ centers and the peer relationships? How did they develop and how can they extend practices in the job to protect them?”  That work has been very satisfying.

What’s a career challenge that you’ve faced?

The funding aspect is always a challenge.  How do you sustain an effort? We can create a good idea or a great intervention, but especially if you work with community partners how do we keep it going?

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

The glaring inequities in the U.S.!  So often we are told that we are the richest and smartest country in the world.  We are the top!  We’re the model for the rest of the world!  That’s not necessarily true.  Those of us in occupational health go crazy over the debate about jobs … because it’s not just jobs!  What kind of job are we talking about?  What’s the quality of the job?  What’s the health of the people in their job?  All of that links together.  Yes, some people are healthy but other people are not.  How did we get that way, and what do we need to address in society to fix it?

What is a persistent public health problem that concerns you?

Injury, illness and death on the job.  Overall, if you look at the statistics of death on the job, the trend is decreasing.  But that trend is not true for all subgroups.  For example, Latino immigrants have a much higher “death on the job rate” than white males.  Why is that? It’s the kind of work that they are doing.

It’s almost like we are coming back around to what Jane Addams and her colleagues at Hull House worked on.  We need to improve workplace conditions for specific groups of people who are on the margins, or those who are trying to integrate into society and don’t get enough support.  Liberty Mutual estimates that we lose $50 billion a year due to injury, illness and death on the job.  It’s important to look at where work happens, who knows about it, and who can create the structure and support.  A lot of effort went into creating OSHA but that’s for traditional work places. What about other work places?  What about day laborers, construction, family businesses?  We should place greater effort into addressing and enforcing non-traditional work.

What’s your ideal solution to this problem?

We should support the education of community health workers and peer educators. What kind of curriculum do they want?  There are some groups doing incredible grass roots work with communities to determine what those communities want and need. They collaborate to develop training and curricula that meets people where they are. How can we support workers to learn and share with each other, and put more energy into their organizations? How can public health teach them how to work in collaborative ways? How can we teach them to teach each other about being healthy and safe, and how can that expand and make their work more secure?  We have very vulnerable workers who are day laborers, or people that have just come in the country trying to find work, they are trying to survive.  We need to explore these issues in public health, and we should do it through workers’ centers, community health workers and peer communities. All these people need to be encouraged and supported.

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.