Alaska Health Policy Review

Dear Reader:

A swirling collage of memories. Maybe two dozen public health activists jammed into a small, hot hotel room early in the morning in the 1980s at an annual meeting of the American Public Health Association. The inescapable smell of cups of steaming coffee everywhere, and donuts and croissants precariously perched on laps and binders. Chaos, as half a dozen small informal groups earnestly discussed what draft resolutions were going to have a public hearing, and where and what needed to be said at the hearings.

Every now and then some guy with a loud voice would try to impose order and figure out who was going where to say what. Only a few listened. Most kept talking. At other times it was a woman's commanding voice that instantly thrust cathedral-like silence to the packed room. It was a forceful, intimidating voice espousing a well-conceived analysis or an effective strategy about how to proceed. It was the voice of Dr. Linda Rae Murray, this week's AHPR interviewee.

I don't remember how it started, but I think it predated me. In those days APHA was a conservative professional association but many of us in public health wanted it to be more than that. We wanted an organization that aggressively confronted the important public health issues even if they were not "safe" issues, even if they were controversial, even if they required public health actions outside our ivory towers and gray cubicles.

A few of us started meeting in a hotel room. The next year, there were a few more. By word of mouth each year there we would gain a few. The informal group never grew in size beyond what could be held in a large hotel room, but we probably influenced APHA policy to an extent greater than our small numbers implied. And of course, we were not alone.

In 1986, for example, when APHA held its annual meeting in Las Vegas, Nevada, a few activists were passing out leaflets at the front door of the main hotel urging participants to assemble a couple of days later to take buses out to a federal nuclear reservation to protest a scheduled underground nuclear weapons test. After all, nuclear weapons manufacturing and use are public health threats of a high order.

I figured the same 50 or 60 lefty activists that usually came to the annual convention would trudge out to the bus and hold a quiet vigil at the weapons testing site. I, of course, had to be one of them. When I went out to find the bus, however, I was astounded to find hundreds of conference attendees milling about, waiting for the extra buses to take them all to the site.

Once at the site, we got out of the buses and stepped into a vast desert area with sandy rolling hills, barbed wire in front of us, and a guarded entrance to the nuclear testing site. There were lots of heavily armed men at the entrance and in the surrounding hills. I was quite surprised to bump into Dr. Rodman Wilson, director of the Department of Health and Environmental Protection for the Municipality of Anchorage of Alaska under then mayor Tony Knowles. I did not realize we had these beliefs in common.

We struck up a spirited conversation, got in the line with hundreds of our colleagues, and slowly walked toward the entrance to the site. I was so busy talking with Dr. Wilson I was not really paying attention to the voice that said, "Please hold out your hands." Suddenly I found myself handcuffed to my colleague. We were hustled off to military buses parked in the desert to await our fate.

We continued chatting, and after a couple of hours we were all released, escorted off the site, and boarded our buses back to the convention. I asked Dr. Wilson what he thought the mayor was going to do with a department director who had been detained and might be charged with unlawful invasion of a federal nuclear reservation. He said he thought Tony "wouldn't mind."

"I hope not," I thought, "because we're just doing our job."

Lawrence D. Weiss PhD, MS

Editor, AHPR

ldweiss@acpp.info

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APHA President: Public Health is Social Justice

For over forty years Linda Rae Murray, MD, MPH, has been a voice for social justice and health care as a basic human right. Dr. Murray is president of the American Public Health Association and chief medical officer for the Cook County Department of Public Health of the Cook County Health & Hospital System among numerous other activities. Dr. Murray also holds leadership roles in other health and social justice organizations including NACCHO's (National Association of City & County Health Officers) Health Equity & Social Justice Team and the board of the Chicago-based Health and Medicine Policy Research Group. Dr. Murray was a keynote speaker at the recent Alaska Public Health Summit, where she presented a thought-provoking talk about how the economy, the educational system, and social equity are important public health issues facing the nation. Below is a transcript of a portion of that talk, recorded on January 17, 2011.

Links to selected topics

Unemployment is a Public Health Problem
Public Health Impact of Foreclosures
The Connection Between Education and Health
Health Care is a Basic Human Right
A Nation in Crisis
Retreat into "Giving Advice"
Public Health Requires Work Across Silos

Unemployment is a Public Health Problem

We know that the health of our people is determined by how we organize our resources, how we set up society, how well we educate people, what our economy looks like, how we address the status of women, how we deal with the problems of racism. We know that there's a complicated interplay between focusing on individuals and understanding a population's health.

The best days of my week are spent when I'm in the exam room one-on-one with patients. Now I know that's not the best use of my time. That is to say, I have more impact on people's health on some other things I do on other days. But the most fun for me is when I'm actually working with individual patients. And the health of those individuals is influenced by what happens -- what these social conditions are, what the public health programs are, what the preventative programs are -- that we work on. They are interconnected. You can't really have one without the other. And in public health we have to rediscover our connection with the important stuff.

"The first fundamental thing that we need in a country like ours is for people to have safe, secure, well-paid -- don't be afraid to say it -- jobs with dignity, jobs that allow people to take care of themselves and their family."

We have to not be afraid to say openly what we know to be true. So we know that our country today is not as healthy as it was five years ago. How do we know this? The unemployment rate is up. The first fundamental thing that we need in a country like ours is for people to have safe, secure, well-paid -- don't be afraid to say it -- jobs with dignity, jobs that allow people to take care of themselves and their family. And to make sure that their children have a future. And to make sure that they have enough money to even rest and have a vacation. This is a basic part of what we need to be healthy.

We live in a nation where the Gini-coefficient, one of those many economic measures that they use to look at income and equality, has been growing. And the reality is the gap between rich and poor in the United States, which had narrowed after World War II and through the 60s and 70s, has begun to widen since the 1980s and is back where we were in 1920 right before the Great Depression. This is a public health problem.

Now we can have disagreements on how to solve this problem. I'm assuming this room, like most rooms, contains people with a whole variety, a whole breadth, of political ideas and ideologies. I'm not, at the moment, arguing about that. I'll be glad to argue at any time about that but I'm not trying to do that right this second. What I'm suggesting is we can disagree on how we should grow or how we might decrease unemployment or how we might make the country economically healthy. We can disagree on that. But one thing I would argue that we can not disagree on as public health people is the fact that we have these big gaps and that they are getting worse is an unhealthy thing. It's not good for the nation.

Public Health Impact of Foreclosures

We are still going through a foreclosure crisis in the country. And as usual, we allow our discussion around this foreclosure crisis to be superficial, to be mandated by the 30-second clips on the evening news. But housing, and especially in a state like this, land, the ability to have a piece of land that is yours has been considered the American dream for many decades. A hundred years ago it wasn't the American reality. A hundred years ago most Americans didn't own their own home. Unless you owned some land that you farmed, most Americans didn't own land. As a matter of fact, mortgages in 1910 were nonexistent. They were unheard of. You couldn't go to the bank and get a mortgage to buy a home. I don't care what your financial status was. If you were going to own a home in one of our cities, you went to the bank or to the person who owned the home with cash. Mortgages didn't exist. You paid cash, which is why so few people owned a home.

And there was federal legislation that really created and made it possible for people to get mortgages. They were amendments to the Homestead Act, which you remember, were federal acts that made it possible for people to expand west and own land, subsidized by the federal government. And there were amendments to those laws that made it possible for people to get mortgages, some people to get mortgages. Blacks, for instance, were explicitly allowed not to get mortgages. In fact, you weren't even allowed to give a mortgage in a community if it meant Blacks and Whites were going to live near each other. This is the kind of history that as public health people we need to remind ourselves of and explain to folks.

"How many of our local and state health departments, as this crisis grew, put out reports that talked about the public health impact of foreclosures, because there is one? Very few. Some, but very few."

So when we look at neighborhoods in Cleveland, Ohio, for example, where the foreclosure rate might be 10 or 15 percent in certain parts of the city. What does it mean to have 10 percent or 15 percent of the houses in the three or four blocks around your house to be empty and abandoned? What does that do for the community? Does that make your kids safer? Does it help the local school? Is it likely you will be able to sell your house should you have to?

When we remember the history of how it is we got homes, why it is we have a structure that allowed working people, ordinary people, to obtain a mortgage and have a home, the biggest source of wealth for Americans still today, the solutions to our foreclosure crisis might look different. How many of our local and state health departments, as this crisis grew, put out reports that talked about the public health impact of foreclosures, because there is one? Very few. Some, but very few.

The Connection Between Education and Health

We live in a country that promises people that if you work hard you will succeed. And yet all across the country we fail our kids every day in school. We don't teach them how to read. We've don't give them a safe place to go to school. We don't even keep the roof from leaking in many of our schools. In fact, too many of our children, we explicitly expect not to learn how to read.

Several decades ago, and I'm afraid this hasn't changed, one of my nephews was in the first grade and my sister went up for a parent-teacher conference. And the teacher, as they always are, "Oh, your kid is just wonderful!" On parent-teacher day, you think every kid is great, right? "Your kid is wonderful. He's doing great and pretty soon we think he's going to be ready to learn how to read." Except Eric was already reading at a third grade level. And when I asked him, "How come your teacher doesn't know you can read?" He said, "Don't tell her; don't tell her!" Because he had figured out that she thought he was going to be ready to learn how to read and he adjusted his performance to meet her expectations.

"In the United States of America, people who build ... decide how many prison cells to build based on how many third graders can read. The more third-graders that can't read, the more prison cells they build."

So when we expect nothing from our kids, that's what we get. A nation that built a public education system to provide educated workers for the industrial powers in our country, and now we are telling our kids that's no longer available. You have to go on hot to finish high school. You have to really go on hot to finish college. What do you think is happening now with all the children in college whose parents have been laid off, lost their houses? We are destroying the basic future of the nation.

You know, as a public health expert, what happens when kids can't read or when people are less educated. And honestly, it doesn't matter whether you have a high school diploma or a college degree if you are still less educated than our generation. What happens to their health? What happens to their lifestyle characteristics? What happens to their understanding of how to stay healthy? We know what happens. When your local area cuts the education budget, where are the public health experts saying, "Stop! This is a danger to the health of the public."

What are we doing about our food systems, about climate change? All of these issues that we know are connected to how healthy people are. We remain silent as a public health community. We're the experts. We know what's going on. We understand the impact. We can scientifically say, "Show me a kid that can't read in the third grade, and I'll show you somebody with diabetes, or high blood pressure, or somebody that's gonna die at 20 years old." Why are we afraid to say what we know? Why are we afraid to use our knowledge? In the United States of America, people who build prisons understand this connection, and they decide how many prison cells to build based on how many third graders can read. The more third-graders that can't read, the more prison cells they build.

Health Care is a Basic Human Right

I don't have enough time [even] if we were here for all three days talking about medical care to intelligently discuss that. Let me tell you just some basic stuff. I believe that health care, including medical care, is a basic human right. And while it's not my purpose this morning to debate what kind of health care reform we should have, I will let you know up front, because I don't believe in being secretive, I personally support a single-payer. But I don't want to discuss those details at this point. In this country, the number of people without medical insurance is [rising (?)]. And the number of people who get their medical insurance through their job has been falling steadily for the past 15 years.

"Let me tell you just some basic stuff. I believe that health care, including medical care, is a basic human right."

While I do not want to see the Affordable Care Act repealed, while I know it contains many provisions that will help certain portions of our population -- if it is adequately funded -- I also know it will not solve the problems that we have in this country with medical care. I am insulted personally and enraged as a public health person that my government accepts the notion that if you're an immigrant to this country, even if you're here without documents -- we hire you in our homes and businesses, those immigrants pay taxes, they enrich our nation -- and we refuse to give them basic medical coverage, a basic human right. This is something that all Americans should be embarrassed about.

A Nation in Crisis

So where are we then? In one of the richest countries of the [world] with resources that most people would die to have. [This is a] diverse, important nation [with] strong histories of people that can solve any problem. How do we end up paralyzed, moving backwards? That's really what I'm trying to tell you this morning. Forget about what direction we should be going forward in, or how fast. The health of our nation has been moving backwards. The number of our children with obesity has been rising, [as has] the number of us with obesity. The educational levels have been stagnant or going down. My grandchildren's generation may be the first generation that live shorter lives than their parents. By any public health measure, we are a nation in crisis. Not moving forward. Oh yes, if we looked at small little measurable things, I don't want to belittle what we do, but moving backwards. How did we get here?

Now, I'm going to come to the really political part. That other stuff, I really think that other stuff is just facts, just the nature of public health. But this is really political and so you don't have to agree with me. I think what has happened in our country is that an ideology -- now, you know, I'm not a social scientist, you'll have to excuse me, but social scientists call it a Neoliberal ideology. It's confusing because it has nothing to do with what we normally think of as liberal. But leave that alone. An ideology, I think when I describe it you will agree with me, that it's growing in our country. I don't want to call it right wing because I don't like those dichotomous terms, but it's an ideology that questions the use of collective action, that raises individual action and individualism almost to the level of religion, an ideology that argues in its extreme that government is useless and collective action is futile.

"Public health people believe that it's just not right that your life expectancy is determined by the class of your parents. ... What you did in life, how long you live, shouldn't be determined on the day you are born. It shouldn't be determined today by where you work or how much money you make."

If you have that ideology, then it follows logically that public health which, after all, is collective action for people's health, is useless. What we need from you -- everyone in this room -- is leadership. Public health has always been about social justice. Social justice argues that collectively, through our planned collective action, we can change things that are wrong. We can make things right. I think that that notion is really what has driven American history. Not this other notion that government is useless.

That doesn't mean government's always right, but those are two very different notions. The notion that we can collectively make things right, I think is what is really woven through the soul of this country -- and certainly that has been the case. From 1850 to 1950 the United States public health activity doubled life expectancy. We fought for sanitation systems, sewage systems, clean water. We fought to eliminate slums. We fought for the health and safety of workers. This is part and parcel of our history as a field.

Public health people believe that it's just not right that your life expectancy is determined by the class of your parents. That's what the American Revolution was about. What you did in life, how long you live, shouldn't be determined on the day you are born. It shouldn't be determined today by where you work or how much money you make. It's never been right that the mortality rates for Alaska Natives are 1 ½ [times] that of White Alaskans or that the suicide rate is 3.6 times greater, or that the infant mortality for Alaska Natives remain twice that of [Whites (?)]. That's just not right -- that your health is determined by the color of your skin or your gender.

These three factors: class -- [jokingly] and I know we're all middle class -- class, race, and gender. In our society, at this moment in our history, are still the major determinants of how resources are distributed, what opportunities people get, and yes, what health people are able to achieve. I would suggest to you that public health retreated from what we know is right. We retreated from our core mission -- to safer areas. It's easy to do when you work for government especially. So we started keeping vital records. We set up communicable disease surveillance, worried about laboratory services -- which now have almost disappeared in state departments at least -- and we struggle with environmental standards and clean water. And we still give categorical medical care; maternal/child care, STDs, tuberculosis.

Retreat into "Giving Advice"

Public health has a long history of doing a lot of stuff with a little bit of money. And generally speaking we feel like victims. We complain that the doctors get all the money, that the AMA has all the power, and the hospitals have all the resources. And we retreated to giving advice to the people that we're supposed to serve, about what they should do and how they should live, and how often they should brush their teeth, and eat five a day. And we don't even do that well. The last time we put up a five-a-day picture poster in our office, my patient came in and said, "Aw, that's great doc! I can have five meals a day?"

Sometimes still today too frequently we're paternalistic in how we give advice, and we give advice without respecting or understanding the traditions of the people we are working with, and we pretend as though we have all the knowledge and they have none. This retreat, starting around World War II until relatively recently, happened for real reasons -- budgets were cut, politicians wanted to get elected. But in doing this, we cut ourselves off from our base of support. So, we say no one knows what public health does because we do the invisible. No one knows what public health does because we don't do the important stuff any longer. And even the stuff we do that's important, we hide its importance. We don't make the logical connections. We don't explain why it's important.

"We told people, 'Stay home if you get sick. Don't infect others.' Perfectly reasonable advice. We didn't point out that many Americans don't have sick days. They're not entitled to sick days. And if they stay at home when they get sick, they don't get paid."

We just came through a worldwide pandemic of flu, something we have been warning about forever. Now we lucked up completely with H1N1. Fortunately the virus wasn't that virulent, but think about what we said, and think about what we could have said. We said, "Get vaccinated." I don't know how y'all did it in Alaska. I really don't. But I know in my community, in the Black community, people don't like the flu shot, they never liked the flu shot, and they didn't get vaccinated. Leave that alone for a moment. We failed to discuss, in the evening news, how the vaccine is produced, and the fact that we use ancient methods in the United States, and what impact that might have had on worldwide supplies of vaccines. There were major issues to be discussed there, and we didn't open our mouths.

We were on the evening news, and believe me during H1N1 a lot of public health people were on the evening news. We said, "Cover your cough." We failed to say: "People in this country that don't have medical insurance will get influenza. Some of them will get very sick. They'll get pneumonia. They will need hospitalization. And many of them will not be able to get the medical care that they need because we don't provide medical care as a basic human right." We didn't say that. I can't tell you, but we all know: People died in this country because they couldn't get access to basic medical care.

We told people, "Stay home if you get sick. Don't infect others." Perfectly reasonable advice. We didn't point out that many Americans don't have sick days. They're not entitled to sick days. And if they stay at home when they get sick, they don't get paid. They can't buy groceries. They can't pay their rent. Where was the call to say, "We should have mandatory paid sick days in the United States." And when we have a public health emergency, no matter how many sick days you've used up, we should have mandatory paid sick days so the epidemic doesn't spread. We escaped this time, but what if the mortality rate from H1N1 had been 10 percent or 15 percent or higher?

Public Health Requires Work Across Silos

Brothers and sisters, our field is a field that forces us to look at things across the breadth of society. And while you may start off being an expert in seatbelts and motor vehicle collisions, you can't really do your job if you don't understand how a local community functions, or how people work and where they work, or why parents don't have access to car seats. We're a field that requires us to work together across a whole range of silos. We know what the right thing to do is. We just hesitate to open our mouths and say it.

"Without justice you can't have a healthy people, healthy communities or a healthy nation. Equity and social justice are not outside of our field. It is part and parcel of our field."

Public health is social justice. Without justice you can't have a healthy people, healthy communities or a healthy nation. Equity and social justice are not outside of our field. It is part and parcel of our field. We must not be afraid to fight for what we know is right. We must stand up against racism and all forms of prejudice. We have to lend our voices to make sure that the social conditions we know are required for a healthy people are there -- the right to organize [garbled], the right to address the status of women. All of these things are critical to what we do every day. And while the nation is focused on economic recovery, we should be calling for a council of social advisers to provide some balance to the president's economic advisers to talk about what it means when interest rates go up or when companies move abroad.

We have to be willing to join our colleagues in the rest of the world, mostly poorer than us, not as well resourced as us. I would suggest to you that if the World Health Organization can argue that with real plans that call for action on social conditions that involve governmental and nongovernmental organizations, they believe health equity can be achieved in one generation, I would suggest to you that in the United States we can do no less.

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Clark School -Based Health Center Update

The Clark School-Based Health Center provides free sports physicals and treatment of minor illnesses and injury to students with parental consent. In the letter below, Tari O'Connor, coordinator of the School-Based Health Center, provides updated information about activities at the center. The December 2010 issue of the Alaska Health Policy Review included an interview with Tari O'Connor.

Dear friends of the Clark School Based Health Center,

Welcome to the first informal newsletter of the new Clark School Based Health Center! We plan to update all of our old and new friends and supporters at least once a semester on the progress we've made. If you know of others who would like to receive this information, please feel free to share this, or reply with their email addresses so that they can be added to the distribution. One day this may look more like a newsletter; for now it'll be pretty basic in the interest of time.

Service overview

The months since the 2010-11 school year started have been busy ones. We started the school year off in August with a presence at Clark registration and an evening sports physical event that stretched over two nights. Regular services at Clark two mornings per week (including sports physicals, diagnosis and treatment of minor illness and injury, and referrals) also started in August. Since then, around 70-75% of Clark students have turned in parent consent forms to use Clark SBHC services, and Clark students have received 265 patient visits! Immunizations are anticipated to begin during the Spring 2011 semester.

Support from our volunteers and school staff has been wonderful. Volunteers (including health care providers and community outreach volunteers) contributed over 160 hours to supporting the Clark SBHC during the fall semester. We especially owe a huge thank you to the Providence Family Medicine Residency, and individuals from Latouche Pediatrics for their support for our regular health center hours. The supportive staff at Clark, especially the school nurse, have similarly made a significant and positive difference to the Clark SBHC. Clark SBHC could not operate without the contributions of all of these wonderful folks - thank you all!

During the next few months the Clark SBHC hopes to begin to offer immunizations in addition to our current services. Future plans include a spring sports physical event targeted especially at 8th graders about to leave for high school. We anticipate needing volunteers for this event -- both health care providers and folks to answer questions, collect forms, and otherwise assist students and parents -- and will put out a call for volunteers once details are available.

Advisory Council

We are currently working with the Anchorage School District to set up the formal School Health Center Advisory Council, and hope that group will have their first quarterly meeting very soon.One of the first tasks for that group will be to form a committee to develop a financial sustainability plan. We recently received funding from the American Academy of Pediatrics -- Community Access to Child Health program via Dr. Jon Lyon to support that effort. Among other things, this effort will develop a plan for us to implement billing for public and private insurance in Fall 2011.

Speaking of finances

We continue to seek funding from a variety of sources. In addition to our original grant from Providence, we have received funding from the Rasmuson Foundation, the American Academy of Pediatrics (as described above), First National Bank of Alaska, and a small donation from the Walmart midtown store. Several agencies and private practices have also contributed significant in-kind support. A number of grant proposals have been submitted to other organizations and foundations, including United Way of Anchorage. As many of you know, the Clark SBHC plans to hire a mid-level provider as well as an admin assistant/medical scribe once funds are available.

If you have questions, ideas, or are interested to volunteer, contact Tari O'Connor (oconnor_teresa@asdk12.org, 907.227.8219).

[Source: Excerpted from an electronic communication from Tari O'Connor, January 25, 2011.]

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Health Impact Assessment to be Included in Energy Development Plan

For the first time in the history of energy development in Alaska, the state Department of Health and Social Services (DHSS) prepared a health impact assessment (HIA) that is to be included in the required environmental impact statement (EIS) currently in development for the Point Thomson project. The HIA report will be an appendix to the EIS.

Exxon proposes developing and operating a hydrocarbon liquids production project on the Beaufort Sea coast between Deadhorse and Kaktovik, Alaska. The project requires authorization from the U.S. Army Corps of Engineers (Corps) and compliance with federal laws, including the National Environmental Policy Act (NEPA).

In compliance with NEPA requirements, the lead agency, the U.S. Army Corps of Engineers, is overseeing the development of an Environmental Impact Statement (EIS). In early 2010, public meetings were held and currently the Corps and cooperating agencies are analyzing comments and developing alternatives to be presented in the preliminary draft environmental impact statement (PDEIS). Upon its release, AHPR will summarize the document and provide a link to the full document.

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Implications of Federal Court Ruling on ACA

Federal Judge Vinson's recent ruling in Florida on the constitutionality of the individual mandate provision in the Affordable Care Act may leave you wondering just what that means for health care reform in the U.S. A recent e-mail alert, distributed by the Georgetown University Health Policy Institute Center for Children and Families, offers insight and resources that may clear up some of that uncertainty.

Dear Friends,

As you are no doubt aware, on Monday [January 31, 2011], a Florida judge ruled the ACA unconstitutional. This ruling has garnered significant attention, but it is important to note that it is the most recent in an array of opinions surrounding the health-care law -- 12 federal judges have dismissed challenges to the law, two have found it constitutional and two (including the FL ruling) have found it unconstitutional.

The Florida decision has generated substantial media coverage on what the ruling means for the future of health reform. It has also resulted in statements from leaders in various states about their intentions to move forward or not move forward with implementation. Experts are still sorting through the legal implications of the ruling and how the differing opinions in the courts will be resolved.

In the meantime, we wanted to share some resources with you to help provide insight into the ruling's implications and to help explain the implications to the media and other stakeholders in your state as needed.

One of the best summaries of the ruling was posted today on Community Catalyst's Health Policy Hub blog. A second valuable resource was produced by PICO and outlines in simple language what the ruling means for health reform.

If you are hearing about your state's response to the ruling (continuing to move forward, halting implementation, etc), please let us know so we can continue to stay abreast of the picture throughout the states.

If we can be of any additional assistance on this or any other issue relating to the Affordable Care Act and implementation, please don't hesitate to contact us.

Your friends at CCF.

Health Policy Calendar