A brilliant thought that just occurred to me ... a note on culture

As a public health professional, I have been indoctrinated to continually consider culture and heritage as a part of interventions. We should, our professors say, carefully examine the normative values immanent in our target populations. We should analyze and plan and really, really think about not only what we say, but how we say it, and how we act when we do so. It's all about sensitivity.

I was thinking the other day, then, about the classroom environment and different teaching styles, and how professors should really be applying these same principles of cultural sensitivity to their students. We are, as master's students, existing in our own culture. We have specific norms and values, specialized language that describes our experiences, and certain socioeconomic concerns (i.e., we're generally poorer than poor). We have arguably created our own subset of society here in our public health school.

Why do I get the impression, though, that some ostensibly enlightened educators are contradicting their own teaching by refusing to understand students' viewpoints? I wouldn't necessarily call it hypocrisy, but I just don't understand how students at SRPH don't constitute a population that deserves consideration on par with needy community members. We're a group of people with specialized interests, and we ought to receive "interventions" (in this case, education) that has the same quality of the interventions we are designing in our courses. We don't berate or belittle people for doing things "wrong" in a health setting; why would we do this to students, who occupy an analogous social realm?

I'm going to bust out an old cliche: Practice what you preach! That's an imperative that is imposed on all of us that are in the health and wellness industries. Like it or not, people are unlikely to trust a nutritionist who only eats cupcakes, a doctor who smokes, or a public health professor who doesn't attempt to understand students' very legitimate cultural norms.

This is what we are called to do, thinking outside of the box. Cultural sensitivity isn't only good for understanding life in the colonias or in other countries, it's important right here in your own backyard. Learn how to apply it in your immediate surroundings, and you're certain to succeed when the tough situations arise.

I've come to the conclusion that being proficient at public health is really just being proficient at life. Here are the basic tenets of our profession, as I interpret them:

• Ask people what they want and need,
• Be nice,
• Try to understand people that are different from you,
• Admit that you don't know everything,
• Admit that you sometimes break things,
• Don't lie,
• Don't waste money or resources,
• Make sure what you're doing is working,
• Don't hurt anyone,
• One size does not fit all.

Were I a public health professor, I would give my students this list and then turn them loose to study whatever health topic they found interesting. I would give them the freedom to intuitively create interventions and then provide constructive feedback. This field isn't about following a formula to achieve a prescribed end. It's about engaging people and showing them that they can change their own health status and maybe even that of their community. It's about coming up with effective, exciting, and innovative ways to get things done.

It'd be great if that started at the institutional level, but I'm running out of faith that academicians can deliver what people really need. If they can't even get it right in the classroom, how can they get it right in the real world? Tough questions.

In defense of innovation

I'm currently reading this excellent book by Gerald M. Weinberg called Becoming a Technical Leader: An organic problem-solving approach. This, along with some recent class experiences, has prompted me to start thinking about the real place that innovation has in the public health care realm.

Public health, unlike computer science and other technical disciplines, is unlikely to be revolutionized by that next great idea; a single spark is unlikely to ignite a flame. That attribute, however, doesn't prevent public health from the need for great and innovative ideas. Ideas that were not forged in a sterile academic test environment ... no, those ideas are inadequate. What we need in this field, what our populace deserves, is a thinking and creative workforce that creates new approaches to old problems.

I was troubled today by a response I received from a teacher during class. I quoted the 1998 book Public Health and Marketing, which asserts that public health practitioners need to adopt strategies and mindsets that exist in the marketing realm. Specifically, we are encouraged to realize that corporate marketing professionals only expect a 2-3% per annum change in purchasing behavior (note the "per annum"). In other words, public health professionals need to set more realistic expectations for mass behavior change. This seems reasonable to me, as someone who does a lot of independent research, because I have yet to see sufficient evidence that behavior change can be achieved through educational efforts.

I was thoroughly trounced, albeit politely, by my professor, who essentially laughed at me, telling me that any proposal that promised a 2-3% change per annum would be swiftly rejected for its inefficiency. Let me bring up the following points, though. For example, in a 5-year program, assuming a 3% change annually, one could effectively change at least 15% of the target market. Perhaps a 2-3% change is warranted because of the characteristics of the health problem; if we're changing 2-3% of the rates of homicide in the U.S., for example, we might have an argument for the program if it's low-cost and efficient. Furthermore, those affected by the change may have the ability to influence their community, effectively changing social norms.

There must be something wrong with me because I have the continuous faith that professors, fellow students, and the public as a whole are as optimistic and revolutionary as I choose to be. Yes, I do my public health research. I read books upon books that have nothing to do with class, but everything to do with actual implementation of public health principles.

Take, for example, the remarkable book Theory in Health Promotion Research and Practice: Thinking outside the box, by Texas A&M's own Patricia Goodson. I won't go into detail about the book (since I'm honestly not done reading it), but the title alone should make us stop and question our motives in this field. Thinking outside the box. Theory does have its applicability, and evidence-based public health practice is important, but our field must also be receptive to the radical and weird ideas that just might change the world.

Why are we stumbling around within our profession when so many questions have been answered by research in other disciplines? We have a problem with our marketing strategy ... why don't we look at marketing research to fix the problem? There's a reason that the big corporations are dwarfing our public health efforts ... they have the resources to hire the best and the smartest campaign development staff. Our field seems to be sinking in stagnation and self-congratulatory angst. I'm kind of not impressed.

I am compelled by Weinberg's leadership model, which calls upon technical leaders to motivate, organize, and innovate. The overall theme of the book calls upon those who have been innovators in the past to stimulate new ideas by creating motivation and organization that supports new ideas.

As a leader in this field (which I hope to be one day), I can only say that I would be remiss if I didn't entertain some wacky approaches to public health; after all, we really have no idea what works in this field, so how can we trust the evidence we have? Goodson says that it's rather insane to think that we can imagine ourselves capable of predicting others' behavior. "Well, I raised his self-efficacy, so there must have been an improvement," we say, without understanding what those catch phrases really mean.

The point of this post, I suppose, is to request that public health academicians step down off their beautiful high pedestals and come join the rest of us in the real world, where things are messy and difficult to define. Allow us to think radically. Allow us to feel empowered to go out into the world and make changes! I don't want to work within the crappy existing framework that public health requires, and by golly, I don't have to.

I want to think critically about problems using a variety of perspectives, and I intend to apply theory from *gasp* other disciplines such as engineering, economics, manufacturing technology, and management. Get it together, folks. Public health is the ultimate conglomeration, the meeting place for all courses of study, and all should be recognized as valid. Who cares if it's theoretically supported if it works?!

Maybe I'm just a starry-eyed optimist, but so are others who really make a difference.

The Prevention Dilemma: DHHS Secretary Urged To Seize Opportunity to Impact Public Health

Few would argue the importance of increasing funding for community prevention. That’s the reason prevention advocates were so delighted Congress established a Prevention and Public Health Fund to “provide for expanded and sustained national investment in prevention and public health programs to improve health and help restrain the rate of growth in private and public sector health care costs.” The fund makes available $500 million in new spending in FY2010; the fiscal year ending September 30. There is a tough decision ahead to spend a great deal of money in a short period of time.

There are many worthy ideas vying for DHHS Secretary Kathleen Sebelius’ attention. She is the official charged by the new law in allocating the funds “for prevention, wellness and public health activities…”

How should the Secretary make the initial trust fund allocation given that so many deserving programs are asking for a slice from the pie?

In an Op Ed (“The Prevention Dilemma”) written for Kaiser Health News, Partnership for Prevention CEO, Dr. Robert Gould, answers the tough question.

“There will never be enough federal money to address every prevention need. What the secretary needs to decide is whether there is sufficient political courage to concentrate early prevention funding to deliver a knockout blow to the leading cause of premature death in the country? … The criteria for prioritizing this specific funding should be simple: what are the evidence-based programs that are primed and ready to go, that are proven to work, that we know will move us toward a healthier society and that we can be sure will deliver a large, measurable return on investment? By these criteria, the top priority for prevention spending should be tobacco control.”

Gould recommends DHHS focus their resources on three well tested, evidence-based components::

1) Nationwide public education campaign modeled on the highly successful Truth® campaign that dissuades thousands of young people from initiating tobacco use and encourages smoking cessation;

2) Fully funding quit lines that provide direct cessation services and significantly improve quit rates efficiently and effectively, especially among disadvantaged populations served by Medicaid; and

3) Support for existing state and community-based tobacco control programs that reach people where they live, work, play and worship.”

The Partnership leader believes the goal of this potentially historic investment is simple and most important, achievable.. Gould concludes:

“If community-based tobacco control programs could be brought to scale nationally, we have a genuine opportunity to drive smoking rates into single digits. The rapid and enduring payoff, in lives and money saved, is there for the taking. It’s a rare opportunity. I urge Secretary Sebelius to seize it.”

Sounds like good advice. Do you agree?

Ripley Forbes
Director, Government Affairs
Partnership for Prevention

Local Health Departments Lose 8,000 More Jobs in First Half of 2009

Local health departments—the public agencies that work on-the-ground to safeguard their communities against the H1N1 flu virus and other threats to public health—sustained accelerated job losses during the first half of 2009, a new survey shows. Because of budget-related cuts, city, county, and other local health departments eliminated 8,000 staff positions between January and June, according to a survey conducted by the National Association of County and City Health Officials (NACCHO).

This loss compounds the disappearance of 7,000 positions in 2008, determined by a previous NACCHO survey, the results of which were announced in January. Departments lost more jobs in the first six months of 2009 than in all of 2008.