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Why It Matters

When it comes to treating chronic stress, it will take a village effort

By Dennis Archambault

I recently had an opportunity to discuss psychotherapy and analysis with a young psychiatrist with a successful practice. He was confident that proper therapeutic intervention really improves the well-being of his patients, many of whom suffer deeply from psychological distress. One of the modalities we discussed was psychoanalysis, an expensive process that has shown to help people recover from severe psychological problems. To be effective, psychoanalysis requires multiple sessions on a weekly basis, often for a long time.

I explained to the psychiatrist that I represent an organization that promotes population health among low income, vulnerable populations where there isn’t sufficient access to mental health services and a lack of financial resources to afford more involved therapies like psychoanalysis, not to mention access to transportation to reach a psychoanalysis. He acknowledged the cost issue, but went further to confirm that people living in the lower economic strata of society endure such depth and breadth of cumulative trauma, that individual psychotherapy wouldn’t be effective.
That message came out of a conference on “Building a Resilient Community,” sponsored by Starfish Family Services http://www.starfishfamilyservices.org/ earlier this year. One of the concepts discussed was a form of community psychology, “trauma-informed community building.” While individual counseling is helpful , care must come through the ongoing reinforcement of a healthy community – specifically family and neighbors.

The State of Michigan offers a good resource list on “Building Trauma Informed Communities” http://www.michigan.gov/mdhhs/0,5885,7-339-73971_4911_69588_80205—,00.html. One of the sources cited was a Robert Wood Johnson Foundation program in Washington, promoting the “self-healing” of the community, which promotes collaboration across sectors of resources, empowers local leadership to think systemically, use data to focus initiatives, and ultimately “instill a real sense of hope in communities that had given up on the prospect of a better world for their children.”

In the absence of a progressive health policy at the national level, local solutions like trauma informed communities and support networks are worth pursue. But, to reference a familiar adage, it will take a village.

Dennis Archambault is vice president, Public Affairs, for Authority Health

Healthy community design requires resilience in the face of chronic stress

By Dennis Archambault

Chronic stress is increasing throughout society, but is becoming an oppressive force among safety net populations. This has been a topic of discussion among mental health and public health professionals for some time. Authority Health’s population health program, this year, is focusing on chronic stress and the application of resilience as a public health strategy.

The Rockefeller Foundation is in the midst of a “resilient cities” initiative http://www.100resilientcities.org/, supporting the work of 100 cities worldwide to become more resilient to the physical, social, and economic challenges that are part of the new reality of the 21st century. The foundation defines building urban resilience as “the capacity of individuals, communities, institutions, businesses, and systems within a city to survive, adapt, and grow no matter what kinds  of chronic stresses and acute shocks they experience. Acute shock is defined as sudden, sharp events such as earthquakes, floods, disease outbreaks, and massive violent experiences. Chronic stress is cumulative, like high unemployment, poverty, violence, and persistent physical and natural environmental disasters.

Resilience thinking demands that cities look holistically at their capacities and their risks. Society is learning that individuals can adopt resilient strategies for surviving repeated onslaughts of pressure points, but perhaps the most challenging lesson — and one that is directly related to healthy community design — is developing collective impact from the cohesion of a resilient culture. That will take some work.

Dennis Archambault is vice president, Public Affairs, for Authority Health.

Hospital mobile van addresses disparities, but what about causes?

By Dennis Archambault

Norwegian American Hospital in Chicago, one of the awardees in the 2017 American Hospital Association Nova Awards program, was credited with helping reduce health disparities among children on Chicago’s Westside through a mobile clinic. While access to transportation may be one of the social determinants addressed through the project (it wasn’t mentioned in the award narrative), other social determinants such as environmental quality, interior household and school air quality, lead abatement programs, and school health and fitness programs were not addressed.

The first two paragraphs of the narrative are revealing:

“Norwegian American Hospital serves some of Chicago’s neediest zip codes. The average per capita income in its core service neighborhood is $13,391, while the unemployment rate stands at 12 percent.

“Those numbers translate into health problems, such as childhood asthma, elevated blood lead levels and high rates of childhood obesity and teen pregnancy. Because they lack regular medical care, many children in the community can’t meet the vaccine requirements for public school registration.”

Norwegian American Hospital certainly is contribution to the public health infrastructure of Chicago through the mobile clinic, but what if it had approached the health issues addressed in the first two paragraphs – asthma, related to internal and external air quality; elevated blood lead levels related to lead-based paint in old housing stock; and high rates of childhood obesity and teen pregnancy. These are social issues the hospital could partner with public health authorities in its community benefit investment. Depending on your source, household air quality is a major contributor to up to half of asthma cases. (Locally, one community development corporation notes that during the winter, houses with forced air push contaminated dust up into the breathing space of children, increasing their risk to lung ailments.)

The ultimate irony in this case is that the mobile clinic addresses a major social determinant – transportation. Providing a mobile clinic financed through philanthropy – an unsustainable funding model – has limited applications. However, funding an alternative transportation system that provides patients access to primary care medical homes might be more cost efficient.
Speaking of funding, it’s curious that the program is entirely funded through philanthropy: children’s Care Foundation, Northern Trust Co. Charitable Trust, the Col. Stanley McNeil Foundation, and the Illinois Association of Free and Charitable Clinics. There doesn’t appear to be an investment by the hospital itself.

A mobile clinic connected with schools in underserved communities is a good idea and could deliver much primary care than would otherwise be provided to this community. But what if Norwegian American Hospital and its competitors found common purpose in this or other health disparities and decided to improve the social systems that helps create the health disparity? Is that still a radical concept for hospitals?

Dennis Archambault is vice president, Public Affairs, for Authority Health.

‘Fugitive Dust’ ordinance is a good step toward health in all policies

By Peter J. Hammer
In 2013, Detroiters awoke to the shock of finding mountains of pet coke looming over the riverfront. The pet coke incident triggered a growing awareness of the environmental and public health consequences of what is more generally known as “fugitive dust.” The incident also highlighted the absence of effective legal tools to address the problem.This is no longer the case. Detroit City Council is about to consider a comprehensive ordinance to better monitor and control fugitive dust. This ordinance has important symbolic and substantive significance as Detroit chooses what type of future it will embrace.

Detroit is at a crossroads that will determine the type of economy, environment and community that will define its future. Policy makers should work constructively to attract and retain businesses that seek to grow their enterprises in a manner that is good for them, but also respects considerations of public health and the environment. It is equally important that we send a clear message that Detroit will not accept a strategy, particularly in the neighborhoods, that permits business to sacrifice the health and well being of historic Detroiters in the name of economic development.
City Council has been working on an ordinance to control sources of fugitive dust that embodies these principles. Fugitive dust is a serious environmental and public health concern that requires appropriate control. The ordinance also sends a signal that Detroiters have high expectations for how business should be done and the types of future economic development that should be encouraged.

Fugitive dust is an elastic term describing particulate matter suspended in the air by wind and human activity. The dangerous dust emanating from the mountains of pet coke provide a good intuitive illustration of the problem, but fugitive dust can be associated with large piles of other solid bulk material, such as asphalt millings, gravel, sand, and limestone. Depending on location, fugitive dust can create highly-localized hot spots of particulate matter pollution due to wind blowing dust into nearby neighborhoods, schools and homes.

Even short-term increases in particulate matter pollution can negatively affect some of our most vulnerable residents. Scientific studies have linked particulate matter pollution to increased rates of respiratory-related hospital visits and the exacerbation of asthma symptoms among children. This is particularly concerning because the Michigan Department of Health and Human Services labeled Detroit the state’s “epicenter of asthma” based on its findings that the rate of asthma-related hospitalizations in Detroit is three times the state average.

The Fugitive Dust Ordinance outlines common sense control for facilities that have large piles of bulk solid materials, including development of fugitive dust plans subject to the approval of the Building Safety Engineering and Environmental Department(BSEED), maintaining monitors upwind and downwind locations at the facility, and controlling dust being emitted from trucks transporting materials. Additional controls exist for facilities that store any pet coke, coke breeze, met coke, or nut coke. Finally, facilities may apply to BSEED for variances from ordinance requirements where appropriate. These provisions are very similar to fugitive dust controls that exist already in Chicago.

The Fugitive Dust Ordinance is also significant for symbolic reasons. The ordinance establishes an important template for the type of growth we want for Detroit. The “tale of two cities” is increasingly fact, not fiction. While downtown is being built up with new businesses and a shiny new trolley car, the danger is that the neighborhoods will be slated for various forms of exploitative development. The U.S. Ecology proposed expansion in capacity to process 64,000 gallons of toxic waste to nearly 666,000 gallons and the need to brow beat Marathon Oil to invest in basic technology to control air pollutants should be seen as warning shots across the bow. Impoverished neighborhoods have historically been vulnerable to environmental exploitation and the lives of their residents seen as expendable.

The Fugitive Dust Ordinance suggests a brighter and more sustainable path forward. The ordinance gets out ahead of a growing problem. The ordinance adopts national best practices and applies them to Detroit. The ordinance makes clear that while Detroit is open for business, development must respect the environment and the public health of all residents.

As democratic institutions begin to reassert themselves in the wake of bankruptcy and emergency management, this is exactly the type of common sense action we should expect of the City Council.

Peter Hammer is director of the Damon J. Keith Center for Civil Rights at the Wayne State University Law School and member of the Population Health Council

When health becomes a factor in paying bills

By Dennis Archambault

“I can’t pay my taxes!…”
– Marvin Gaye

Marvin Gaye’s exasperation in “Inner City Blues,” a generation ago, is sadly relevant today as households need to come to terms with which bill to pay and when. Or which not to pay and what are the consequences? Is it the heat bill? The cell phone bill? The rent or mortgage? The car note? Water bill? Assuming the best money management, many working class households face this stress every day. Decisions may be made rationally or irrationally, and with those decisions come consequences.

Utilities like water and heat are essential to life. But they are considered services for which consumers are responsible to pay. There a population – likely served through the Healthy Michigan expanded Medicaid program, but also including some of the lower income levels in the commercial insurance market – that is making choices about which bills to pay. Those choosing to not pay their water bill find ways to get by – borrowing water from friends and family, buying bottled water, and likely not having enough for proper hygiene or hydration.

Prolonged absence of regular access to clean water results several public health concerns, according to
Dr. Wendy Johnson, a public health professional who directs La Familia Medical Center in New Mexico, weighed in on the Detroit issue at a news conference recently:
• Dehydration, which causes a litany of problems, specifically for elderly and young people and those with chronic diseases.
• Poor hygiene, which can help spread and create water-related problems like the skin disease MRSA, as well as various GI issues.
• Unhealthy choices that can cause other health problems. If someone is without water, he or she cannot cook, which means he or she is eating cheap fast-food and drinking sugary beverages, which are less expensive than bottled water.
• Mental health issues. For example, she said, the inability to bathe negatively affects one’s sense of self-worth, as well as the ability to concentrate at school or work.
• Ripple effects; many of the water-borne diseases are contagious.

The Population Health Council has taken a clear position on this issue as being consistent with the federal commitment to providing a level of health care for a level of society struggling with the effects of poverty. Access to water should be provided for populations served through the Medicaid program, not as a consumer service.

Payment assistance, funded through philanthropic funds, may seem compassionate and appropriate, but philanthropic priorities change and demand will increase during economic downturns. Beyond the practicality of charity, it comes down to a systemic argument: Can a society afford to underwrite the cost of water service in a managed access system like Medicaid? And if so, should it?

Dennis Archambault is vice president, Public Affairs, Authority Health

A definition for health equity: new, improved, and universal…

By Dennis Archambault

This May, after months of research, reflection and consultation among the nation’s leaders in health disparities and health equity research and policy, under the auspices of the Robert Wood Johnson Foundation, a unified definition of health equity was arrived at:

“Health Equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.”

Paula Braveman, a physician and public health practitioner, the director of the Center on Social Disparities in Health, was one of the framers of this definition. She writes in a recent Health Affairs journal blog post, “The growing interest in health equity – and in getting clearer about a definition – signals readiness for a paradigm shift in the focus of health equity research and action in this country… and a willingness to say: This is about core values – namely, fairness and justice.”

Dr. Braveman adds that while this is a time when health policy experts are willing to have tough conversations about the policies and programs that have led to inequitable gaps in health, “Unfortunately, the current national political context is more hostile to health equity – and to justice in general – than any other during my lifetime. And that makes it all the more crucial for us to be crystal clear and strategic in our words as well as our deeds.”

Dennis Archambault is vice president, Public Affairs, for Authority Health.

Returning to our point of origin?

 

“History repeats itself; first as a tragedy, second as a farce.”
– Karl Marx

By Dennis Archambault

Authority Health was established in 2004 as the Detroit Wayne County Health Authority due to a crisis involving Detroit hospitals inundated with uninsured patients, primarily through their emergency facilities. The Detroit Medical Center said that Detroit Receiving Hospital and Hutzel Hospital could not continue to sustain the debt of uncompensated care. The Michigan governor, Wayne County executive, and City of Detroit mayor, acting on the recommendation of a local commission, established this organization to strengthen the health care safety net and minimize the pressure on hospital emergency services. Early on, we operated with the slogan, “It’s about access for all.”

The Affordable Care Act did much to relief the access problem by offering a method of insuring most Americans, and in states like Michigan, enabling low income residents an opportunity to qualify for expanded Medicaid benefits. That was then – well, not quite. Depending on how Congress acts regarding its efforts to repeal and replace the law, the ACA may be with us a few months longer – and perhaps longer, with revisions. But what seems certain is the elimination of the Medicaid program – not only expanded Medicaid, but a significant portion of traditional Medicaid.
The specifics have been widely documented in the popular press. What population health advocates are facing is a massive regression in policy to a time when the poor sought health care in hospital emergency departments as a clinic of last resort. Many individuals and organized groups have protested this. Public approval for the Senate legislation is much lower than any reasonable politician would want to risk. Yet, the Senate soldiers on – or at least its leadership. And the president, trying to make a deal, has suggested that the ACA should be discontinued immediately and let the replacement process follow due course. Or not.

Expanded Medicaid has provided access to health care services for over 600,000 people in Michigan. Traditional Medicaid provides important maternal health, care for the disabled, and for the low income elderly. Ron Lieber, a business columnist in The New York Times, offers a cautionary tale regarding the latter category https://www.nytimes.com/2017/06/30/your-money/plan-on-growing-old-then-the-medicaid-debate-affects-you.html?_r=0. Typical business readers would not consider themselves at risk for becoming an impoverished elder. But as Lieber writes, one in three people who turn 65 will find themselves in a nursing home at some point. Citing the Kaiser Family Foundation, 62 percent cannot pay the bill on their own.

The Hill, a policy-oriented news publication in Washington, D.C., has reported that the proposed Senate health care legislation is likely to have deeper cuts in Medicaid than the House bill, which does not bode well http://thehill.com/policy/healthcare/338411-senate-gop-considers-deeper-medicaid-than-house-bill.

Medicaid is meant to be a safety net program. It’s clear that a lot of people are at risk at losing access to essential health services – taking us right back to where we started in 2004.

Dennis Archambault is vice president of Public Affairs for Authority Health

Why would anyone want children to eat ‘crap’?

By Dennis Archambault
Michelle Obama has responded to the Agriculture Department’s position which effectively reverses much of the work that the former first lady did to create progressive school nutrition policy during the Obama administration years. And she didn’t coat her language: “Think about why someone is OK with your kids eating crap.”

Agriculture Secretary Sonny Perdue announced this month that school meals would no longer have to meet some requirements connected with Obama’s initiative to combat childhood obesity by reconstituting the nation’s school meal menus. The nutrition regulations were part of the “Healthy, Hunger-Free Kids Act of 2010 and advocated through the “Let’s Move” campaign, created by Michelle Obama as first lady.
Perdue argues that the regulations add costs to school budgets and waste – students aren’t eating the food. “If kids aren’t eating the food, and it’s ending up in the trash, they aren’t getting any nutrition – thus undermining the intent of the program.

“You have to stop and think, why don’t you want our kids to have good food at school?” Obama said recently at a public health summit. “What is wrong with you? And why is that a partisan issue? Why would that be political? What is going on? … Take me out of the equation – like me or don’t like me. But think about why someone is OK with your kids eating crap. Why would you celebrate that? Why would you sit idly and be okay with that? Because here’s the secret: If someone is doing that, they don’t care about your kid.”

A lot of people have worked very hard, against multiple odds, to change policy and change behavior in our troubled educational environment. The MOTION Coalition, which organizes around the issue of childhood obesity, advocates policy that reinforces good nutrition and eating behavior, not the other way around. To have this reversed in a single action hurts – not just the egos of advocates, but the youth of America who have become less fit and more prone to diet-related disease than ever.

Obama, who represents a model for healthy parenting for many women in American, responded to Perdue’s assertion: “How about we stop asking kids how they feel about their food because kids, my kids included, if they could eat pizza and French fries every day with ice cream on top and a soda they would think they were happy, until they get sick. … You know what? Kids don’t like math either. What are we going to do? Stop teaching math?

Dennis Archambault is vice president, Public Affairs, at Authority Health.

Public Health Commission report may be ‘transformational’

By Dennis Archambault
One of the promising developments to come out of the Flint water crisis has been the Public Health Advisory Commission. As commissions go, it initially appeared to be an action that was as promising as a constructive dialogue could be – short of substantive and systemic change. That doesn’t seem to be the case, at least as far as the report goes.To begin with, the commission was well-represented with health providers, educators, non-profit executives, academicians, and several other stakeholders of the public health system. Eden Wells, M.D., MPH chief medical executive of the Michigan Department of Health and Human Services, served as chair. His comments introducing the commission’s report reflect the potential of its recommendations: “hope that the recommendations will energize a statewide effort towards a more comprehensive, cohesive, accountable and effective public health system.” He also acknowledged that the state “is committed to public health excellence, recognizing the need for change in order to truly achieve a transformational public health system.”

One should key into the word “transformational.” One might also add a word: “disruptive.”

The three top priorities for consideration are significant:
1. Create a permanent Public Health Advisory Council. This would ensure that a vehicle exists to address emerging state and local health issues;
2. Ensure all state departments employ a “health in all policies” approach when implementing policies and programs, “elevating public health”;
3. Recognize disparities in public health funding and unmet needs throughout the state.

These are only three of 39 recommendations. If the governor addresses just these three the state will be much better off. We have been advocating for a health in all policies approach to government decisions, along with others throughout Michigan. Now is the time to advocate for this method of ensuring that actions taken by government are indeed in the interest of the citzenry – certainly in the health interests of the citizenry.

Check out this report for yourself: http://www.michigan.gov/documents/snyder/PHAC_Final_Report_556718_7.pdf

Dennis Archambault is vice president, Public Affairs, for Authority Health

State public health advocates offer governor opportunity to strenghten public health integrity in Michigan

By Dennis Archambault
As Gov. Snyder considers the final report of the Michigan Public Health Advisory Commission (http://www.michigan.gov/documents/snyder/PHAC_Final_Report_556718_7.pdf) it’s an opportunity for all population health advocates to consider this moment as a potential breakthrough in struggle to improve public health in Michigan. The report submitted to Gov. Snyder includes three basic recommendations:

1. Continuing and Expanding Collaboration:
Collaboration is often talked about but seldom achieved in a world of intense competition for scarce financial resources. The advisory commission’s report recommends that collaboration be enforced to engineer a broader engagement around efficient use of public and private funds. The recommendation to establish forums for regional collaboration makes sense.

2. Collaboration between State Departments:
The essence of this recommendation is establishing a “Health in All Policies” requirement for state departments in implementing policies. It’s a process used in California and one advocated at the county level throughout Michigan. It is a means of ensuring that the health risk to our communities is properly assessed prior to state policy action. The ethical principle that underscores this recommendation is environmental justice. Too often, vulnerable populations fall victim to injustice due to a lack of voice or influence in public policy decisions.

3. Investing in Michigan’s Public Health:
Anyone working in public health, or related community health initiatives, knows that national public health expenditures has decreased steadily in the past decade. This has had a direct impact on our emergency response capability, as well as our ability to address the health impacts of poverty, racism, food insecurity, and adverse childhood experiences, as the advisory commission report confirms. In an era in which government is intent on reducing taxes and overlooking the human service infrastructure (in lieu of the physical infrastructure and military), advocates need to convince elected officials that this is not an issue limited to vulnerable communities and populations – even though pockets of vulnerability are showing up in seemingly affluent communities. Just as roads deteriorate if they aren’t maintained, so does the social infrastructure.
The governor asked representatives from the public health sector for their advice. They have provided a very thoughtful and comprehensive report. Now it’s up to the governor and legislature to determine if they really want ensure good public health in Michigan.

Dennis Archambault is vice president of Public Affairs for Authority Health.