Population Health Blog

Population Health Blog

Why It Matters

The pressures of refugees navigating the health system motivate Schweitzer Fellows

By Nadeen Dakhlallah and Yusef Bazzy

The saying, “With knowledge comes power, and with power comes great responsibility,” took new meaning one cold winter afternoon volunteering for Zaman International. Amid packing and delivering food to a group of refugee clients we knocked on an apartment door on Detroit’s west side that housed five children and their mother. As the door opened it was an orchestra of deep coughing and sneezing. When we asked the mother if the young children were okay, she shared with us, in her native Arabic dialect, that the children have been sick for over two weeks and now she is starting to become ill herself. Knowing that medical services were available to her family we asked why she has not sought medical attention without hesitation. To our disbelief she responded by telling us how as a refugee she has lost trust in the medical profession and fears the American medical system due to the language and literacy barrier. Distraught by her words we asked her to elaborate and she shared an instance where she attempted to go to the emergency room for a ruptured appendix but left prior to admission, as she felt overwhelmed by the paperwork, physician questions, and lack of cultural competency.

After speaking with this mother at length we got back in the car and sat in silence. Our hearts hurt as we reflected on helpless words of this mother and the view of her innocent sick children. Although we were unaware at the time it was in this very moment that our journey to the Albert Schweitzer Fellowship began. The knowledge of this experience, both of our pursuits to become physicians, and the realization that there are thousands of additional marginalized women and children not receiving medical attention because of lack of understanding and fear of the American medical system lit a fire within us. We knew that as a brother and sister to all of mankind, let alone medical students who have taken an oath to heal humanity, we could not turn a blind eye to this situation. We felt that the knowledge of the situation and the power of our medical education have created a great responsibility for us.

As a part of the Albert Schweitzer Fellowship and working with Zaman International, we have put together Passport SAHA. Passport SAHA begins with ownership of one’s health and freedom to make life choices that can prevent chronic illness. Our philosophy is designed to keep the mother stable so her children have a fighting chance to beat the social determinants of health. We believe that owning one’s health begins with self-worth. We chose a passport concept because for many immigrants, and especially refugees, it is a symbol of movement and freedom. It is coveted and often means you leave something behind to travel to something better. It is often something carried in your purse so it becomes a portable guideline for their health, especially if going to the emergency department and visiting new health clinics.

At the half way point of our project we are proud to announce that we have successfully created and vented the health passport with clients and physicians. In doing so we have completed a soft launch and worked with 25+ clients thus far. We typically begin with a brief presentation about the benefits of the passport, a short survey and then working with tutors to overcome any language barrier we filled out the passport. We have also built a short-term collaboration with the National Kidney Foundation and Michigan State University.

In the upcoming months we have many goals set up for our project. We hope to hold educational seminars regarding ways to maintain optimal mental and physical health. We believe that this next step in our mission will add another dimension of advancement and excitement. It has been a very educational experience thus far and we are looking forward to what comes next.

Nadeen Dakhallah and Yusef Bazzy are medical students at Michigan State University College of Osteopathic Medicine and are 2018-19 Albert Schweitzer Fellows

Guided Storytelling in Late Life: The Road to Positive Aging

By Sarah Charbonneau

There used to be a common belief that people who reminisce are living in the past. Over the past several decades, this notion has shifted as the literature surrounding life review and reminiscence has expanded. Dr. Robert Butler, a physician, gerontologist, psychiatrist, and the first director of the National Institute on Aging coined the term “life review” and believed that it did not make people senile but instead was a way to benefit older adults as they coped with end-of-life issues.

Why does it matter?
Reviewing, reminiscing, and telling stories about the past in late life can act to empower older adults to gain a sense of hope, meaning, and value in their lives. Capturing and understanding how past experiences have influenced the path of one’s life can assist with understanding how an individual has become the person they are and where to go in the future. Family members might also find that the process of life review and storytelling can capture the history of the family to pass down from generation to generation. For example, there might be a philosophy that a family has held on to when it comes to certain values and beliefs. Making sense of these passed down philosophies, values, and beliefs can come from listening and documenting our familial elder’s oral histories.

What are the possible benefits?
There have been several documented benefits to an elder reviewing one’s life. Some are a decrease in depression and anxiety and an increase in life satisfaction. Completing life review, story-telling, and reminiscence in a group setting can also be a way to increase social networks and decrease social isolation. As groups of older adults review their lives together, they can make sense of how their experiences have been very similar or different from one another. This understanding can bring one to see that they are not alone in what they have gone through or to see how and why others have the ideas, values, and beliefs that they bring to the table.

How this is currently being done?
Life review, reminiscence, and story-telling can be conducted in several different ways. It can be done one-on-one or in groups. It can also be very structured or flexible as thoughts flow through one’s mind. As a Schweitzer fellow, I am conducting the life review process in groups to understand the most feasible way to capture the benefits of the process. I am doing this in a more structured way, distinguishing different themes and using several questions to guide these themes. So far, groups have expressed their notion of feeling more connected and closer, creating a sense of community. I have observed that several older adults participating in the life review process have visited memories that they have not thought about in a very long time. Some of these memories have seemed to help the older adults come to accept their past and notice how their past is important in shaping the person they have become today.

Sarah Charbonneau is a master’s student in the Wayne State University School of Social Work and 2018-19 Albert Schweitzer Fellow.

Rx for Racial Healing

By Dr. Gail Christopher

I define Rx Racial Healing as the individual, collective and societal process of replacing the now consciously and unconsciously embedded belief in a false taxonomy and hierarchy of human value with a heartfelt awareness, appreciation, and belief in the sacred interconnectedness of humanity. It is the process of learning that we are one expansive human family. This is a journey from factionalization to wholeness; from division and separateness to unity.

The idea of healing racism is not new. It emerged in the 20th Century. There are now centers and Institutes for the healing of racism in many states and cities across America. What distinguishes Rx Racial Healing from the various approaches to the healing of racism is the focus; the subject matter. In Rx Racial Healing our subject is healing. The modifier is racism. Healing means to make free from injury, fear and disease; to make sound or whole. My emphasis on healing reflects my understanding that our capacity to heal and to be whole as individuals and collectively as a society has been and continues to be hampered, indeed thwarted, by racism. We should never underestimate the power of human beliefs. The belief in a hierarchy of human value is as core to America as is our asserted belief in democracy. Changing, eradicating this belief is our work in the 21st Century. Neither the Civil War, nor the Civil Rights movement addressed this fundamental driving belief system. Both attempted to address the consequences of the belief – enslavement and the discriminatory polices and systems that were created. However, America has yet to eradicate the belief itself; the fallacy and absurd idea that human variation in superficial physical characteristics is a basis for assigning personhood and value, as well as freedom, citizenship, and access to opportunity.  Our failure to create this vital consciousness change makes us vulnerable as individuals and as a society. Our enemies exploit that national vulnerability. Our bodies are weakened by the exposure to the stress that is created by the belief and its consequences.

The pathways through which the resulting stress can interfere with our healing and wholeness are beginning to be understood and elucidated within health, genomic, biological,  psychological, social and political science. In my forthcoming book, Rx Racial Healing: A Handbook: Answers to Your Questions, I explore some of this science and offer guidance in the practice of racial healing.


This blog was originally published in the fall 2018 newsletter of the National Collaborative for Health Equity. Dr. Christopher, formerly vice president of the W.K. Kellogg Foundation, is the founder of the Ntianu Center for Healing and Nature.

The dog bite epidemic: a public health crisis

By Kathy Beard

The economic resurgence in Detroit has lead to many improvements in the Midtown and Downtown areas, as well as some neighborhoods. The Detroit Parks and Recreation Department is reactivating many community parks.Walking and biking paths are being built and bikes are now available to rent. Still, some residents are reluctant to use them due to the fear of roaming dogs. Their fears are not unwarranted.

Although estimates of stray and feral dogs were once as high as 50,000, newer estimates put it at one stray/feral dog for every 14 residents: still too high. In a city where residents struggle with poverty, diabetes, heart disease and obesity, access to inexpensive exercise, such as biking and walking, could significantly improve residents’ health. So, how is the city responding to this? And how can the MOTION Coalition Support these initiatives?

A recent study by Laura Reese, professor of Urban and Regional Planning at Michigan State University showed that dog bites are more likely to occur in areas with vacant homes and commercial properties. Stray dogs tend to live in the buildings as a means of shelter and a source of food. So, boarding up or demolishing vacant buildings should help mitigate the problem. In the past year, the city launched an aggressive demolition and boarding up program. Since then, the Board Up Brigade has boarded over 10,000 homes. The demolition project has razed over 15,000 commercial and residential buildings.

The city has also improved Animal Control Services. They released the following statement about the situation:

Detroit Animal Care and Control (DACC) has increased its number of animal intakes by more than 850 in 2017, compared to [previous year], and the number of dog bites has decreased by 32.7 percent.

The safety of our residents is our primary concern and DACC is doing the following to reduce the number of stray dogs in the community: 

  • Canvassing neighborhoods throughout the city three nights a week.
  • Taking in stray dogs seven days a week.
  • Enforcing ordinances that require residents fix their fences where dogs are present.
  • Writing tickets to residents who do not comply with Detroit City Ordinance.
  • Partnering with non-profit agencies for free/low-cost spay and neuter services.
  • Hiring more employees to respond to calls.

All residents should call 911 if they feel there is an immediate threat to their safety.

Additional staff and vehicles along with a 7 day work week is currently in effect. This has resulted in a 106 percent increase in citations in the first half of 2018 and a decrease in the number of reported bites by 13 percent. Whether these measures have had an impact on the stray dog population remains to be seen. MOTION Coalition can be impactful by supporting the city in its on-going efforts to control blight and alleviate some barriers to outdoor activity.

Second, Dr. Reese’s study showed that not all areas of Detroit have the same issues. Some zip codes have a higher number of reported bites, particularly among young males. In these areas, violent crimes are also significantly higher than predicted. These factors may suggest a link between bites and dog fighting. Reporting these activities could help reduce the incidences; however,residents have legitimate concerns for their safety if it becomes known that they reported a crime. One solution is to use the city’s new interactive crime databank, Crime Viewer (http://detroitmi.gov/crime-viewer/index.html). It allows anyone to view crime statistics by crime, date, time and location. Missing from the crime list is animal cruelty. Adding this crime to the database would help develop neighborhood-specific policy efforts to addressthis crime without putting the safety of residents in jeopardy.

In order for Detroit to promote active living, it needs safe neighborhoods. Managing the wild dog population is one big way we can support this objective. MOTION Coalition can support these initiatives by voicing its support for these initiatives.

Further Reading:

Detroit’s Stray Dog Epidemic: 50,000 Or More Roam The City

The Dog Days of Detroit: Urban Stray and Feral Animals

Detroit’s Board-up Brigade marks 1 year changing lives, communities

Emergency Department Visits and Inpatient Stays Involving Dog Bites, 2008

Agency for Healthcare Research and Quality

Detroit Demolition Program

A Closer Look at Dogfighting

Detroit Crime Viewer

Kathy Beard is program manager for MOTION Coalition. The MOTION Coalition, an initiative of Authority Health, is a coalition of over 80 organizations in Southeast Michigan focused on obesity and wellness.

Sudden Infant Death Syndrome

By Lee Watson

October is Sudden Infant Death Syndrome Awareness month. The leading contributor to infant mortality is Sudden Infant Death Syndrome (SIDS). SIDS is the unexplained death of a seemingly healthy baby usually occurring during sleep among infants less than 1-year-old. As part of its Infant Mortality Reduction Plan, Michigan is promoting reducing sleep-related infant deaths and the expansion of home-visiting and other support programs to promote healthy women and children as two of its nine top priority goals.

Programs like the Detroit Nurse Family Partnership, administered through Authority Health promote prevention of SIDS through education and training in proper sleep positions for babies to reduce the possibility of SIDS in addition to their programs dedicated to the overall wellness of mother and child.

“Infant mortality is higher in Detroit that it is in some third world countries, but NFP is making a difference, one family at a time,” says Sharon Burnett, a registered nurse, and director of the Detroit NFP program. “Infant mortality and SIDS is real here in the city of Detroit.”

NFP is a national evidence-based home visitation model that pairs baccalaureate- prepared nurses with first-time mothers from the third trimester of pregnancy to 24 months after giving birth. Poor health outcomes for mothers and babies are frequently attributed to social barriers like racial inequity, poverty, stress, food insecurity, lack of education and resources, limited access to transportation or health care can contribute to poor health outcomes for mothers and babies. Addressing the psychosocial needs of first-time mothers result in healthier maternal outcomes, improved parenting, and promoting healthy family development. The goals of the Nurse Family Partnership program are to:

  • Improve pregnancy outcomes by helping women engage in good preventative health practices, including thorough prenatal care from their health care providers, improving diets, and reducing their use of cigarettes, alcohol, and illegal substances.
  • Improve child health by helping parents provide responsible and competent care.
  • Improve the economic self-sufficiency of the family by helping parents develop a vision of their own future, plan future pregnancies, continue their education and find work.

It’s clear that contextual factors that influence infant mortality differ between communities, and the NFP program is part of the solution for addressing health inequities. The nurses counsel the mothers and provide guidance for successful pregnancy and delivery and promote healthy habits for early childhood development. Their mission is to mobilize the community through education and support and a unified strategy to reduce infant deaths.

“NFP nurses and their clients build relationships over two and a half years and many of them are like family,” says Burnett.

September was Infant Mortality Awareness Month. It is important that the issues surrounding infant mortality and its contributing factors are not relegated to just one month of reflection but as an ongoing practice in solution. To find out more about the Detroit Nurse Family Partnership program and how you can support its mission, please click here or call 313.319.5717.

Research confirms that expanding Medicaid is good for the economic of low income people

By Dennis Archambault

The proponents of Healthy Michigan have not had much share of voice in the debate over work rules for the expanded Medicaid program. However, a recent University of Michigan Ross School of Business study has confirmed the economic benefit of the health insurance benefit for low income individuals and suggests that the proposed work rules would put thousands of unemployed enrollees at risk.

It’s interesting to read, in specific detail, what proponents of expanded Medicaid have felt for some time. On one hand, the target population is struggling and in debt. They also are likely to have a chronic disease, which requires regular medical care, if not urgent episodes of hospitalization. On the other hand, however, having their health insurance covered reduces the economic burden and makes it more likely that their health will be better managed.

Note some of the findings:

  • Reduced the amount of medical bills in collections that the average enrollee had by 57 percent, or about $515.
  • Reduced the amount of debt past due but not yet sent to a collection agency by 28 percent, or about $233.
  • Led to a 16 percent drop in public records for financial events such as evictions, bankruptcies and wage garnishments; bankruptcies alone fell by 10 percent.
  • Resulted in enrollees’ being 16 percent less likely to overdraw their credit cards.
  • Led to improvement in individual credit scores, including the number with a “deep subprime” rating falling by 18 percent and the number listed as “subprime” falling by 3 percent.
  • Allowed enrollees to engage in more borrowing to buy cars or other goods and services, which is consistent with better credit scores. Enrollees experienced a 21 percent increase in automotive loans. Other studies have found that Medicaid expansion reduced use of payday loans and reduced interest rates for low-income people.
  • Helped people with chronic illnesses and those who had a hospitalization or emergency department visit during the study period with bigger reductions in their bills sent to collection and bigger increases in their credit scores.

Miller and colleagues published an academic report on the research in the Journal of Public Economics. Check that out for more details: https://www.sciencedirect.com/science/article/abs/pii/S0047272718300707.

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


What does urban agriculture have to do with the Farm Bill?

By Kathy Beard

MOTION Coalition in Support for 2018 Revision of Agricultural Act of 2014

The growing movement towards urban farming has a champion in Senator Stabenow, but her efforts may be jeopardized soon. In 2016 she introduced the Urban Agriculture Act of 2016[1]. The act provides assistance to urban farmers with the goal of providing fresh, healthy options to the underserved. This Act became part of the revisions by the Senate to the Agricultural Act of 2014, frequently referred to as the Farm Bill. Section 7212 of the revised Senate Farm Bill amends the 1990 version to include grants for research, education and training to enhance urban and indoor agricultural production and for evaluation of these methods. It provides $4 million dollars per year (2019-2023) and an additional $10 million each year to carry out the process. It also authorizes $14 million for a two-year census data-gathering project to collect information on urban agricultural production including community gardens and farms, rooftop farms, greenhouses and vertical farming[2]. The House Bill does not address urban agriculture[3].Excluding urban farmingputs the Senate’s bi-partisan proposal addressing this issue at risk for a number of reasons.

As in the general legislature, the conference committee is dominated by Republicans (34/22), putting any chance of a democratic initiative in jeopardy of being cut from the final proposal. Second, the influence on the type of agriculture is heavily biased toward commodity cash crops, corn, wheat and soy. Texas, for example, which has the largest representation on the committee, produces primarily cattle and cotton[4]. California, with four representatives is the largest vegetable and fruit producer[5]. Commodity cash crops, dairy and farm animals are the primary sources of income for the remaining States represented on the committee. In most urban areas, it is still against the law to raise farm animals. The focus then, of the committee will not be on urban agriculture but on those cash producing items that bring money to the State.

Further, House Republican Chairman, Mike Conaway is a strong proponent of a improving the rural, not urban, environments and was the driving force behind the recent  HOUSE review of SNAP benefits which ultimately led to the proposal to restrict SNAP benefits by “offering SNAP beneficiaries a springboard out of poverty to a good paying job, and opportunity for a better way of life for themselves and their families”[6] – code for tightening the work restrictions for ABAWD (Able Bodied Adults Without Dependents)[7]. It is this portion of the bill that will be the most heavily debated.

There is a sense of urgency to speed the process of completing a bill by September 30 when the 2014 version is set to expire. In cases like this, what many would consider a small matter may be sacrificed for expediency. Proponents of urban agriculture should be vigilant during this time and prepare to react to any threats to this portion of the bill. Click here to learn more about the committee hearings.

Recommended sites:

House Committee on Urban Agriculture

USDA Data on Cash Crops by State








Kathy Beard is program manager, MOTION Coalition, an initiative of Authority Health

Fix the (social) potholes!

By Dennis Archambault

Throughout the primary election the overstated campaign issue was “fix the potholes.”  It’s not too much of a stretch to suggest that this is a metaphor for fixing or strengthening the state’s physical infrastructure. What about the social infrastructure?

The Citizens Research Council has released a report  (https://crcmich.org/an-ounce-of-prevention-what-public-health-means-for-michigan/)  that documents the drop in spending on public health in Michigan, pushing the state to the bottom in per-capita public health expenditures. You’d think that the Flint disaster would have prompted greater debate about the need for a stronger public health system, and specifically “health in all policies,” which could have prevented, or certainly minimized the damaged caused by poor government oversight.

According to the CRC report, Michigan has seen a worst-in-the-nation outbreak of Hepatitis A, numerous outbreaks of vaccine-preventable diseases, an infant mortality rate well above the national average, and above average prevalence of chronic disease.

The report notes that the state has spent just enough to match federal public health funding, leaving local health department scrambling for funds to do little more than their required duties.

Why wouldn’t this be a campaign issue? Why is it that public health is seldom even mentioned in policy debates?

Eric Lupher, president of the CRC, concludes, “While the state has been engaged in a very successful Pure Michigan campaign to promote the state as a place to live, work, and play, its neglect of public health services creates negative press that often washes out the benefits of the promotional campaign. It detracts from the state’s investments in workforce development and job training. And it inflates healthcare costs that are high to begin with.”

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

The next generation of lower income seniors face a perilous future, which is bound to impact population health.

By Dennis Archambault

Advocates of low income housing are anticipating a “tsunami” as gentrification pushes existing low income tenants out of rental properties, more people losing their homes due to the collapse of their household income, and fiscally unprepared people retiring – some earlier than expected. The latter is a particularly acute problem as the Boomer generation retires with inadequate retirement savings. The homeless population in this segment is expected to climb, if not soar.

The New York Times did a good job reporting on the economic issue (https://www.nytimes.com/2018/08/05/business/bankruptcy-older-americans.html?nl=top-stories&nlid=67835882ries&ref=cta). This will be a critical concern for population health in the coming years.

Dennis Archambault is vice president for Public Affairs at Authority Health



The link between demolitions and childhood blood levels in Detroit

By Laura Wilson

In the last several years, Detroit’s demolition program has received media attention for its potential association with increased blood lead levels in Detroit children. The demolition program, which began in 2014, has resulted in over 14,300 demolitions. The percentage of elevated blood lead levels (EBLL) in children has steadily decreased in Detroit and statewide. However, 2015 marked the first increase in this percentage in Detroit in decades, from6.5 percent to 7.9 percent. In 2016, the percentage increased again to 8.8 percent.

The topic resurfaced recently with a public feud between Dr. Abdul El-Sayed, the former director of the Health Department now running for governor, and Mayor Mike Duggan revolving around whether the city appropriately heeded Dr. El-Sayed’s warnings about demolitions and childhood lead exposure a few years ago. There is little evidence to know what occurred between Dr. El-Sayed and Mayor Duggan, but the conflictraises important questions around the prioritization and complexity of public health efforts.

The hazards of urban blight are well-known. Unfortunately, the renovation and demolition of older buildings brings its own environmental health hazards, as dust is kicked up into the air from homes that may contain lead or other harmful chemicals. This can be problematic in cities like Detroit, where 93 percent of homes were built before the banning of lead paint in 1978. As a result, such an expensive large-scale demolition program becomes a challenging balance act of efficiently removing blight while also trying to ensure hazardous exposures are minimized through appropriate protocol, contractor compliance, and educational programs.

Since the beginning of the program, the city has taken steps to mitigate the hazards of demolitions. In 2016, though, the Detroit Health Department, led by Dr. El-Sayed, conducted a study to evaluate the association between demolitions and children blood lead levels. They found that the odds of blood lead level elevation in children increased by 20 percent if they lived within 400 feet of a single demolition and 38 percent if there were two or more demolitions. This relationship was specific to summer months when kids are out of school and spending more time in their homes and neighborhoods. The researchers concluded that demolitions may have contributed to about 2.4 percent of cases of EBLL in Detroit, which would account for the recent uptick in EBLL percentages.

In light of these findings, Dr. El-Sayed convened aDemolitions and Health Task Force. In early 2017, the taskforce met four times to develop recommendations for the city,prior to Dr. El-Sayed’s gubernatorial run. In the last year, the city has incorporated a few of the taskforce’s recommendations, including protocol improvements and a texting service program launched in November 2017 that residents can enroll in to be notified of nearby demolitions.

This year, the city is taking a more proactive, preventive approach to lead paint exposure. A new Interagency Lead Poisoning Prevention Task Force was announced in March that is focused on exposure resulting from lead paint in the homes of children. As part of its $1.25 million pilot program, the city is halting summer demolitions in the fivezip codes with the greatest percentage of EBLL (48202, 48204, 48206, 48213, and 48214) where they will conductdoor-to-door outreach and educational programs, specifically targeting the homes of children and pregnant women.

Despite this promising new program, large demolition projects include a lot of players and a lot of moving parts. Detroit, like other cities, has a complicated history with management of demolition and ensuring compliance among contractors. For this reason, it is important for both residents and population health researchers to be watchful of what is being prioritized and what is being compromised in even the most well-intentioned efforts.

Laura Wilson is a Masters of Public Health Candidate at the University of Michigan School of Public Health. She is serving a Health and Housing internship at Authority Health.


Percentage of children under age 6 with elevated blood lead levels
Year Detroit Michigan
2011 10.2% 5.0%
2012 8.5% 4.5%
2013 8.0% 3.9%
2014 6.5% 3.5%
2015 7.9% 3.4%
2016 8.8% 3.6%
Data from Michigan DHHS Childhood Lead Poisoning Prevention Program Annual Reports

Elevated blood lead levels:  > 5 µg/dL as defined by the CDC.


Figure 1: Blood Lead Levels by ZIP Code


Figure 2: Demolitions by City Council Zone


Figure 3: Demolitions by Location