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Project Homeless Connect provides ‘disaster relief’ close to home

On May 17, 2013, I participated with other employees in my public health department working at Project Homeless Connect.  This is, at present, a quarterly endeavor to provide a range of medical and social services to the estimated 2,000 homeless individuals of Pierce County, Washington.

However, the people who line up as early as 7 a.m. for a range of needed services are not entirely the homeless. Many have jobs, but lack health and dental insurance. They basically are coming for primary or even emergency care that they cannot access elsewhere.

The Washington State Department of Social and Health Services is one of many organizations participating in Project Homeless Connect.

The Washington State Department of Social and Health Services was one of many organizations participating in Project Homeless Connect, held on May 17, 2013 at Calvary Community Church, in Sumner, Wash.

Project Homeless Connect, in its communications for its volunteer-run event, said it offered the following:

  • Medical and urgent care
  • Urgent dental care
  • Mental health services
  • Social service referrals
  • Vision/glasses
  • Haircuts
  • Child/adult immunizations
  • Veterinary care
  • Legal and financial advice
  • Housing, shelter, employment and education information
  • Tobacco cessation
  • Homeless assistance
  • Veterans services
  • Chemical dependence and assessment

This was no small effort. Months of planning went into pulling off this disaster-relief style engagement that is more associated with hurricanes and tornadoes than with meeting the basic needs of Pierce County, the second most populous (pop. 812,000) in Washington State.

Large, converted vans/trucks lined up providing veterinary services, dental care, and other interventions. Yet, oddly, there was no media present to put the story on the 5 p.m. news or in the daily newspaper the following day. (I checked but found nothing doing Google searches.) Why? Everyone who was homeless in Pierce and most social service and medical service providers likely was aware the event was taking place, for months in advance.

I did see not any elected officials (they may have come, and they may even have volunteered). All of this took place in a county whose hospitals are making profits of $1,000 per patient visit more than the state average and in a county where nonprofit hospitals are earning up to and more than $500 million in profits.

I saw all kinds of people—young, old, white, black, Asian, Latino, Pacific Islander, disabled, able-bodied, veterans, you name it. Volunteers came in all stripes as well. There were military personnel, dental assistant students from Pierce County community colleges (Bates and Pierce ), trained medical providers, church volunteers, hair stylists, and more. The list goes on. What struck me the most was how polite and appreciative the attendees were. Many drove or were driven from remote parts of the county to this somewhat semi-rural area in Pierce, southeast of Tacoma.

One of the providers, Medical Teams International, had one of its full-service converted mobile home vans providing dental care.

Medican Teams International brought one its converted mobile home vans to Project Homeless Connect on May 17, 2013, in Sumner, Wash.

Medical Teams International brought one its converted mobile home vans to Project Homeless Connect on May 17, 2013, in Sumner, Wash.

That program boasts a fleet of 11 mobile dental clinics in Oregon Washington, and Minnesota that use 38-foot converted motor homes. Each clinic contains has two full medical stations and all necessary equipment, instruments, and supplies. The organization claims it has helped more than 200,000 adults and children with its mobile medical program since 1989.

Medical Teams International defines itself as a christian global health organization “demonstrating the love of Christ to people affected by disaster, conflict, and poverty.” The group works globally, including in Africa, South America, Asia, and North America.

Yet, it was in Pierce, addressing what clearly that organization perceived as akin to disaster and conflict.

In Washington State, 14 percent of all residents are without health insurance, according to the Kaiser Family Foundation. In Pierce County, the percentage is roughly the same.

All of this I find remarkable. Less than five miles from this revolving quarterly circus of human need there was a major shopping center, South Hill Mall, with about every major electronic gadget and consumer good on the market. Truck and car lots were also close by, with products selling from $25,000 and up. The disconnect to me was palpable, particularly the same week the Republican-led U.S. House of Representatives passed its 37th legislative measure to repeal or defund the market-driven health care reform known to its detractors as “Obamacare.”

I recall what one of my University of Washington School of Public Health colleagues—the one I respected more than nearly all others—told me when we talked about our peers who had worked or would work in public health in Africa or in developing nations. My friend asked somewhat ironically, why don’t they work at home. We have plenty of problems here. Given what I saw at Project Homeless Connect in Pierce County in mid-May 2013, I could not agree more.

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Why Joan of Arc matters to beleaguered public health

Milla as Joan

Milla Jovovich in her role as Joan of Arc in the film The Messenger: the Story of Joan of Arc.

Recently, I watched a movie about the life of Joan of Arc (Jeanne d’Arc) called The Messenger, the Story of Joan of Arc by French director Luc Besson and starring Milla Jovovich. Though the movie got tepid reviews, I was mesmerized by it.

The period epic faithfully re-tells many key moments in the short life of the world-renown young French leader, including her actual words that were recorded in detailed written accounts. I found the movie intoxicating because of Jovivich’s exuberance as Joan, inspiring her countrymen to arms to free their nation, ensuring the crowning the Dauphin Prince in the Reims Cathedral as King, and following in her view the will of God.

Few other single individuals had such an impact on world history as this illiterate peasant girl, who rose to prominence in a violent male world and became one history’s greatest and most inspirational figures—and a saint for Catholic believers.

In fact no single historic figure from Europe during the 100 Years War between France and England remains as famous today as Joan. By the age of 17, she unswervingly acted on voices in her head telling her to drive the English from France and crown Charles VII as King of France. This came at France’s weakest moment in its history, with the English and Burgundians in control of half the country.

Yet, this virtual unknown girl never waivered. She gained access to the French court in the spring of 1429 in Chinon, France. She withstood questions from learned and suspicious church officials and a virginity test. She arrived in the besieged city of Orleans in April that year, bearing a standard and ready for action.

In defiance of cautious male commanders, she singlehandedly helped lead the French to defeat the attacking English, suffering several nearly fatal injuries. Her foes called her a witch and remained fearful of her talismanic powers. She brought together violent, power hungry men, like the Count of Dunois and the Duke of Alencon, around a common cause to the point they even would stop swearing and offered blind loyalty to her. Most importantly, she restored confidence of the French people around a common goal. Soon, all of Europe was talking about the Maid of Orleans and her battlefield exploits.

Joan Burning Picture

Joan of Arc being burned at the stake after being tried by the English and church leaders in 1431. She was only 19 years old.

By July that year, Charles VII was crowned king. Yet within a year, the young peasant who worked miracles was captured and ransomed to the English, tried as a heretic, and burned at the stake in Rouen on May 27, 1431, for having worn men’s clothes, no less.

Five centuries after her murder, she was pronounced a saint by the Catholic Church for the miracles that are linked to her remarkable accomplishments. While she did promote violence, she always offered her opponents opportunities for peaceful alternatives, and she reportedly showed great kindness to those captured.

So why should anyone in public health care about Joan of Arc?

As a student of history, I found many elements of her remarkable story relevant for my reality. Instead of beleaguered 15th century France, I find myself in the reality of the beleaguered U.S. public health system.

Religion you say? That has nothing to do with healthcare and public health, right? Well, that ignores the fact that religion has everything to do with healthcare and public health. For example:

Well, an illiterate peasant girl can teach nothing of value to doctors, PhDs, and other well-educated professionals who run our nation’s public health system, right?

I recently read an article highlighting leadership and public health. Some of the attributes associated with leadership include: serving, complex thinking, being a change agent, self-empowerment to empower others, risking failure, creating a future one envisions, and being confident in one’s beliefs and then living the change one wants. I am actually hard-pressed to find examples of such traits in leaders in my field who are resonating widely with the American public. Joan of Arc consistently showed all of these leadership traits, from risking her life on the field, to being a catalyst, to having supreme confidence in her vision.

Former U.S. Surgeon General and "Public Health Hero" Dr. David Satcher.

Former U.S. Surgeon General and “Public Health Hero” Dr. David Satcher.

In the United States, there are always “unsung hero” awards for people who no one outside of the particular field giving the award have heard of, or even care about, it seems. While these may help sustain the field of providers, they likely do little to inspire the public.

The University of California Berkeley in February held its annual event for “public health heroes,” awarding its 2013 prize to former U.S. Surgeon General Dr. David Satcher. However, I doubt few Americans know who Dr. Satcher is, what he accomplished, and why such facts matter to the nation’s crisis of promoting public health in the 21st century.

This is not to belittle Dr. Satcher’s many accomplishments, such as his calling attention to the oral health epidemic in the United States. (Oral health experts have been talking about his report for more than a decade because he and it were spot on.)

Public health, teetering like France before the arrival of Joan of Arc?

Or course medieval France has nothing in common with the reality of modern America and its healthcare system, right? But if you take the view of that history can teach open-minded students of the present many valuable lessons, regardless of their field, one might find parallels.

France at Joan’s time was on the verge of collapse, lacking strong leadership and a vision to restore hope and unity. Joan arrived completely confident in her vision and religious mission, and she never wasted a day. She famously said, “Better today than tomorrow, better tomorrow than the day after.” She also is remembered by her words, “go forth boldly.” Such words and such inspiration are lacking in the U.S. public health system, to me at least.

For those working in the field of public health, one is constantly exposed to the reality of budget cuts that continue to hack away at programs that do everything to promote chronic disease interventions to immunizations. Between 2008 and 2010 alone, in the aftermath of the Great Recession, more than half of all local public health departments had cut core funding and shed 23,000 jobs, as well as cut programs, mainly due to falling tax revenues that hammered local and state funding.

Things continue to spiral downward as the recession’s effects linger, and mandatory across the board federal budget cuts known as the sequester will soon impact every local public health department in the country and national agencies who help fund local efforts.  The Public Health Institute warned that sequester related cuts will be “devastating to the public’s health.” Such cuts, the institute says, “will cost jobs and resources in the short run, and the long-term costs—in money and lives—will be borne by families and communities for years to come.”

Crises also prevent departments from looking to innovation as they focus on life support and triage. Morale suffers, which impacts service and core functions. Leadership, perhaps what little that may exist in this beleaguered environment, is lacking. Public health managers struggle to connect with the public about what public health is and why it matters.

They fail to show that the U.S. health system’s treatment, not prevention, focus is largely unsustainable for the population’s health and the economy. In 2009, U.S. public health spending (at all governmental levels) amounted to $76.2 billion – only 3% of the nation’s overall healthcare outlays of $2.5 trillion. Yet, chronic diseases, which public health efforts can address, make up three quarters of all health care costs.

Public health spending versus all other healthcare spending in the United States.

Public health spending, as measured as billions of dollars, versus all other healthcare spending in the United States and spending on chronic diseases and all other healthcare costs.

Reform does happen, and it can be bold when breakthroughs capture the public’s and globe’s attention.

HIV/AIDS assistance, which is now at the heart of a larger global public health agenda, was launched in the late 1990s when activists outside of the medical and public health establishment demanded that antiretroviral drugs, or ARVs, be made available to many of the world’s poorest and most afflicted nations, most in Africa, to reduce the spread of the virus inside the bodies of infected people and make it possible for them to live long lives.

It was not reformers inside “the system,” it was radicals outside “the system,” who offered a clear vision and the groundswell for change that the establishment eventually fully embraced.

As someone who works inside “the bureaucracy,” however, I am ever mindful of how the great Joan of Arc was ultimately marginalized, tortured, and burned alive at the stake for her completely unorthodox ways that challenged nearly all in authority in her day. The English did not trigger her downfall, it was palace politics and sexism, and likely fear of her power.

Joan statue

One of many Joan of Arc statues in France honoring one of the French nation’s greatest heroes.

The lessons are telling today. You can work miracles, but the machinations of any bureaucratic system can be deadlier than slings and arrows of a battlefield of your sworn enemies. You could transpose the palace intrigues of 15th century French and English courts to any bureaucracy today and it would be a near perfect fit, really. Would any bureaucratic leader trust an uneducated, poor, unconnected interloper to provide a vision for change for the failing health and public health system, such as the one facing the United States in 2013?

Sure, such a thought is laughable, but it happened, and can happen again. It may even be needed if things continue on the present course.

In the end, no one remembers the bishops who tried and convicted Joan or the weak king she helped to bring to power, or in fact any of the kings of her day. Likewise, no one remembers or cares about bureaucrats in the end. Why? Quite simply they are not visionaries.

It is Joan who has statues in her honor, countless biographies recounting her legend, and many movies and documentaries exploring her incredible exploits.

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Coptic Christians under assault, and memories of my Egyptian travels

On April 7, a mob in Cairo attacked a funeral procession of Coptic Christians, a minority in the now Muslim Brotherhood-led nation of Egypt. The attackers became violent during their seige, firing guns and throwing petrol bombs according to press reports. Prior to the fall of former president and practically dictator for life, Hosni Mubarak, state police protected Christian monasteries and churches in Egypt, due to the historic persecution of the minority Christians over decades.

Coptic Egyptians protest the assault that killed two and left nearly 100 injured at St. Mark's Cathedral in Cairo on April 7, 2013.

Coptic Egyptians protest the assault that killed two and left nearly 100 injured at St. Mark’s Cathedral in Cairo on April 7, 2013.

During the violent outburst at St. Mark’s Cathedral, two persons were killed and nearly 100 were injured. Christians inside the walled compound sustained what was called a “frenzied assault” from unknown perpetrators.

I visited in Egypt in 2004 and saw well-armed and manned police garrisons at multiple monasteries, including those in unpopulated areas, as well as at St. Mark’s Cathedral, the seat of the Coptic Christian Church. Amid the disintegration of Egyptian civil society and the ascendancy of the long-banned Muslim Brotherhood, Coptic Christians and their most sacred sanctuaries are now under direct assault. Tensions have escalated since the election of U.S.-educated and Islamist Mohamed Morsi as Egypt’s president in June 2012.

Egypt’s Coptic leaders had grown increasingly wary of worsening conditions over the last five years, particularly since the demise of U.S.-backed Hosni Mubarak. Muslim clerics, the Muslim Brotherhood, and its political wing, the Freedom and Justice Party, are credited by some media observers for inciting views hostile to the nation’s Christian minority.

Inside Bishoi Monastery, one of the oldest Coptic monasteries in Egypt 2004)

Inside Bishoi Monastery, one of the oldest Coptic monasteries in Egypt (2004).

Coptic Christians, like the young men seen here from my 2004 photo, are a persecuted minority in Egypt.

Coptic Christians, like the young men seen here from my 2004 photo, are a persecuted minority in Egypt.

In 2009, amid the swine flu scare, the Mubarak government destroyed more than 300,000 pigs, which was rebuked by the United Nations as unnecessary. Many believed the act was motivated Islam’s prohibition for eating pigs and the fact that Egypt’s pork industry is run almost entirely by Copts, many the urban poor.

One blogger wrote, “It is a national campaign to rid the country of its estimated 300,000 pigs in the name of public health.”

Copts allege the military council in the post-Mubarak era—the military still runs many Egyptian institutions and business sectors—is doing little against perpetrators of the attacks. Copts also have long complained of discrimination, including a law requiring presidential permission for churches to be built.

The Daily Star Newspaper of Lebanon reports that many Copts question their future as Egyptians. The paper notes the latest round of violence is the worse since Morsi was elected in June 2012: ”Christians have been worrying about the rise of militant Islamists since the fall of President Hosni Mubarak in 2011. But after days of fighting at the cathedral and a town outside Cairo killing eight – the worst sectarian strife since Islamist President Mohammad Morsi was elected in June [2012]–many Copts now question whether they have a future in Egypt.”

Who are the Copts?

Today, Copts purportedly number about one in every 10 of Egypt’s 85 million residents. However, official statistics placed them at half that figure, or 5 million. The Coptic Church challenges that estimate, pegging their numbers at 15-18 million.

Father Tawdros at St. Anthony's Monastery in Egypt, taken in 2004.

Father Tawdros at St. Anthony’s Monastery in Egypt, taken in 2004.

The original term “Copt” simply meant a native Egyptian with no religious connotation, only later taking on its religious meaning today.

The Coptic Church is among the oldest Christian churches, preceding Islam’s arrival in Egypt by centuries in a land that is central to Judaism and Christianity. Some of the most important places to both faiths are within Egypt’s border, including Mt. Sinai and St. Catherine’s Monastery in the Sinai Peninsula.

The Copts split from the Eastern Orthodox and Roman Catholic Churches in 451 AD over a theological dispute over the nature of Christ. Today Copts are more similar to the Eastern Orthodox Church and perhaps the Armenian Orthodox church. In addition, the Coptic language, which is similar to the ancient Egyptian language, and written with the Greek alphabet, is still used in parts of Coptic services.

Increasing violence targets Christian minorities in the Middle East

Among the worst attacks on Egypt’s Coptic minority in recent years was the 2010-11 New Year’s Eve bombing in Alexandria. It targeted a Coptic church and killed 21. No individual has been arrested or brought to trial for the terrorist attack in one of Egypt’s most cosmopolitan and historic cities. The deed was largely forgotten with the world’s attention focussed on the “Arab Spring.”

Since the U.S.-led overthrow of Saddam Hussein in Iraq in 2003, Christians throughout the Middle East have been feeling increasingly under siege. Terrorist attacks and murders of Christians have occurred widely in many countries. (See map of the dispersion of Christians throughout the region—in all cases Christians had preceded the ascendency of Islam, but today are distinct minority communities.)christians middleeast

In Egypt and to a greater degree civil-war plagued Syria, the “Arab Spring” has brought intense disorder and violence to many minorities and minority faiths (Christians, Chaldeans, Kurds, Alawites, among others). Christians regionally remain fearful of a peaceful future of coexistence in the region that gave birth to contemporary Christianity.

In Egypts, Copts are now claiming life was better under dictator Mubarak, who dealt brutally with Islamists and their radical military wing, who waged a military and political campaign for decades.

Many Copts believe Muslim radicals want to eradicate Christianity, whose roots in Egypt predate the Islamic era.

According to an article published by the Middle East Quarterly, Muslim rulers historically have denied collective minority rights of non-believers. The concept of dhimmitude—itself a controversial term—explains the Islamic practice of denying equality to Jews and Christians, who historically since the Middle Ages have lived within the political realm of Muslim rulers and nations. Islam provided religious autonomy, not national freedom. To be fair, political rights for many groups, women, economic classes, and faiths everywhere in the world have not been fully realized until the last two centuries, and slowly at best and still not even today.

Memories of monasteries and my travels in Egypt

Whenever overseas events occur, it is often impossible to feel a connection to them. For me, in the case of Egypt, the collapse of Egyptian civil society has had great resonance for me. I had a chance to tour many parts of the country in 2004, observing the great poverty experienced by tens of millions of Egyptians on Mubarak’s corrupt rule. I was treated well, and I met many wonderful people, Muslim and Christians alike.

My visit to the St. George Monastery near Luxor required the permission of the local army commander for entire region around the Valley of the Kings (2004).

My visit to the St. Tawdros Monastery near Luxor required the permission of the local army commander for the entire region around the Valley of the Kings (taken in 2004).

CopticEgypt5

Suryani Monastery (2004).

I also visited many remote monasteries throughout the country—St. Catherine’s in the Sinai (run by the Greek Orthodox), St. Anthony’s in a remote inland oasis 30 miles from the Red Sea, Bishoi and Suryani monasteries in the Wadi Natrun oasis about 80 miles northwest of Cairo, and St. George’s and St. Tawdros’s monasteries, in the desert near Luxor.

The monasteries date as far back the 4th century AD, preceding the Islamic Arab conquest of that followed in the seventh century. Today about 50 monasteries remain.

I found the Coptic monasteries to be breathtakingly beautiful and peaceful. These are continuously inhabited facilities, but also significant cultural and historic sites.

The monks who greeted me were generous and gave me tours of their facilities. At St. Tawdros’s Monastery, I required a police escort of no less than the commander of the entire military contingent protecting the Valley of Kings region, one of the most popular tourist destinations in Egypt and the scene of one of Egypt’s more violent terrorist assaults. At all of the compounds, there were armed guards in large numbers.

Those guards have now melted away. In fact, it was the Egyptian military that led a coordinated assault on the Bishoi Monastery in February 2011, shortly after the terrorist bombing in Alexandria.

The video shows nothing less than a full assault of armed men, equipped with armored personnel carriers and bulldozers, demolishing an outer protective wall that I recall seeing built during my 2004 visit. The government denied responsibility despite the glaring video evidence. Today the monastery, one of Egypt’s great historic treasures, is now at risk of increased mob and organized violence by Islamic radicals and political extremists.

Egyptian military were filmed leading an attack on the Bishoi monastery in February 2011, which destroyed a protected outer wall.

Click on the image to see the full of the Egyptian military eading an attack on the Bishoi monastery in February 2011, which destroyed a protected outer wall.

I’m not sure what will happen in Egypt. It is likely Egypt’s Christians will remain a persecuted minority and some of the world’s greatest historic treasures will be desecrated by extremists and opportunists, as was seen after the U.S.-led invasion of Iraq and as the world is observing in Syria amid its civil war.

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America’s cultural zeitgeist and the emerging Don Corleone of public health

This has been one of the wildest weeks exposing the extremes of America’s cultural zeitgeist I can remember. What could be more American than gay marriage moving to the mainstream of American life and semi-automatic weapons readily available at a Walmart  near you, right?

Need a weapon of war to feel safe? Just drive to the nearest Walmart near you and select from their popular product lines.

Need a weapon of war to feel safe? Just drive to the nearest Walmart near you and select from their popular product lines.

On one hand, you have the U.S. Supreme Court hearing two landmarks cases, one on the legality of a voter approved ban on same sex marriage and another on the constitutionality of the federal Defense of Marriage Act, which aligns hundreds of federal benefits to promote that only a man can legally marry a woman.

Meanwhile, a full-court press was taking place in Congress to advance legislation that would require criminal background checks on all gun purchases and that would close the so-called gun-show loophole, which allows for up to 40% of all firearms sales to evade any scrutiny at all. However, efforts to include Sen. Dianne Feinstein’s amendment to restrict the sale of semiautomatic, military style assault rifles —the kind used to slaughter 26 civilians at Newtown—were dashed when Sen. Majority Leader Harry Reid (D-Nev.), on March 20, pulled it from the current gun legislation in the U.S. Senate. GOP members of Congress are already promising to filibuster the bill.

Will Ferrell, actor, comedian, and cultural clairvoyant, seemed to sum up the obvious best.

Will Ferrell, actor, comedian, and cultural clairvoyant, seemed to sum up the obvious best.

Will Ferrell’s now much repeated tweet seemed to put the pulse of the nation best: “I feel so blessed that the government protects my wife and me from the dangers of gay marriage so we can safely go buy some assault weapons.”

And, as we have so often seen in our country, sometimes tasteless, but also very popular, comedians can best summarize the seemingly craziness of political reality, where serious-minded commentators fall flat. Perhaps only through comedy can we see the absolutely surreality of our current reality.

Bloomberg takes on the NRA: no quarter asked, and none given

This week also saw the launch of Mayor Michael Bloomberg’s $12 million campaign in 10 states to promote federal gun legislation, through his national coalition of big city mayors called Mayors Against Illegal Guns. “I don’t think there’s ever been an issue where the public has spoken so clearly, where Congress hasn’t eventually understood and done the right thing,” said the multi-billionaire leader of a national political movement to restrict the proliferation of weapons that claim more than 31,000 lives annually.

Bloomberg’s newly created super PAC, Independence USA PAC, infused millions in the last federal election cycle, helping elect four of seven candidates who promoted legislation to reduce gun violence in the United States, a major public health threat that only now is getting the attention of public health  officials nationally after years of self-imposed silence.

Wayne LaPierre went head to head with Michael Bloomberg on the talk shows.

Wayne LaPierre went head to head with Michael Bloomberg on the talk shows.

Likely fearing the emergence of a national political movement, the National Rifle association (NRA) launched a counter-strike against Bloomberg’s media campaign. NRA head Wayne LaPierre sparred with Bloomberg on Meet the Press on March 24, framing Bloomberg as a plutocratic, public health-minded uber-nanny who threatened America’s freedoms, including the alleged right to own guns and the right to eat unhealthy food:

“And he can’t spend enough of his $27 billion to try to impose his will on the American public,” said LaPierre, the national face for the most powerful gun industry lobby.”They don’t want him in their restaurants, they don’t want him in their homes. They don’t want him telling them what food to eat; they sure don’t want him telling them what self-defense firearms to own. And he can’t buy America.”

Which multi-billionaire do you want to champion public health, Gates or Bloomberg?

Bloomberg’s efforts to limit the size of sugary drinks in New York City was recently struck down by the courts. But Bloomberg remains determined to preserve his emerging national status as the Don Corleone of public health.

From pushing upstream interventions to tackle obesity to funding multiple efforts to reframe the national dialogue on guns and America, Bloomberg appears to be everywhere at once these days. In many ways, the bolder, tougher, more confrontational face for public health and the national voice for legislative action on clear public health threats is the 71-year-old Boston native.

By force of will and deep pockets, Bloomberg is emerging as a rival brand for plutocratic public health warrior to reigning champion Bill Gates, whose Microsoft-based wealth helped fund the biggest non-governmental player in public health, the Bill and Melinda Gates Foundation. With $34 billion in assets it is the largest openly run private foundation on the planet.

Which Don Corleone do you want to promote public health, Bill Gates or Michael Bloomberg?

Which Don Corleone do you want to promote public health, Bill Gates or Michael Bloomberg?

Multi-billionaire Gates carefully has chosen non-confrontational public health initiatives that many limited-government and conservative minded leaders can champion, such as poverty reduction programs, education programs, and promoting technological efforts such as genetically modified crops.  Bloomberg’s approach is a much more in-your-face, New York style. He has proven very effective on the bully pulpit by staking out public positions and articulating views that few in the field of public health or even elected office have championed since the assault weapons ban was passed in 1994 as part of a major cops bill under the Clinton White House.

One thing is clear. Leadership, in the wake of repeated gun-fueled tragedies, like the Sandyhook Elementary School mass murders, is making a difference. And for a change, it appears that the NRA’s seeming unshakable momentum to promote the ever-expanding sales of firearms and legislation that allows for the deadly use of force has been called into check.

This also has rippled down to the public health departments, which are now showing greater resolve and passing measures calling firearms-related deaths a threat to public health and totally preventable. Maybe Bloomberg’s moxie is rubbing off. Such symbolic efforts by public health departments clearly are not a true fix, but they are a long-awaited and long-overdue baby step forward.

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The politicization of public health (and everything else too)

maherobama

Click on the photo to open a link to the video clip of Maher’s commentary.

Some might say TV host Bill Maher is so political that he cannot be trusted. I disagree.

On March 8, on his TV show, Maher delivered a very provocative commentary that everyone in the field of health promotion, public health, and public policy should watch. Maher rightly asked, “Since when in America did everything have to be so political?” It was a smart piece of punditry, because he correctly showed how efforts to promote public health, nutrition, and healthy eating had become as politicized as the debate over regulating the proliferation of firearms.

Showing pictures of First Lady Michelle Obama, a champion of a national nutrition and exercise campaign called Let’s Move, Maher opined, “If seeing this nice lady on TV saying she likes the movies, or nutrition, or exercise fills you with rage, get help.”

Maher further correctly noted, “Big portions, conservative; knowing where your food came from, liberal.” In short, Maher said what few in the public health profession are saying or have the courage to say—that a deep schism exists in the public space that taints and will continue to taint all efforts to tackle some of this country’s biggest health problems.

These include the obesity epidemic and the threat posed to our healthcare system and our national health by chronic disease.

Ever a political lightning rod who is ready to fan conservative flames, former half-term Alaska Gov. Sarah Palin used her speaking appearance  at the 40th annual Conservative Political Action Committee (CPAC) conference on March 16, to lambaste New York City Mayor Michael Bloomberg’s efforts to tackle obesity by limiting the size of sugary-sweetened beverages. Bloomberg’s New York City law to limit the serving size of such drinks to just 16 ounces was  overturned by a New York State Judge on March 11.

This perfectly framedAP file photo from March 16 shows Palin's eager embrace of red-meat politics that seeks to prevent small measures to address the proliferation of obesity in the United States.

This perfectly framed AP file photo from March 16 shows half-term former Alaska Gov. Sarah Palin’s eager embrace of red-meat politics that seeks to prevent small measures to address the proliferation of obesity in the United States.

Completely ignoring the obesity crisis that is afflicting her own former state and the country, where two-thirds of all residents are obese or overweight, Palin slurped soda from a 7-11 Big Gulp. The theatrics, all perfectly inline with Palin’s anti-government theology, again proved Maher’s point about the politicization of even micro efforts by some local elected officials to address the public health threats facing the country. (Side note, Palin briefly was governor when I lived in Alaska, and I saw her at health promotion events like community runs–an action that she likely would brand as “liberal” today.)

Whenever I would engage Puget Sound area public health officials during my two years of study at the University of Washington School of Public Health (2010-’12), I always asked, how can you prevent the public perception that efforts to promote healthy activity and nutrition are not perceived by conservative voters and Republican elected officials as part of a liberal, activist agenda. I never got a good answer, mainly because I do not believe those officials had an answer. I did not draw any great wisdom from my faculty or UW SPH peers either.

Some wonkish types have tried to investigate this issue in “philosophical terms,” along traditional axes of egalitarianism/choice minded conservatism against regulation-minded “big government” liberalism. One 2005 article on responsibility in health care choices argued, “Holding individuals accountable for their choices in the context of health care is, however, controversial.” There may be some truth to this, but I discount the “core political values” explanation as a way of understanding the politicization of public health initiatives.

Perhaps the biggest fight  in the U.S. political system today is over tax policy and the future of major social/medical programs—Social Security, Medicare, Medicaid—that provide the true underpinning to the public wellness of our country. This is, at its core, is vicious political battle that will shape the public health of the country unlike any action taken by any regulatory or health agency of the U.S. government.

Regulation to promote health has been at the heart of the public health enterprise ever since the field emerged as a profession in the United States in the late 1800s. According to the Centers for Disease Control and Prevention, many of the most successful public health achievements of the 20th century  (food safety, motor vehicle safety, identifying tobacco as a health hazard, etc.) were “upstream” interventions that, by definition, were regulatory in nature and thus purely political.

However, public health, by being a public enterprise, is by definition a creature of the political process, and thus influenced through the power of the purse to curtail its authority and stymie its reach. Public health departments today, for instance, are managed by publicly accountable officials. A local public health department board of health, like King County’s, includes a broad range of elected officials and a few medical professionals.

The nation’s leading de facto public health official, the U.S. Surgeon General (Dr. Regina Benjamin), today remains a mostly toothless position that has little if no sway over the public policy debate concerning the nation’s public health, according to New York Times health blogger Mark Bittman. He writes, “… there is no official and identifiable spokesperson for the nation’s public health, and the obfuscation and confusion sown by Big Food, along with its outright lies and lobbying might, has created a situation in which no one in power will speak the truth: that our diet is making us sick, causing millions of premature deaths each year and driving health care costs through the roof.”

I personally believe that the position of Surgeon General remains that of a paper tiger because those who have power, members of Congress and the Executive Branch, do no wish to allow an advocate for public health to embarrass them with pesky things like facts and science that call for action.

Dr. C. Everett Koop, former U.S. Surgeon General and effective communicator and advocate for public health.

Dr. C. Everett Koop, former U.S. Surgeon General and effective communicator and advocate for public health.

The most effective Surgeon General in living memory who recently passed away in February, the late Dr. C. Everett Koop, proved unpredictable. Though a staunch conservative appointed by President Ronald Reagan, Dr. Koop staked out very controversial political positions on moral and medical grounds, in defiance of his boss, Reagan.

His notable actions still stand out today for their audacity to challenge powerful interests and their embrace of morality as a tactical advocacy tool:

  • Koop’s office produced the plainly worded, 36-page “Surgeon General’s Report on Acquired Immune Deficiency Syndrome,” which clinically detailed HIV transmission, making clear it was not spread by casual contact and affirming that, “We are fighting a disease, not people.” Koop promoted sex education and condom use, enraging conservative critics.
  • Koop also took on the all-powerful tobacco industry and lawmakers who received its many contributions with his pronouncements that smoking killed and should be banned. He famously called purveyors of cigarettes the “merchants of death.” (When is the last time anyone has heard a medical leader embrace such powerful language for a public health cause?)

Though Koop reportedly claimed morality never “clouded his judgment,” he remained an effective advocate on the bully pulpit by literally shaming those in power. “My whole career had been dedicated to prolonging lives,” he said, “especially the lives of people who were weak and powerless, the disenfranchised who needed an advocate: newborns who needed surgery, handicapped children, unborn children . . .people with AIDS.”

I keep waiting for someone, anyone besides billionaire Mayor Bloomberg, to enter the political discourse on behalf of public health and use straight language that cuts through the hype. The problem is, they cannot teach you leadership when you enter the fields of public health or politics. It is something you either are capable of, or simply lack. Right now, it is lacking.

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Do community health fairs really make any difference at all?

As a frequent community event and festival attendee in Seattle and many other communities, I have always wondered how effective these events have been in achieving their goals of promoting health and wellness. In the public health world, we call these “health fairs,” and they are fairly ubiquitous nationally and accepted with de rigueur. But do they really work?

Somewhat new to the field of public health, I am more familiar with trade shows, which I have been attending for many years. These much more ubiquitous activities provide a common space where companies, governments, and a mass market meet to hopefully find audiences and make sales. They do not seem to be going out of fashion. One show I attended, the biennial Oil and Gas Expo in Calgary, one of the continent’s largest energy shows, draws 20,000 attendees from around the world and sells out every hotel room during its June run. The massive trade fair also attracts some of the world’s largest and most influential companies. So clearly where money is to be made, “the show must go on.”

The super-sized Oil and Gas Expo in Calgary is a perfect example of how important trade fairs are in the private sector.

The super-sized Oil and Gas Expo in Calgary is a perfect example of how important trade fairs are in the private sector.

But what of health fairs that cater to smaller subpopulations, and sell messages, behavior change, and health awareness that can be even unwanted by the audience? I recall distinctly that one of my public health professors at the UW School of Public Health, who shall remain nameless, said s/he had never seen any evidence this public health activity had any measurable outcomes, yet they proliferated as a best practice.

One fan of community health fairs is Dr. Kevin Pho, an internal medicine specialist who also runs a blog that attempts to reach out to a mass audience. On his blog, KevinMD.com, he gives space to another blogger, who does not give his name and thus we do not know if he is a true MD. But Dr. Pho claims he is, and by endorsing his colleague, he publishes a passionate defense of health fairs as a way of extending medical care without medical hierarchy: “Meeting in this context fosters rapprochement between patient and doctor. The once hierarchical encounter is no more. In this habitat, doctor and patient are in fellowship.” The mystery doctor, who we cannot fully validate, claims that health fairs:

  • Are an excellent way to engage underserved communities in caring for their health.
  • Offer a unique opportunity to engage patients in the community with which they self-identify, particularly when they are in the “precontemplation” phase of action.
  • Are a great opportunity to field patient questions–he claims to have fielded many questions about Bill Clinton’s post-bypass surgery veganism.
  • Uncover and provide the platform to correct misconceptions, in a nonconfrontational setting that can lead to positive discussions.
  • Can grow a doctor’s practice.
  • Are fun.

    At the 2013 Tet Fest at the Seatte Center, a health clinic table was set up amid other tables hawking cell phone plans and new bank accounts.

    At the 2013 Tet Fest at the Seatte Center, a health clinic table was set up amid other tables hawking cell phone plans and new bank accounts.

The Centers for Disease Control and Prevention (CDC) publishes how-to guides how to organize events that engage target communities, such as this guide focusing on injury prevention for kids. Seattle, where I live, is virtually awash in corporate medical events that also involve local partners, like the Seattle Housing Authority and social service providers like Neighborhood House.

These event focus on many of the many minority populations in King County, such as the Latino community, which was engaged at the annual Fiestas Patrias event held in September at the Seattle Center. This particular fair focussed on HIV testing, behavioral health, dental care, long-term care, cancer, chronic disease, and culturally appropriate care for the Spanish-speaking community.

I was recently at the annual Tet celebration at the Seattle Center the weekend of Feb. 16-17, 2013, and not to my surprise saw a table promoting health-fair-styled information for the nearly entirely Vietnamese-American audience in attendance. I did not have the ability to know if anyone attending bothered with that booth or were more interested in the photo booth, the deep fried tofu and Vietnamese coffee, or stage shows.

A booth offering Tet pictures appeared to be more popular than the health clinic table at the Tet Fest in Seattle in February 2013.

A booth offering Tet pictures appeared to be more popular than the health clinic table at the Tet Fest in Seattle in February 2013.

One non-profit, called Unite for Sight, published an article that reported that there was inconclusive evidence about the benefits of health fairs and community screenings. The medical literature has often viewed them with great skepticism. “Health fairs are neither regulated nor routinely certified in the United States, and complete data on their numbers and content are not available.” The article further noted that tests at fairs may be more harmful than helpful because the may unnecessarily alarm participants with bad results, or provide false reassurance that results shown are normal.The article cites a 1985 study that found “rates of false alarm of healthy people and false reassurance of those at risk may be high for some tests, and the benefits of detecting new disease are easily overestimated.”

A more recent 2011 study on blood pressure screenings at community health fairs, published in the Journal of Community Nursing, looked at outreach on hypertension. The article reported “nurse-operated health fairs, crafted to identify those with high BP readings, are promising as a simple and effective means in motivating individuals to seek follow-up care.”

Another study from 2003, Reconsidering Community-Based Health Promotion: Promise, Performance, and Potential, published in the American Journal of Public Health, found that “evidence from health promotion programs employing a community-based framework suggests that achieving behavioral and health change across an entire community is a challenging goal that many programs have failed to attain.” The authors, Cheryl Merzel and Joanna D’Afflitt, write that “interventions themselves probably are too limited in scope and intensity to produce large effects across a community. Many programs focus primarily on individuals, with most people receiving mass education alone, and interventions and messages are not sufficiently tailored to reach various population subgroups.”

How well do health tables compete with the private sector like banks, as seen at Seattle's 2013 Tet Fest.

How well do health tables compete with the private sector like banks, as seen at Seattle’s 2013 Tet Fest.

The article, however, reported that community interventions have been found to work for, say, HIV. They call this the “prevention paradox,” or the fact that prevention measures that bring big benefits to the community have little benefit to individuals. Thus, most community-based chronic disease prevention programs have  reportedly found it hard to get individuals to change their behavior, but HIV-related programs have reportedly worked.

Merzel and D’Affliti suggest that HIV programs may be more successful than other health fair promotion events because they go after small and homogenous groups. This is harder to do with large, diverse groups. So “getting identifiable social groups to change specific behaviors with discrete levels of individual risk may be more achievable than developing multiple interventions designed to motivate numerous subgroups of varying risk found within a broad geographically defined community.”

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Are Swedes more beautiful, or do they just have a better public health system?

I have always thought about what makes some people look better than others — at the individual, ethnic, and national level. Having travelled on six continents, I have been able to test ideas and stereotypes—including my own—through personal observations.

Is "Jenny," who I saw on a YouTube video teaching yoga-type exercises, good looking because she is Swedish, and if so, what does that mean?

Is “Jenny,” who I saw on a YouTube video teaching yoga-type exercises, good looking because she is Swedish, and if so, what does that mean?

This all came back to me last night while I was surfing YouTube for a video on ski waxing, where I, yes, got distracted by what looked like a very healthy and attractive woman doing yoga. Instead of it being a yoga tutorial, it was a video published by two young Swedish women that is mostly a product of personal vanity and that natural desire to express one’s self. I believe their names are Jenny and Andrea, and they appear to have a preoccupation with their admittedly very good looks. I cannot fault them for that.

Yes, these two are very physically attractive. But I again thought about why? Why are many Swedish and other Scandinavian women I have met so attractive?

First, I do not ascribe to the idea of “national beauty” or the national ranking systems that have little scientific validity. Social and popular media are obsessed with the idea that Swedish women are among the world’s most beautiful. A dubious online source called Traveller’s Digest claims Sweden tops their list of countries with the hottest looking women. (The country’s men also rank No. 1). Such rankings amount to Internet silliness.

I traveled to Sweden in 1990 for about a week, staying with friends I met in India (Eva and Eva — yes the real names). I found many people I met there to be healthy and attractive, but not to an extreme. I did find an excessive amount of out of control binge drinking in the social circles my generous hosts ran with, particularly among college-age and slightly older Swedes. In fact, globally, I have found few places that matched the excessive drinking I saw all over Sweden.

I also have seen Swedes globally, and in general many do appear more fit and healthier than the typical American, who rightly has earned a reputation as being overweight and thus unhealthy, and therefore unattractive in the eyes of many. Such data is borne out by national health statistics, as America is the fattest country on the planet, and because of that, my country does not have the reputation as Sweden does for the hottest men and hottest women, I think.

One of the most ubiquitous stereotypes of nationalities is that of "hot" Swedish women--perpetuated by photos like this one.

One of the most ubiquitous stereotypes of nationalities is that of “hot” Swedish women–perpetuated by photos like this one.

Globally, Sweden does very well in terms of health rankings and public health investments. Sweden scores highly in terms of life expectancy from birth, ranking No. 16 among all countries (81.8 years). Its Nordic neighbor, Norway, ranks 25th (80.32 years). The United States fares worse than both, and Jordan, and New Zealand, and, well, 50 other countries, at 78.5 years. By comparison the much poorer Cuba, with a vastly lower standard of living (less than 20% of the United States per capita), ranks No. 60, with a life expectancy of 77.9 years.

In 2010, according to the World Bank, Sweden spent 9.6% of its GDP on public and private health, including preventive and curative services, family planning activities, nutrition activities, and emergency aid designated for health but not water and sanitation. Norway spent nearly the same amount, or 9.5%, while the United States was staggeringly inefficient, spending 17.9% of its GDP, and the trend is getting worse.

The socialist and undemocratic Cuba, which invests heavily in public health for its population, spent a mere 10.6% of its GDP, but had nearly the same life expectancy per person as its mighty northern neighbor, America. So even though the United States spends nearly twice as much as these three countries, it does not have results to show for it.stats for four countries income health obesity

Such discrepancies are frequently cited highlighting how grossly inefficient U.S. health care is compared to countries with strong government-backed and financed health systems.

But do such investments have anything to do with physical appearance, and thus beauty?

Well, expanding waist lines and bulging bottoms, which nearly most people globally do not view as physically attractive, seem to indicate that Americans are likely to be less attractive than Cubans, Norwegians, and those stereotypically “hot” Swedes.

The International Obesity Task Force estimates that, globally, 1 billion adults are overweight (BMI 25-29.9 kg/m2) and 475 million are obese. In the United States, two-thirds of all residents are obese or overweight. The United States is the world’s heaviest country per person–a dismal and frighteningly scary statistic for our healthcare system and for future incidence of many of our top killers (cancer, heart disease, as well as diabetes, though further down the list).

So why, say, is Sweden doing better than many countries and the United States.

For starters, everyone in Sweden has equal access to health care services under a decentralized, taxpayer system. The Swedish Institute reports that every city council “must work to promote good health for the entire population.” Again, this is a vastly different value system than the United States’, where taxes are viewed with increasing hostility by the political right and where individuals are still, for the most part, considered responsible for their health.

This photo published by the Swedish Institute highlights a view of health, from youth to old age, and by most measures, Swedes are healthier and live longer than Americans.

This photo published by the Swedish Institute highlights a view of health, from youth to old age, and by most measures, Swedes are healthier and live longer than Americans.

In Sweden the responsibility for health and medical care is a shared responsibility of the central government, county councils, and municipalities. The country’s Health and Medical Service Act regulates the roles of county councils and municipalities, and it gives local governments freedom in this area, while the central government sets principles and guidelines for health and medical care.

What’s more, Sweden’s maternal mortality, another key public health indicator, is among the world’s lowest: 2.74 in 1,000 babies and less than than 1 woman out of 100,000 die in birth. “Swedish maternal care is often highlighted as a success story in international contexts,” boasts the Swedish Institute. By comparison, the United States infant mortality rate is 6 per 1,000 (bested by Cuba’s 4.73 per 1,000).

So in the end, you have a country that invests more in its people and in the health of its people, who likely have a good chance of being active and also avoiding stigma associated with excessive weight. It’s not so much that Swedish women, like Jenny in the exercise video, is anything extraordinary, though she is very attractive because she is healthy. She is, perhaps without her full awareness, the recipient of extensive investments in her education, her health from cradle to grave, and a social contract that values the well-being of the population.

The International Obesity Task Force published this map of obesity rates globally; some data likely is missing for African nations.

The International Obesity Task Force published this map of obesity rates globally; some data likely is missing for African nations.

And how do we react when we see Swedes, on YouTube or traveling abroad, or in business or education settings? We react positively.

An August 2012 story published in Psychology Today (“I’m Successful Because I’m Beautiful”– How we Discriminate in Favor of Attractive People) highlighted some frequently cited studies on how specific physical traits are rewarded.

The article quotes Dr. Gordon Patzer, who reportedly conducted three decades of research on the topic and found that human beings are “hard-wired” to respond more favorably to those who are attractive: “Good-looking men and women are generally regarded to be more talented, kind, honest, and intelligent than their less attractive counterparts.”

Still, obesity is afflicting even the Nordic countries, which has universal health care and strong safety nets. A 2010 study by Kirsti Matlerud and Kjersti Ulrisken in the journal Patient Education and Counseling (“Norwegians fear fatness more than anything else”–A qualitative study of normative newspaper message on obesity and health) looked at how newspapers in that affluent country sent messages on body weight. They found in a public survey, when people were asked what health problems they would like the health authorities to give priority to, obesity ranked highest, and then followed by care for the elderly, cancer, psychiatry, and cardiovascular disease. They also reported a general attitude of fatness being associated with being lazy and irresponsible.

So yes, they do care about their looks in Nordic nations and discriminate against overweight persons, much they way we do in the United States. They just do a better job of ensuring their population stays healthier. Jenny and Andrea have reaped the benefits and get the added benefits of being viewed as  attractive and being seen more favorably than those who have not had a national health system ensuring its population has the best possible chance of being healthy.