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Why a Shortage of “Disease Detectives” Threatens Cities

by Mark R. Miller

My father is an entomologist (a scientist who studies insects), but I was always more of an etymologist (someone who studies words). And now I work for an epidemiologist. It’s a mouthful, and maybe that’s why people often refer to epidemiologists as “epis” or “disease detectives.”

Whatever you call them, they play an important role in protecting communities, our nation, and the world against health threats. They identify the causes, factors, and patterns of illness, determine who’s at risk, gather evidence to recommend preventive actions, and implement control measures. As a profession, epidemiology gets some attention for responding to major hazards like Zika, Ebola, and natural disasters like hurricanes and floods, but every day, epis are addressing threats to community health like obesity, diabetes, cancer, drug abuse, HIV/AIDS, and preventable injuries.

Today the Big Cities Health Coalition (BCHC) and the Council of State and Territorial Epidemiologists (CSTE) released a study documenting a shortage in the field, especially in the areas of chronic disease, substance abuse, and infectious disease. The 27 BCHC health departments reported that:

  • 1,100 epidemiologists work in big cities, protecting more than 55 million Americans.
  • Most focus on infectious disease, maternal and child health, disaster preparedness, chronic disease, vital statistics, and environmental health.
  • Fewer departments have epidemiologists working on mental health, substance abuse, and injury prevention.
  • To reach full capacity, these departments would need a 40% increase in the number of epidemiologists, or 434 more. Specifically, they would need them in these areas:
    • 121% increase in injury/violence
    • 86% increase in maternal and child health
    • 72% increase in chronic disease
    • 66% increase in disaster preparedness
    • 51% increase in substance abuse

Don’t miss the webinar on the report’s findings on Oct. 24 at 2:00 EDT.

The report identifies a number of challenges in meeting the demand for more epidemiologists, including these:

  • Advocating for resources can be hard because many people don’t understand the role of epidemiologists or public health departments.
  • While health departments often receive short-term funding to respond to a disaster or epidemic, there is a lack of sustainable funding, which makes it hard to recruit and retain employees. Many epidemiologists work under federally funded contracts, and funding can be delayed or cut.
  • The positions for epidemiologists are often very specific, and it’s challenging to attract a strong pool of qualified candidates.
  • There is a need for new skills in areas including systems thinking, informatics, data analysis, communications, community engagement, and cross-sector partnerships.

See the full report for detailed findings — Big Cities Health Coalition Epidemiology Capacity Assessment, 2017.

Register for a free webinar with BCHC and CSTE at 2:00 EDT on Oct. 24.




New Voices: Millennials and the Future of Public Health

The de Beaumont Foundation is looking forward to a lively panel discussion on Millennials in the public health workforce at the APHA Annual Meeting and Expo in November. To give you a preview, the foundation’s vice president of communications, Mark Miller, sat down with Brian Castrucci, CEO, and special assistant Lizzie Corcoran, who recently served as the foundation’s 2017-18 ASPPH Philanthropy Fellow. As the only non-Millennial on the panel, Brian wants to make it clear that he recognizes he is not a Millennial and will be happy to let the other panelists take the lead!

Note: We’re using the definition of Millennials from the Pew Research Center — people born from 1981 to 1996.

Mark: How did you get this idea for the panel, and why is it important?

Lizzie: It’s come up at nearly every meeting I have attended for the past year. Many speakers reinforce the negative stereotypes about Millennials from the podium, jokingly or otherwise. I understand that some managers feel frustrated about the challenge of attracting and retaining young people in public health (especially state and local government agencies). But I can’t tell you how many times I’ve heard generalizations about our need for participation trophies, dependency on technology, and our sense of entitlement.

Brian: As you know, I’m not a Millennial, and that’s exactly why this issue interests me. It bothers me to hear public health professionals share negative stereotypes in a way that wouldn’t be acceptable for any other demographic group. We’ve all heard the generalizations — that Millennial workers are disengaged, or they want to be in charge after their first week, or they aren’t loyal to their employers. But that hasn’t been my experience, and I thought it was important to hear directly from Millennials who are already working in public health. If we can understand what’s working and what can work better, we can find ways to effectively engage all of our employees and create a diverse and thriving workforce.

Mark: And what is the problem with retention and employment among this age group?

Lizzie: Young people are underrepresented in the governmental public health workforce. Turnover and retention are a challenge across the board, and agencies need to be able to attract, train, and nurture the leaders and managers of the future.

Mark: Why do you think public health has a hard time attracting young people?

Lizzie: When you look at the numbers of students earning MPH degrees, there’s no shortage of people who are interested in public health. The study of public health appeals to young people’s interests in problem-solving and systems thinking. Many Millennials are passionate about communities and causes, and they see public health as an avenue to pursue these passions. The challenge is that after school, students have many options of where to work, and governmental public health isn’t among the top choices.

Mark: Do we know why that is?

Lizzie: I think there are many reasons. Speaking from my own experience, my professors and advisors in grad school didn’t recommend government as a career option. And getting hired by a government agency often takes longer than other types of jobs. I personally received a rejection letter from a health department a year and a half after I applied. New graduates can’t wait that long.

Brian: It’s also an issue of talent management and acquisition. Governmental public health isn’t recruiting or retaining talent in effective ways. I would love to see health departments change the way they search, find, and interview prospective talent so that they can really get the people who can change and advance our health departments. There are changes we can make in health departments and in human resources to start fixing this. Instead of blaming issues on a particular age group, the field needs to keep up with the times so they can compete with businesses and nonprofits for quality candidates.

Mark: What myths would you like to challenge or flip about millennials?

Lizzie: There are so many! I think the perception that we feel entitled actually comes from our desire to do meaningful work. The idea that we need attention and recognition is really about our eagerness to learn and improve. Specifically, in the public health field, I’ve heard this assumption that people aren’t interested in government work because it’s bureaucratic, maybe because we’re impatient or obsessed with technology. But as part of my fellowship, I got to spend a week at the Baltimore Health Department, and I went on restaurant inspections, observed a needle exchange program, sat in on discussions about policy and partnerships, went with the health commissioner to her speaking events, and got trained in using naloxone. That’s exactly the kinds of hands-on, meaningful work that many millennials are looking for! These are some of the stereotypes that need to be flipped on their heads.

Brian: And people can say that bureaucracy is the problem, but bureaucracy is everywhere — in the public, private, and nonprofit sectors. Don’t forget that a federal bureaucracy got us to the moon. To me, this is a management issue — managers need to help their employees navigate their internal processes so they can make the biggest possible impact. I’m not saying it will go away, but it’s not always the barrier that we think it is.

Mark: If you had a friend or a fellow student who just got their public health degree, would you recommend applying to a public health department?

Lizzie: Brian once told me that 10 or 20 years into my career, in order to have real credibility, I’ll need to have spent time on the ground in a public health agency, and I understand that. So yes, I’d recommend it. And for me, I’m still thinking about what will be the best fit for me. I think health departments that are embracing innovation and creative problem-solving could be very attractive options for people who want to use their skills to make a difference.

Mark: Okay, here’s your chance to sell your session. Why should people come to the APHA Live Session: A Dialogue with Millennials?

Lizzie: This age group is often overlooked in public health, and this will be a chance to hear a wide range of perspectives from young people serving in public health organizations across the country. We’ll talk about the disconnect between young people and governmental public health — not just the challenges, but also practical recommendations. We want it to be an engaging and interactive session and won’t shy away from any questions!

Brian: I want to add that there will something for everyone with this panel. Managers, supervisors, students, young people in and out of governmental public health….everyone will get something out of this discussion. You’ll be able to bring lessons and tips back to your intergenerational workplaces and continue the conversation.

Join us to hear more at New Voices in Public Health Workforce: A Dialogue with Millennials on Wednesday, Nov. 14, at 10:30 a.m. PST in San Diego. If you can’t attend in person, register for APHA Live. This is one of the premier APHA 2018 sessions available via livestream and on-demand.

This post was first published on the APHA Annual Meeting blog on Oct. 9, 2018.

Winners Take All: A Wake-Up Call for Philanthropists

by Mark R. Miller

The new book Winners Take All: The Elite Charade of Changing the World is creating a buzz in the philanthropy world, and not because philanthropists and corporate leaders like what it has to say. Mario Marino, founder of Venture Philanthropy Partners, described the book as a “gut punch” that “will generate many uncomfortable, unquestionably important conversations in our sector and beyond.”

Author and former New York Times columnist Anand Giridharadas makes the provocative case that rich and powerful philanthropists are interested in fighting for justice and equality, just as long as it doesn’t threaten the systems that put them in power and keep them there. Instead of seeking to do more good through top-down philanthropy, he argues, corporate leaders would help society more by doing less harm. He says that by prioritizing profits, resisting taxes on inheritances and financial transactions, and negotiating tax breaks in the communities they operate, for example, corporate leaders have contributed to the inequality that leads to the social problems that they then claim to address through their charitable activities.

The book is full of challenging insights for people who work in philanthropy and social change, and Chapter 6 on “Generosity and Justice” should be mandatory reading for anyone who is working to make social change. It shares the complex perspective of Darren Walker, an African American who was raised in poverty by a single mother in Louisiana, worked his way through school, had a successful career in finance, and served as vice president of the Rockefeller Foundation before becoming president of the Ford Foundation, where he oversees a $13 billion endowment and $600 million in annual grant-making.

As he began his third year at the Ford Foundation in 2015, he created an uproar by publishing a public letter titled “Toward a New Gospel of Wealth.” (Consider it a prequel to Winner Take All.) He challenged his employees, partners, and fellow philanthropists “to openly acknowledge and confront the tension inherent in a system that perpetuates vast differences in privilege and then tasks the privileged with improving the system…..We need to interrogate the fundamental root causes of inequality, even, and especially, when it means that we ourselves will be impacted.”The letter stunned many of Walker’s “elite” friends, who enjoyed the same galas and other high-profile gatherings. As Giridharadas put it, Walker had “broken what in his circles were important taboos: Inspire the rich to do more good, but never, ever tell them to do less harm; inspire them to give back, but never, ever tell them to take less; inspire them to join the solution, but never, ever accuse them of being part of the problem.”

“It is timely that we openly acknowledge and confront the tension inherent in a system that perpetuates vast differences in privilege and then tasks the privileged with improving the system.”

Darren Walker, President, Ford Foundation

Giridharadas states very clearly that many of the people he references in the book — corporate leaders, entrepreneurs, philanthropists, “thought leaders,” and consultants — are decent and smart people who want to make change and improve lives. But “many of them are trapped in what they cannot fully see. Many of them believe they are changing the world when they may instead — or also — be protecting a system that is at the root of the problems they wish to solve.”

Why does this matter? Giridharadas says that without even realizing it, Americans are entrusting the people who benefit the most from the status quo to assume leadership for reforming the status quo.  He says we need to ask ourselves if we want the decisions that affect all of us to be led by government representatives who are elected and accountable to us, or by “wealthy elites claiming to know our best interests.”

The book is sparking healthy discussions and introspection here at the de Beaumont Foundation, because like many of the organizations Giridharadas challenges, we are funded with an endowment created by a successful entrepreneur. Our CEO, Brian Castrucci, acknowleges that reality, and is willing to ask the hard questions — and accept the hard answers — about the forces that influence our decision-making and our ultimate impact.

The foundation’s focus is on improving public health, and while we recognize the importance of the private sector and applaud the growing interest in societal change and justice, we believe that government is ultimately responsible for the health and well-being of all citizens. We’ve seen over the years that we can make the biggest impact by working with existing organizations and systems to address the root causes that lead to poor health. We agree with Giridharadas that private dollars, top-down solutions, and “thought leadership” – especially in a vacuum – are insufficient to bring about lasting societal change. And they bring with them inherent biases and, often, self-serving motivations. That’s why one of our most important priorities is to support and strengthen governmental public health, especially at the state and local levels.

Just as healthcare interventions will never be able to address the factors that make people sick or prevent them from achieving their optimal health, top-down philanthropic solutions will never make lasting change without addressing the root causes of poverty and inequality, including those they benefit from personally and professionally.

The inequality gap is particularly striking in health. As Giridhardas points out, “American scientists make the most important discoveries in medicine and genetics and publish more biomedical research than those of any other country, but the average American’s health remains worse and slower-improving than that of peers in other rich countries, and in certain years life expectancy actually declines.” And wealthy American men now live 15 years longer than poor American men, whose life expectancy is similar to men in Sudan and Pakistan.

From an income perspective, since 1980 the average pretax income of the top 10th of Americans has doubled, and the salary of the top 1 percent has nearly tripled. But with all of these advances, over the past 35 years, the income of the bottom half of Americans has stayed almost the same. In other words, our vast growth has had no impact on the average pay of more than 100 million Americans. This inequality gap in income is directly related to the gap in Americans’ health. We need everyone at the table to build healthy communities, especially our government leaders.

Giridharadas’s book comes at an especially defining time in American politics and philanthropy, and provides an important reminder that generosity does not equal justice. Achieving justice, Giridharadas says, will require the people and organizations with the most power to have the courage to not just talk about root causes of inequality, but upset systems that benefit them.

Video: 10 Things We Should Talk about When We Talk about Health

At the annual meeting of the Association of State and Territorial Health Officials on Sept. 26, Sandro Galea, dean of the Boston University School of Public Health, shared “10 things we should talk about when we talk about health.” We agree with his list 💯 and incorporate these beliefs and values into our efforts to shift the national conversation from healthcare to health. View his entire talk on the BU School of Public Health Facebook page below.

  1. Health not healthcare.
  2. Health emerges over a life lived.
  3. Power, politics, & money are health.
  4. There is no health for many if we exclude the few.
  5. We need the wisdom, and humility, to understand health.
  6. Health is a public good.
  7. Compassion has to be at the heart of health.
  8. Health should be a means, not an end.
  9. We need to value health, and demand health.
  10. We should be free to choose health.

Strange Bedfellows, Effective Partners in Public Health

by Karen Remley, MD, MBA, MPH, FAAP

I’ve been fortunate to work with dedicated health professionals in many different capacities. In my roles as a pediatric emergency physician, a state health commissioner, a hospital executive and the medical director of a large for-profit health plan, I’ve seen many examples of collaboration, but also, unfortunately, many missed opportunities.

Building healthier communities where people can achieve their optimal health must involve stakeholders from public health, health care, business, elected officials and other sectors. But too often, misperceptions and preconceived notions about potential partners and their motivations get in the way of effective, trusting partnerships.

Fortunately, public health practitioners are well positioned to address these obstacles and create new opportunities. The same skills and values that make us successful at working with communities and populations — compassion, respect, analysis, community-building — can and should be applied to partners in health care, government and other sectors.

New partners often begin meetings by talking over and around each other, using phrases and terminology that may be a foreign language and even foreign culture to others. These behaviors can alienate groups before they have even begun to explore relationships and collaborations. I think we can all learn from Aaron Burr’s line from the musical “Hamilton”: “Talk less, smile more.” Effective partners start with a spirit of openness and an interest in understanding what others bring to the table. And that starts with mutual respect.

I felt the distrust of other sectors when I first went to work for Anthem BlueCross BlueShield. Many of my former clinical and public health colleagues asked me why I had joined the “dark side.” While I know it was meant in jest (most of the time), it’s hard to deny that insurance companies don’t have the best reputations within these communities. But when I was at Anthem, I saw people at all levels who were just as committed to improving lives as my former colleagues in pediatrics and public health, and I realized that we all shared a common goal of improving people’s health and lives. After learning about the company’s drivers, concerns and goals, I was able to propose public health solutions that made business sense and were likely to improve health outcomes.

In this new role, I knew I’d need to learn the language of my new “health insurance community.” I first listened and asked a lot of questions so I could understand the leadership group’s key drivers, concerns and goals. Only then was I able to discuss a public health problem — early elective deliveries (EED) — in a way that engaged this group. I appealed to them as thoughtful and accountable leaders for the plan and their communities and explained how it would improve the health of babies throughout Virginia.

I told them about the impact of EED on NICU days (a key cost driver); on childhood outcomes, including ADHD (another cost driver); and on parental time away from work (a concern of our employee customers). I made sure to not lecture but to appeal to their business sense and their concern for families.

By describing the problem using their language and data, I was able to get buy-in for a plan to lead a multidisciplinary group to proactively and voluntarily put in place hospital protocols that were led and implemented by physicians, beginning in 2014. In 2012, Virginia’s early elective delivery rate had been 8 percent. By 2016, the state had the lowest rate in the country — 1.3 percent.

Knowing that all sectors bring needed skills and perspectives, I’d make the following recommendations for strong cross-sector partnerships:

Approach potential partners with humility and openness.

The core principles of public health practice are community engagement, cultural humility and collaboration. We respect our communities and engage them in conversations about how best to address the health issues that affect them. We should bring that same humility and respect to our partners and potential partners.

Understand your partners’ needs.

Before asking for their help, take time to understand their strategic objectives, their priorities and their motivations. Ask what success looks like for them. What problems can you help them solve?

Recognize your own biases and preconceived notions.

Mutually beneficial partnerships require mutual respect. Admit your own biases and preconceived notions about other people and other sectors.

By recognizing the obstacles that get in our way, we’ll build effective and non-traditional partnerships that will build healthier communities and better health for all.

This post was first published on APHA.org as part of the de Beaumont Foundation’s “Fresh Perspectives” series.

de Beaumont Foundation