The New Hot Spott3rs By Monica Mehta

I’m now reflecting upon the recent annual Mailman Health Policy & Management Conference.  It was great to see generations of EMPHers:  my classmates milling about our predecessors and successors, sharing stories, and getting updates.  I realized at one point that I really must put some time into creating the all-essential one-liner to describe my work and path.  Somehow “clinical pharmacist transitioning into public health” doesn’t seem to fit anymore…and that’s when I ran into Rami who had the best one-liner ever.  When asked what he was up to, he told me,  “I now pay people to exercise.”

Rami Rafeh (c/o 2012) surprised me with his update. Since his graduation just six months prior, he has done what many of us aspire to…give birth to a project based on an idea.  He started a company.  He named it spott3r.  And they pay people to exercise.  Yeah, that’s right.

I was curious about all the steps leading up to it, so we chatted in Columbia Club’s plush leather foyer while I got the back-story.  After studying biology (undergrad) and biomedical sciences (for a masters), Rami became a young, up-and-coming wiz at Pfizer working in drug safety.  He quickly grew more proficient at the biz side of drug development and considered going back to school to pursue an MBA.  His boss and mentor, an epidemiologist by training, encouraged him to pursue an MPH instead.  This ended up becoming what Rami now reflects upon as being a great decision at a critical crossroads (yet another reason we should all have mentors).  Rami came to Mailman with the ultimate goal of being a consultant, specifically at Mckinsey or Booze.

During the program, Rami proved himself to be quite the multi-tasker.  At Pfizer, he transitioned to the Worldwide Business Development & Innovation team, took a health information technology program also at Columbia (a 7-month certificate program), became a limited partner for a healthcare start-up accelerator (more on this later), and an advisor to startup incubators.   He was layering his skill set (science to business to technology and public health) in order to become an “out of the box” thinker and an asset to employers.  And with this, he was able to beat out the MBA competition in an emerging niche.   As superhuman as it all sounds, it turns out it was.  Rami confessed to getting maxed out at one point, realizing he was possibly doing too much.  Nonetheless, “it carved the path to entrepreneurialism” as he puts it.

Aside from a flashback to Back to the Future, I was unfamiliar with the term accelerator, so Rami set me straight.  Essentially, they grow viable companies out of fledgling ideas.  Good ideas.   Or perhaps a cool solution to an existing problem.  The accelerator (Blueprint Health, for example) provides space (co-shared with other innovators) + seed money + marketing assists + the proper mentors in exchange for part ownership.  As a limited partner, Rami was surrounded by people converting ideas into companies, a contagious phenomenon.  Combined with MPH classes (like strategy, marketing, social entrepreneurialism), Rami started brainstorming.  At school, we spend countless hours discussing problems with the system.  He simply thought of one solution.  Spott3r grew from a school project.  When he realized it was actually a good idea, he patented it.

How do you pay people to exercise, I wondered.   And how is this a viable business model?  He told me that people like to exercise – it makes them feel good and look good, but that’s not always enough to keep them going to the gym.  Money might be the necessary boost.  Furthermore, many health insurance companies recognize exercise as an investment and cut checks to customers who submit gym logs.  In spite of that, many people don’t bother to make claims.  And that’s where spott3r fits in – by partnering with gyms and insurance companies with consent by customers to create a win-win-win situation.

Why don’t people just make the claims themselves?  The typical process is multi-step: providing a gym agreement, proving payment, sometimes showing evidence of cardiovascular equipment, filling out insurance reimbursement requests, and submitting them by mail.  With spott3r, the customer simply fills out an online form and sits back while receiving checks.  Rami’s company does the backend work and in return, takes a small percent from the customer’s reimbursement.

Rami still works at Pfizer.  He also recently joined the Startup Leadership Program in NYC, which connects him with over 900 entrepreneurs worldwide to share best practices.   Apparently approximately half of the NYC folks are alums or current students of Columbia University (news to me!).

As far as his dream of becoming a consultant?  He tells me, “Nah, not for me anymore. Not to bash traditional careers, but I think I’ve found a way to make an impact while pursuing a passion.”  He went on, “coming out of a program like ours with insights into healthcare delivery inefficiencies begets a lot of opportunity.”  He wants this to be a call to action to other students…to partner up, mentor a start up, invest in projects, or do it oneself.  There’s gratification in knowing that you are applying class work to the real world. Ultimately, Rami wants to tie the company’s efforts to health outcomes (obesity rates, cardiovascular disease, etc).

Next moves for spott3r?  To partner with gyms and run pilots.  They plan to launch widely late summer.   Rami’s research indicates that there are over 25 million Americans who might be eligible.  And the name spott3r?  He reminded me that a spotter is the person who assists and protects when lifting weights.  And the 3 for the e stands for “sign up, work out, and cash in.”

Sometimes the simplest ideas are the most elegant and perhaps even most impactful.  Partly because simple translates into doable.  Rami’s story makes me wonder about what walls we put up between change and us.  It’s not really about the one-liner, is it?  Perhaps the idea comes first, then the action, and the one-liner organically follows.  Stuff to ponder…

Check out the spott3r video here: http://bit.ly/spott3rlaunchvideo

“Don’t Tear Down a Park to Build a New Yankee Stadium” and other words of wisdom from Susan Dentzer’s talk at Mailman by Monica Mehta

After listening to Susan Dentzer’s one-hour-ish talk entitled, “America’s Health Deficit: what we can do about it,” it became abundantly clear to me why she is the editor-in-chief of Health Affairs, the journal Washington Post calls “The Bible of Health Policy.”  For those of you who missed the talk (given at Mailman a couple weeks back), you can catch it via the link below.   In that short time, she distilled and packaged a tremendous amount of information, from key components of the Affordable Care Act (including its unfinished business) to right-off-the-press findings around social and behavioral determinants of health outcomes.   It’s that later half that I listened to a second time.

There’s so much to reflect and comment upon, but it’s perhaps the stuff around education and women that resonated with me the most.  We learned in our Health Economics course that education (not health education, but education itself) contributes more to health outcomes than the actual delivery of health (i.e. healthcare AKA what we do).   That was a paradigm-shifter for me.   Susan Dentzer summarized a study published in Health Affairs in August 2012 (written by Olshansky et al) stating that today’s adult Americans with less than 12-years of education (i.e. didn’t graduate from high school) have a life expectancy similar to Americans from the 1950’s.  It is startling to say the least that 60-years of medical and scientific progress hasn’t impacted this population.   She went on to share that life expectancy has actually fallen for less educated women in particular.  American women who didn’t graduate from high school live four fewer years compared to their 1990 counterparts, which is a drop comparable to patients with HIV in Sub-Saharan Africa.   Contributors include obesity, smoking status, stress involved in trying to make ends meet, as well as a new contributor: prescription drug abuse (which interestingly falls under category, “accidental poisonings”).

“Don’t be poor” is one of the ten tips for better health as part of the Center for Social Justice’s publication on social determinants of health.  Ms. Dentzer echoed this and reminded us of a study (by Dr. Christopher Murray from Harvard) that identified “eight different Americas.”   An Asian American baby girl in Northern New Jersey is expected to live 91 years (amazing, even for international standards) compared to an African-American man (69 years) or Native American (58 years).   This is a 33-year life difference!  She goes on to describe an IOM (Institute of Medicine) report describing American life expectancy and health parameters throughout life as being worse than other rich countries, partly due to chronic disease (especially cardio- and cerebrovascular) but also motor vehicle accidents, abuse of prescription drugs (there that is again), and gun violence.  Along these lines, she also described unfinished business after ACA – addressing drivers of poor health such as obesity, physical inactivity, social circumstances, etc.   And more interestingly, that “most of the action is where these things interact.” For example, not walking (or doing other outdoor exercise) because you’re worried about being shot.  We should not tear down parks to build stadiums, etc.

Suffice to say that Susan Dentzer is incredibly knowledgeable and it would behoove all of us to share the wealth by listening to the talk, getting inspired, and continuing the work.  She asks us to conduct research and to “help build the case for public health investments” (funding cuts due to sequestration are reducing access to contraception for the poor and supplemental nutrition for pregnant women, among other things).  Our sphere in public health is not just about management of healthcare institutions, but rather also about population health.  And we should think creatively about contributors large and small (mostly large) like poverty, income inequality, access to produce, residential segregation, adolescent pregnancy rates, healthy food in schools, etc.  She ended aptly with a quote, “Those who say it can’t be done should not interrupt those who are doing it!”

Link to the talk:  http://youtu.be/wHruHjAHLyo

“Coming to Terms With an Epiphany: An Interview With David Ramos” by Monica Mehta

As our class takes a step forward toward graduation, I thought we should take a step back and explore some of our motivations of going back to school in spite of the opportunity costs.  And more importantly, how these ideas have changed since that decision.  I also want to start digging into next steps.   Here goes…

He describes himself as someone “incapable of stress” and yet, by others as “provocative”, two things that rarely coexist.  But do so in the venerable Dave Ramos, classmate and cardiologist.  Clearly, he’s a man with a vision.   Since our class’s earliest days, Dave has been one to turn heads, quiet a room, and create sparks from our professors.  He wants to “start things over” in healthcare.  I’ve jokingly accused him of nihilism, to which he simply laughs back, a sign I take as acceptance.   I’ve always appreciated the edge. I get the sense that he wants to build it right, from the foundation up.  I spent a lunch with him trying to access the spaces behind the ideas.

Dave Ramos in class with fellow classmate Catherine Dentinger. Picture courtesy of Barbara Kirrane.

“Why an MPH?” I wondered. Dave shares that he came to the program thinking that the biggest concern in healthcare reform is that there wasn’t “physician participation in the conversation”.  He believed that MDs were the “center point.”   I remember well when Dave mentioned this in an early Masters Class, our professor responded by saying that physicians were also a “big part of the problem.”  And here’s the thing.  This was a comment that Dave welcomed.  He came to the program to acquire tools and was happy to give up old ones.  So that was his first epiphany.  “The U.S. healthcare delivery system is magnitudes bigger than just physicians,” he told me.

Dave described a culture of doctors from his generation.  These were the “old schoolers” who believed that medicine was also about entrepreneurialism, where the culture was intertwined with autonomy and self-preservation.  He wonders if a lack of unwillingness to be self-critical has led to stagnancy in the system.  “On the surface, no logical person could believe that fee for service is a good thing.” In this world, physicians were professionals who charged for services – no different from lawyers, accountants, and the like.  At a time when physicians felt underappreciated and undercompensated, fee for service was the antidote. There may be no rationale for doing an EKG every six months based on outcomes, but the lack of data allowed for a blank check under the auspices of “patient care.”

“But what was your first Aha moment?” I asked him.   He shared a story…  Three years into his private practice (circa 2003), Dave met with his business accountant to go over productivity stats (I already sensed this didn’t end well).  The accountant told Dave that his partner was out-producing him, not in terms of number of patients seen, but rather in number of tests ordered.  Dave, coming to terms with his new self, told him “this isn’t justified.” And that this was an assault on his profession.  Dave knew what he brought to the table – representation of his patients’ best interests.  While others considered another lucrative scan to be “neutral to the patient,” he didn’t want to increase radiation exposure, force patients to endure the road of “false positives,” etc.

This planted the seed that there was something “very wrong” with healthcare in this country.   The story doesn’t end there.   In 2007, Dave left that practice and joined another. The pendulum had swung. The new practice was riddled with gross inefficiency, fragmentation of care, and provider-focus over patient-focus.   Although the practice was run by well-trained physicians who were incentivized by their academic credo, they paid little attention to the business.  Over time, Dave became manager of the practice, which five years later, merged with Columbia University.  Integration became the change that spawned Dave to think more broadly about the delivery system.  He wants a specialty practice balanced on high quality and efficiency while being comprehensive and well integrated.

“Isn’t this the vision of healthcare reform?” I asked him.  Dave maintains the calmest of expressions, but I register a hint of disagreement.  He responds that government is simply changing the carrot.  They aren’t asking the right questions.  He explains that we are changing the game but not impacting the right endpoints.  That there is a danger inherent is that the new system can be easily gamed with no improvement in quality.  For example, a recent value-based scoring of hospitals showed that the highest rankers had no overall improvement in morbidity and mortality.  And markers aren’t real outcomes.  Like giving discharge instructions for patients with heart failure instead of actual improvement.

Where’s the middle ground?  That’s when Dave thought of the MPH.  And since starting, he has learned about all the players – from pharmaceutical companies and administrators, to scientists and health economists.  Everyone is contributing to providing quality of care. This is a partnership. “Even the lawyers, “ he said jokingly (a playful dig on two of our classmates).   He says that many of his business instincts have been confirmed, such as “looking forward and folding back” a concept we learned in Strategic Management.  It’s not just school for school’s sake – this is go time for people like Dave.

He describes himself as humble, and its clear to us that know him that he truly is.  But he says that people assume that humility is weakness. I think that this humility allows him to be open to growth.  Where does he want to go post-MPH?  Dave says he would like to be the CEO of his faculty practice organization, which is made up of six multispecialty centers.  He wants to bring bench and medicine together.  To bridge the gap between university and community.  And to make sure that academic findings trickle down into the community.  Because ultimately, it is about the health of the community.  After all, his heart now belongs to public health.  Or does it?  For that we have to stay tuned to the next chapter in the post-epiphany era of our own, Dave Ramos.

Letting loose later that evening during a post-class outing to Bard Hall. Picture courtesy of Barbara Kirrane.

“A Gallon of Soda, De-Criminalized” by Monica Mehta

There’s been a buzz about fizz in NYC after Mayor Bloomberg set out to ban the sale of large sodas from restaurants and the like in early March.  And by “large”, he means greater than 16 ounces (almost 500ml). From a public health standpoint, irrespective of obesity rates, it’s hard to be an advocate for the consumption of one-gallon sodas (7-11 big gulp* = 128 oz = one full gallon = ~1,500 calories).  As a point of comparison, a 16-ouncer of Coke is ~200 calories and a large at McD’s (32 oz) is 300.  So if we know that the stuff is just short of poison, why did a State Supreme Court Justice shut the law down last week, calling it “arbitrary and capricious?”   Is this about health or about business?  And moreover, can the two co-exist?

* Ironically, the Big Gulp would not have been banned since it comes from a grocery store of sorts (7-11).  Also, drinks with at least 50% milk would not have been banned because they provide “nutrients” (as opposed to empty calories).  Rest assured, you would have still been able to get your macchiato du jour before class (which is, by the way, ~350 cal).

As a society, we insidiously tolerate larger and larger soda sizes.   A soda from McD’s in 1955 was a mere 7 ounces, which is ~18 times smaller (!) than a Big Gulp.   People are walking around drinking buckets of sugar water and somehow we don’t stop in our tracks, aghast at the site.  Though it’s not exactly smoking out of your tracheostomy tube…or is it?

Although most New Yorkers and folks I’ve talked to oppose Bloomberg’s ban (including classmates), I’m still conflicted.  More than 50% of New Yorkers are obese (with a BMI at least 30 kg/m²) and the numbers who die from health problems “related to obesity” is ~5,000 (roughly equal to the number of undergraduates at Columbia to put in perspective).  Further, more than a million New Yorkers have been diagnosed with diabetes (and almost half that are undiagnosed) per NYC DOH. Hard for us to imagine, but many people don’t equate drinks with food and don’t understand they contribute to weight gain.  DOH campaigns on subway cars educate otherwise with provocative signs stating, “Are you pouring on the pounds?  Don’t drink yourself fat” and the like.  But it’s not clear if these signs impact behavior.  

Can we trust people to do the right thing?  Is it over-bearing and paternalistic to say, “no – we can’t”?  But high risk and costly to say otherwise?

We discussed the book Nudge by Richard Thaler and Cass Sunstein in our Social and Behavioral Science class, which introduces the idea of “libertarian paternalism” and “choice architecture.” Although the Times called the book “a bit wearisome,” The Economist named it “Best Book of the Year”  (since we love our econ profs, I will refrain to comment on this…other than to agree that it’s a fantastic book).    The idea behind libertarian paternalism is that one can employ behavioral nudges to influence behavior and choices while not actually taking away the power of choice.  Like automatically renewing magazine subscriptions for example, which give you the choice to call and cancel (active) or continue to subscribe year after year (passive).  Or like having an HIV test done at a hospital under protocol (passive) unless you “opt out” (active).  In these cases, people will more likely follow the passive route. But they weren’t robbed of their ability to choose.  This is also the idea behind “choice architecture,” a phrase you should most certainly use at dinner in spite of risk of being called “bookish” (to put it nicely).  

Thaler and Sunstein argue that we can take advantage of this psychological inertia, if you will, in order to nudge people into behaviors.  This just might be a better approach than Bloomberg’s all out ban.  There’s no doubt that the same corporations that opposed the ban will oppose the nudge (and similarly threaten to decrease funding for NAACP and the like), but it won’t evoke quite the same outcry from folks who value individual rights.   

At the end of the day, if no ban, we need to nudge.  Expecting the powerful food industry to compromise profits and grow a conscience is unrealistic at best.  As a public health community, we have to continue the discussion around health vs. free will to be unhealthy and the societal consequences of the later.   

In the mean time… as long as the evidence falls favorably on red wine, dark chocolate, and olive oil, I’d gladly trade away my big gulp for these indulgences.

 

Extra Virgin By Monica Mehta

With our class just wrapping up epidemiology with Dr. Stellman, I thought it appropriate to drop a quick blog about the much talked about Mediterranean Diet study published in NEJM this week.   And since most of us are recovering from studying for the final, I thought I’d summarize it for you.  The article brings new light to our hummus Sundays during class weekends (as long as you don’t partake in the baklava).  The study written by Ramon Estruch and colleagues from the Department of Preventive Medicine and Public Health in Pamplona, Spain compares two Mediterranean diets with a “low fat” control group with the end point of reduction in major cardiovascular events.  These include heart attack, stroke, and cardiovascular death.  Included patients had no cardiovascular disease (CVD) at entry but had either diabetes or at least three risk factors (such as high blood pressure, being overweight, or smoking, among others).   This was a parallel-group, multicenter, randomized control trial (i.e. the pinnacle of studies).

So what were these diets?  It’s much more than an extra helping of hummus, I assure you. The first group consumed at least four tablespoons of extra virgin olive oil (EVOO) per day, which was used for cooking and salads.  The chosen oil was polyphenol-rich and supplied by a local Spanish vendor.  This was in addition to fresh fruits (at least 3 servings/day), veggies (at least 2 servings) plus a prescribed amount of sofrito (tomato, garlic, herb sauce), legumes, and white meat instead of red.   Interestingly, participants in this diet also consumed at least seven glasses of wine with meals per week (optional for “habitual drinkers”…you know who you are).   Discouraged items included soda, commercial bakery goods, sweets, and pastries (i.e. not homemade), spread fats, and red/processed meats.  The second group was essentially the same except that they were to consume one serving of nuts instead of the olive oil.  And the control consisted of a low fat diet: at least three servings of low fat dairy, grains, fruits, veggies, and lean fish/seafood.  The control was discouraged to consume vegetable oil (including olive oil), sofrito, as well as nuts (in order to differentiate them from the Mediterranean groups).  They were also discouraged to consume red fatty meats, spread fats, and the same pastries.   I liked that the diets were easy to adhere to (as opposed to previous “all meat, no apples” diets that were popular a few years back).

Diet was communicated via training sessions by nutritionists at baseline then quarterly and adherence was assessed via questionnaires with supplemental personalized advice based on surveys.  I know what everyone is thinking – that questionnaires are imperfect ways to measure adherence and that people may state adherence when they’re really not.  Let’s face it; diets are very hard to change.  This turns out to be a huge plus for the study because they actually measured biomarkers such as urinary hydroxytyrosol levels (to confirm olive oil consumption) and plasma lapha-linolenic acid (to confirm nut consumption).  Cool, no?  These Spaniards take their olive oil consumption very seriously and have it down to a science!

For the class of 2014, who are knee deep in stats, you may be expected to do the power calculation if Professor Weinberg catches wind of this, so let me just give it to you now. They estimated that 9,000 participants would be required to provide a power of 80% to detect a relative risk reduction of 20% in each Mediterranean-diet compared to the control.    And they almost made that, but falling short didn’t end up mattering.  During October 2003 to June 2009, they had 7,447 participants.  The groups were well balanced in terms of risk factors and drug-treatments at baseline (for the most part; there were some adjustments made for differences later).  Participants were followed for a median of almost five years, during which there was similar adherence reported.  In terms of results, the trial was ended early because the endpoint was achieved.    In the olive oil group, the crude rate of CVD events per 1,000 person year was 96 compared to 83 in the nuts group and 109 in the control (resulting in significant p-values for both).  This is a 30% relative risk reduction.  After adjustments, the difference was still significant.  In the secondary analysis, there was also a significant reduction in stroke, but not in heart attack or other secondary events. To quote Dr. Stellman’s response to the study, “One clear finding was that any advantage of the EVOO or nut supplement was most clearly evident in the obese (BMI > 30) and those with hypertension, but did not seem to favor any other subgroups.”

Why does all this matter?  Heart disease is still the leading cause of death in the US for both men and women (and combined).  Dr. Stellman went on to comment on the implications. “So where does that leave us? There is almost universal agreement in the world of preventive medicine that diet and nutrition are closely linked to adverse health endpoints, including heart disease and cancer.”  He goes on to cautiously recommend, “In my view, the trial does provide us with valuable, if limited, data that show, as most of its predecessors have shown already, that compliance is achievable albeit with great effort and expense, but that single dietary manipulations rarely lead to unequivocal results. A major problem that I doubt will ever be fully resolved is that all such studies are plagued by imprecise measurement of diet, so that even if a trial were to demonstrate an undeniable superiority of one intervention over another it would be difficult to identify the component or components that made the difference, and that the magic ingredient, whatever it is, is more likely to be combinations of foods rather than single items.”  I also asked our classmate, Dr. Alan Beinstock, who is our resident nutritionist/anti-obesity activist of sorts, to comment on the article.  He stated, “I subscribe to a Mediterranean diet saturated with fish, fresh vegetables and fruits, and olive oil and nuts is a natural and healthy way of being for it promotes and maintains a natural, healthy, and organic lifestyle.”  And that folks, is good evidence.

A Visit to Consumer Reports (October 2012) by Eliane Pottick-Schwartz, EMPH class of 2013

Imagine this – a room full of baby strollers waiting to be beaten up, rolled, roughly tilted, and  tested in the harshest conditions and all this in order to make sure that when a baby is taken for a walk, she will be safe and protected against any potential harm.  This is how our tour started at the watchdog of American consumers.

To broaden our public health horizon, we, Larry Marsh, Yossi Schwartz, Brad Wilken and Eliane Schwartz from the executive MPH program, at the Mailman school, were invited by our very own Paige Amidon, for a visit at the Consumer Reports’ facility in Yonkers, NY.  Paige, who is the VP in charge of  the Consumer Report’s Health Rating Center, planned a fascinating visit in this facility, which tests thousands of products for us consumers. Everything from fabric, baby products, home appliances, electronics, to blood glucose measurement devices (glucometers), and home blood pressure monitoring devices are tested here, by an enthusiastic group of engineers that even create their own testing devices by themselves.

We started with an overview of the organization, which was founded in 1936 in NYC by a radical group that was involved with unionized workers. The main focus at that time was safety. Safety is still the main passion here but with the years, value testing was done and consumers were placed at the center of attention.  One of the first products that they tested was Alka Seltzer, and they found it didn’t do much more than “plop plop fizz fizz”.  Consumer Reports  is a not for profit organization, and funding comes mostly from selling publications and subscriptions. The organization doesn’t allow advertisement in their publications and currently 4.3 million people read Consumer Reports magazine, 3.3 million people subscribe to the website, and 800,000 subscribe to the Consumer Reports on Health newsletter.

The quiet pristine building in Yonkers is the home of 50 (!) labs that tests almost every product you can think of, except cars and car seats that are tested by Consumer Reports at their auto test facility in Connecticut.  The labs test batches of products at one time and over 4000 unique products yearly.  The testers are subject matter experts – including electrical engineers,  mechanical engineers, statistians and social scientists . Each groups checks products within their expertise.  The tested products are chosen after a detailed market interest analysis. After choosing the products, an employee buys, anonymously, a few units of it and brings it back for testing. This is to avoid biases. The products go through a series of testing protocols that are intended to break, tilt, tear, or make the product unsafe and not usable. Other products, like medical devices are checked for measurement precision.  No stone is left unturned.

There we went, from one lab to another, to see how cribs are tested with forty pound weights thrown at them from different angles and how strollers, appliances, fabrics and various  electronics are tested. Did you know that dryers are not only tested for their impact on your clothes at the thread level, but also for the impact they have on your floor tiles?  Every product is not only tested for safety but also for performance, ease of use, durability, and quality.

The highlight of the labs for me was the anechoic chamber. A fully sound proof room that allows testing of sounds systems. Paige and Mike our tour guide took us in, closed the door behind us, and … you hear nothing except your own heart beat.

What struck us were the enthusiastic faces of the employees in the labs. They almost looked like kids in a theme park, waiting for the next adventure.

We asked our hosts: how do the companies that produce the tested products respond to the testing? Apparently, some of the companies try to recreate the testing devices that the engineers at Consumer Reports develop. These are kept secret so the testing will be as objective as they are. If a company that makes elliptical machines like the ones we saw tested, know how the Consumer Reports testing is done – they may improve only the functions that are tested.

However, after seeing the testing of the elliptical, I think they have nothing to worry about. If the elliptical manufacturer mimic the testing and their product processes – nothing will go wrong. The testing is detailed even to the level of the gender of the user. Different norms are used for males and females users.

The doctors were very interested to learn about the medical device testing that is done here, like the blood pressure monitoring and the blood gluco-meters. The testing of the meters is done by six willing diabetic employees that try them at home for ease of use and consistency of results. In addition, precision and credibility is compared to venous blood testing in the lab by a nurse. The allowed error is marginal.

Five years ago, the health division of Consumer Reports started their health rating initiative. The initiative focused on value , which is derived from efficacy as well as price. Paige surprised us with a delicious lunch in the company of the health rating and impact group that leads this initiative.  In addition to Paige Amidon the group consists of Dr John Santa, Director of the Health Ratings Center (HRC); Dr. Doris Peter, Associate Director of the HRC and PI for Consumer Reports Best Buy Drugs; and Tara Montgomery, Director of the Health Impact Team.  Dr Santa shared his experience working for Govenor Kitzhaber in Oregon with us. By evaluating efficacy and value, with head-to-head information comparisons of drugs, a coalition of states including Oregon worked together to prove that saving can be done without compromising quality in health care.

The “Choosing Wisely” initiative was launched in April to educate health consumers regarding drugs, tests, and medical practices.  They not only need to educate the patients to choose the most effective, least harmful health care product, but they also need to convince the physicians to deliver such care. This is how the “Choosing Wisely” campaign was born in collaboration with the American Board of Internal Medicine Foundation. The campaign is to advocate for the safe and effective choice to be made by the doctor in consultation with the patient, leading to the just and cost effective distribution of finite sources. A just distribution of finite resources calls on physicians to be responsible for the appropriate allocation of resources and to avoid superfluous tests and procedures. One of the first professional societies that came up with a list of five unnecessary procedures is the American Academy of Family Physicians. I must say that I agree with their choices. If you want to read more about the Choosing Wisely campaign, go to http://consumerhealthchoices.org/campaigns/choosing-wisely/.

While munching on a delicious food, this enthusiastic group told us about their work, the obstacles they face relaying their efforts and outcome to consumers, as well as the professional medical societies and pharmaceutical companies. They also discussed their efforts to keep the brand unbiased by not accepting funds from outside commercial sources. After creating multiple health related publications, the group is working on market penetration. The health publications concentrate on consumer education that will empower patients to have discussions about quality and cost with their providers. They are also pushing for cost transparency to patients and providers. Although the majority of the cost is often paid by the health insurance companies, showing the price to the patients may change their preferences. According to the Consumer Reports experts, patient’s behavioral changes may follow such price transparency and education regarding potential harm by drugs and tests. Changing consumers’ behavior may result in a more cost effective health care with less harm to patients.

It was a very exciting visit that opened our eyes to the work behind the scenes of this important consumer advocacy group. With the changes that are occurring now in the healthcare scene, aiming for cost effective health care is essential to maintaining  the quality of care the insured American people are used to getting while extending coverage to the uninsured. It is reassuring to know that the consumers have a voice in the process.

Thank you Paige for sharing your professional world with us, we hope to be able to visit again and perhaps invite your group to share your experience with us in our “public health of the future” salon.

Public Health as a Tool for Social Justice: My Interview with Mailman Professor, Dr. Leslie Roberts

After emailing back and forth for weeks, the day had arrived.  I woke up at five o’clock in the morning on this unseasonably cold day in October to meet Dr. Leslie Roberts, a professor at Mailman.  I found his biography while perusing the faculty directory and became very curious about his work in Sub-Saharan Africa.   My goal was to expand our definition of public health beyond hospitals and disease (in the traditional sense), which is the focus of our Health and Policy Management EMPH program.   After running down an atypically empty 168^th Street and weaving through Bard Hall, I found a single light in a corner room in the Population and Family Health Department.  Dr. Roberts (Les) looked up from his computer and greeted me with a welcoming smile and enormous blue eyes.  For the next hour, we were lost in conversation.

He started his career perfectly content as a high school physics teacher and cross-country coach in a small town.  Due to funding cuts in education, at the age of 22, he found himself suddenly without a job.  His brother was in a student exchange program in Kenya, so Les decided to take a leap and join him to teach physics there.  Soon thereafter, he realized that the world didn’t need more physicists. Les was completely unraveled by witnessing Kenyan women carrying water jugs on their heads over long distances without a well in sight.

Twenty-five years later, he works on documenting human rights abuses.  He came to public health because he was interested in social justice.  Now that’s a concept:  public health as a tool for social justice.

But what happened in Kenya?  What motivated the transformation? I wondered…

Back in 1984, Les was an idealistic young teacher on the brink of change.  One day, he witnessed what seemed to be an attack on an Indian woman.  (At the time, there was a coup that resulted in brutality and backlash against Ethnic Indians in East Africa.)  Les noticed the guy rip a necklace off the woman’s neck and instinctively took off after him.  After a kilometer chase through the market and down streets, Les caught up with the man and pinned him down on the roof of a car with his arm twisted behind his back.  An angry mob gathered.   Almost everyone had been robbed at some point, and they were vengeful.  As bystanders moved in to rough up the thief, Les found himself protecting the very man he chased.  Suddenly, an enormous guy arrived on the scene, asked Les what happened, and began to bash the thief repeatedly in the face.  Les tried to restrain him, but then slowly realized that this big guy was a policeman!  After more of the same in the interrogation room, where policemen were eager to get their chance at a swing, Les realized how little he knew about the culture he was now immersed in.  How to “do the right thing” became less clear.  His world was changing.

Later on the same trip, Les encountered his second path-altering experience.  He caught malaria.   With headache and fever, he was bed-ridden and miserable, barely knowing up from down. He would make frequent visits to the latrine and flop himself back into his tent in exhaustion.  He realized that this excruciating experience was commonplace for Kenyans, including children who missed much of their education because of life-threatening infections like malaria.  It was another glimpse into this incredible new world.

Why did you pick epidemiology?  I asked. 

“I didn’t,” he replied.  “Epidemiology chose me.”  After Kenya, Les went south to Tulane University in New Orleans (which was in some ways more of a culture shock than Kenya!) for a master’s degree and then to Johns Hopkins for a PhD in water engineering with a public health focus.  He was able to piece together engineering, epidemiology, and economics in his training.  While doing work with water sanitation in Peru, he became inspired to take the next step in his path for social justice and public health.  He met a couple of CDC employees who were studying cholera under the Epidemic Intelligence Service or EIS for short (just like our own classmate, Catherine Dentinger).  Since his background was not clinical, Les didn’t match immediately.  But with determination and pure tenacity, he contrived the system to get a position in the refugee health branch.  The EIS program trains officers via four main tasks: evaluation of a survey system, investigation of an outbreak, conducting an analytic analysis of a large data set, and creation of a presentation and paper on one’s work.  Interestingly, an outbreak could span from investigating a toy with a possible choking hazard to an Ebola outbreak where people are actively dying.  During his EIS training, Les was overseas 13 out of the 24 months of training.  Although many of these experiences were wonderful, others where terribly inconvenient, including a trip to Bosnia two days after his new wife moved in with him in Atlanta.  He had no idea just how impactful this trip would become…

He pauses before he proceeds. 

And then goes on to tell me that Bosnia was the first time in his life that a place actually “gave him nightmares.”  What he saw was horrific.  The Bosnians, who were being targeted by the Croats and the Serbs, commonly described horrors that seemed like hype to Les.   He couldn’t imagine that it was true – that Serbian snipers actually shot Bosnian children in the legs in order to lure adults into shooting range.   Les couldn’t believe it to be true until one day when he walked into Kosovo Hospital in Sarajevo.  Once in the ward, all he saw nothing but children in hospital beds with gunshots to the legs.  He thought of the Geneva Convention – about a room of academics discussing the issues and how a list of statistics couldn’t compare to the actual sight.  Shortly thereafter, he witnessed young boys running through an intersection, making a game out of avoiding sniper bullets and high-fiving each other after making it through alive.  

Once again, Les recalled the common thread among his experiences in water engineering, public health, and human rights, which is social justice.  Little did he know that his ultimate challenge was yet to come.

After a stint at the WHO, where Les became disheartened by the self-promotion and politics of the organization, he moved to West Virginia to enjoy the countryside with his wife while working on freelance projects and teaching.  Then, in 1999, an old EIS contact stopped by the house in West Virginia with a proposal to study water consumption in the Congo.  Wes explained to me that a common epidemiological problem stems from difficulty in quantifying the denominator.  In other words, measuring overall water production was easy, but without a population, one could not calculate water consumption per person.  And that’s what they sought out to do.

They went to the Congo.  Through surveys to understand water consumption, they stumbled upon the fact that many people were dying prematurely.  More than reported.  And further, they discovered that more than 1,400 children had died from measles within their smallish sample.  Les contacted UNICEF, the organization responsible for immunization in Eastern Congo at the time.  While waiting for UNICEF to gather vaccinations, Les conducted another survey, which revealed that immunization rates were as low as 20%.   In an unbelievable turn of events, UNICEF came back saying that they searched “all of Africa” and found no vaccines!  As expected, Les didn’t give up and proceeded to leverage his EIS contacts and through the CDC, a professor at Emory with good contacts at the WHO, they located 100,000 MMR vaccines. 

And if this story wasn’t crazy enough…

The 100,000 found vaccines were stored in a UNICEF warehouse approximately 200 kilometers south of where they were…in the Congo!  Another shocking revelation as to how these organizations work.  Les and team proceeded to arrange for vehicles and administration of the vaccines.  Within weeks, the incidence of measles cases dropped dramatically.

During our conversation, Les spoke of his many “learning points” and “game changers” throughout this path (though he didn’t use these terms and even mentioned that the phrase “tipping point” was overused). Nonetheless, another one occurred post-Congo as he collaborated with the International Rescue Committee (IRC) to publicize findings from the Congo.  A New York Times article described the war in the Congo, but severely underestimated the number of deaths. Les knew better and hoped to publish the numbers from his study in The Lancet.   He knew that the number was more like 1.5 million dead instead of the 50,000 reported in that Times article.  His contact at the IRC asked him – why publish in the Lancet when we could negotiate for a front-page article in the Times? Les was stunned!  The very idea that one could “negotiate” with the NY Times to get a cover story rocked his world.    After the story ran, Les was invited to governmental agencies like US AID, the House Subcommittee, the National Security Council, and more.  These meetings didn’t translate into immediate aid as Les had hoped due to politics and timing, but ultimately, the killings greatly decreased after Colin Powell forced negotiations that resulted in the invading troops to withdraw.

The stories continue, but my time was up.  In an hour’s time, I learned a lifetime of lessons.  And I realize that my definition and scope of public health had expanded and shifted.   At present, Dr. Leslie F. Roberts teaches classes at Mailman in the Population and Family Health Department like “Water and Sanitation in Emergencies” and “Epidemiology and Methods in Human Rights Abuses” among others.   I felt privileged to be one of his students for an hour.  We plan to invite him to the EMPH public health salon (hosted by our classmate Ellen Coleman) in early 2013 and hope you will join.

Visit to Morris Heights FQHC (AKA Tammy’s clinic)

Since starting the Mailman EMPH program, our cohort has learned so much from each other both in the classroom and out.  Thus far, we’ve visited the Morgan Stanley Children’s Hospital emergency department (via Allison Lyons-Ankeny).  And my economics project group was lucky enough to get a mini-tour of Barclays (including the trading floor) when visiting Larry Marsh in his Times Square office.

They were glimpses of the worlds in which our classmates work, which is something we hope to do more of in the coming months.

More recently, Larry and I visited our classmate’s (Dr. Tammy Gruenberg) Women’s Health Clinic at the Morris Heights Health Center (an FQHC) where she works as an OB/GYN.

An FQHC, or federally qualified health center, is a safety net provider serving migrants and homeless.   We met her amazing team of health educators, nurses, midwives, housekeepers, the CEO, HIT team, and PA/MPH, among others.  The clinic was impressive, providing services to the community from obesity programs (Tammy is also starting a zumba class), baby showers for almost moms, complete GYN services, many quality improvement endeavors, and more.

We learned the ins and outs (ups and downs) of Centricity (their CPOE) and RHIO (the Bronx Regional Health Information Organization) as well as the challenges of interfacing with other systems (we had to calculate 1,000 factorial to really understand the complexity of interfacing between Centricity and other systems).

It was inspiring and impressive.   It’s really something to see – all of our courses distilled into one little clinic in the Bronx.

Thanks for reading!  Stay tuned fore more..

Monica

EMPH c/o 2013 blogger

http://www.emph.columbia.edu/

Engaging the disinterested learner

Here’s an article by Ana Berlin (EMPH Class of 2012) which was recently posted through the American College of Surgeons Residency Assist Page.  The ACS supports and provides solutions to the challenges inherent in surgical residency programs and education.  In her piece, Ana discusses how surgical educators can best engage hard to reach students.  The advice she gives teachers is readily applicable to others of us:  leaders, providers, and advocates alike.

Engaging the “Disinterested” Learner:  How to Use  Advocacy and Inquiry to Develop a Shared Mental Model for the Learning Experience

by Ana Berlin MD, Columbia University Department of Surgery, New York

 

 

http://www.facs.org/education/rap/berlin0512.html

 

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So we are getting measured for caps and gowns this weekend!  I wonder if our heads have grown larger over the past 2 years. . .

When my mother-in-law headed into retirement (after several decades as a librarian) she hung a string of paperclips from the lampshade on her night table.  Every month she removed one paperclip, bringing her a step closer to R-Day.

We have 3 paperclips left.

paperclips