Week 10: Rural Healthcare

This week’s articles focused on rural healthcare, and in some cases how medical institutions in urban environments are trying to advance and improve rural healthcare by infiltrating more education and partnerships. Each article seemed to, in one way or another, provide pros and cons of having urban institutions branching out to rural healthcare establishments. I personally think this concept is wonderful; I think programs such as Project ECHO, mentioned in Arora’s “Partnering Urban Academic Medical Centers and Rural Primary Care Clinicians to Provide Complex Chronic Disease Care”, are beneficial not only for today, but also for the future. What I like about Project ECHO in New Mexico is that it focuses on the partnership between primary care clinicians in rural, underserved communities and specialists at the University of New Mexico Health Sciences Center; because Project ECHO isn’t about specialists and clinicians from urban medical centers and research facilities coming into rural areas and providing healthcare, it will benefit future rural communities as well because of the education and collaboration available.

Similarly, I think the same method(s) should be applied to critical access hospitals (CAHs), as mentioned in Joynt’s article “Quality of Care and Patient Outcomes in Critical Access Rural Hospitals”.  Because CAHs are so important for providing small, isolated rural communities, it is just as important for them to have strong connections and relationships with academic and medical centers in the urban population. I know cost is a big factor in keeping CAHs running and accessible, but I think these relationships would ensure the ability for better healthcare to be provided to underserved, rural areas.

Many times we assume that temporary infiltrating an underserved or impoverished rural community with medical experts and specialists is the best solution- but it’s definitely not. In my opinion, that is just a temporary fix. While it might be beneficial to have those experts and specialists for the time-being, it is more important to focus educating the public and the relationships and partnerships between urban medical specialists and primary care clinicians in rural communities.

Week 9: Community Research

This week’s readings focused, more or less, on Community-Based Participatory Research (CBPR) and local research in general.  In “Governing through community allegiance: a qualitative examination of peer research in community-based participatory research”, Guta describes Community-Based Participatory Research (CBPR) as an up-and-coming, alternative method of research. The process directly involves community members at all stages of the research. This method has been proven to be beneficial because it empowers community member participants, which increases the capacity and quality of the data. I’m not an expert, but that makes total sense to me; by involving the community in a study about the community, the results are going to be more accurate and valuable. Like Jenike and Silka, Guta describes an example qualitative study that tests the assumptions and hypotheses made about CBPR. In this comparative study, researchers compare the responses of specific peer researchers on issues such as the experience of homelessness, living with HIV, being an immigrant or refugee, identifying as transgender, and of having a mental illness to the responses of research members that responded in separate groups.

“Come take a walk with me: The ‘‘Go-Along’’ interview as a novel method for studying the implications of place for health and well-being” by Carpiano, on the other hand, doesn’t focus on CBPR as much as the other readings for this week. Instead his piece serves as an introduction to the ‘‘go-along’’ qualitative interview process for studying health issues in a community-based context. He begins by describing the purpose and different types of “go-alongs”. He also focuses on the advantages of the interview process and why this method is beneficial compared to others. He then discusses the strengths and limitations of the method as well as other study approaches that work well in accordance with the “go-along” interview process. 

Week 8: LGBT Health

This week’s readings were focused primarily on gender and sex, and some of the health disparities LGBT people face today. Last semester I took a Gender and Women’s studies class called “Intro to Lesbian, Gay, Bisexual, and Transgender Studies.” In the class we learned about many different aspects of the LGBT community, each week having it’s own particular “topic”. These weekly topics were accompanied by 5-6 weekly readings, which we discussed in further detail in our discussion sections. One of the weekly topics we covered was actually LGBT health disparities and the LGBT community in healthcare today. The articles we had to read for that week were very similar to this week’s readings, so I was glad to see I’d actually have a little more background in the subject this week.

I especially liked the article by Cherlin titled “Health, Marriage, and Same-Sex Partnerships.” In my LGBT class we mainly focused week to week on the LGBT community, its history, and multiple disparities and oppression LGBT people face on a daily basis. However, our discussions never really lead to how the LGBT community is affecting others, only how other populations were affecting the LGBT community. Cherlin begins the article by discussing the ongoing argument of ‘whether marriage is beneficial to an individual’s health and well-being’. Many studies have shown a positive correlation between marriage and health, but there is not enough to prove any causation. That’s where Cherlin introduces the LGBT community; now that same-sex marriage is legalized in several states, we are able to observe and compare marriages without gender differences. It is probably too early to expect any statistical changes in research, but as same-sex marriage becomes legalized and more accepted nationwide it will be easier to analyze marriage statistics, causation (if any), and benefits without gender playing a part.   

Week 7: Health and Racial Inequality

As all of the readings and videos for this week alluded to and discussed, racism has an evident affect on health. I couldn’t believe 70% of white Americans think racial discrimination is a “problem of the past”. Prior to reading these articles I definitely saw the correlation between socioeconomic status and health and between race and health, but only if race was tied to a particular socioeconomic status. I was very surprised to learn about racism influencing health in cases where socioeconomic status wasn’t even a factor. In the video segment, “When the Bough Breaks,” they talk a lot about the effect of racism on health, particularly regarding pregnancy and birth outcomes. Chronic stress, a severe symptom of a life of racial discrimination, can really take a toll on one’s body and can have a long-term impact on the health of not only individuals, but also entire families. This is a predominant problem in the African-American community in the United States today. Racism is affecting African-American children before they are even born. Dr. Michael Lu, M.D., suggests this problem can be explained by the “Life Course Perspective”; birth outcomes are directly influenced by the entire life course of the mother and all of the stress and exposure she has endured during her life.

I also found many of the statistics and ratios presented in the articles very surprising, such as the fact that African-American women with a college education have the same rate of infant mortality as white American women high school drop outs. The most surprising fact, however, is that the United States is ranked 34th in the world in infant survival. Maybe I am just naïve and haven’t been exposed to enough information about infant survival and prenatal care, but that is a hard realization to wrap my head around. I do not deny that racism still exists in the United States, but I am surprised how much correlation lies between race and health, even when you disregard socioeconomic status. 

Week 6: Rural Health, Population Health, and Health Care Disparities

This week’s readings discussed rural health in comparison to urban health and health care disparities and inequalities concerning location. I particularly liked David Hartley’s article, “Rural Health Disparities, Population Health, and Rural Culture,” in the way it discusses the current transition from focusing on rural health to population health, health care inequalities which are often due to location, the background context he includes, and the cultural aspects of rural health he writes about. Hartley begins by examining how the field of rural health has grown and developed over the past 30 years. Rural health research and policy has become more and more established over the last few decades; there is now more research and publications in journals than ever before. In fact, the rural health field now includes dental medicine, mental medicine, and emergency medical services as well. Hartley then goes on to explain the specifics of rural health research; typically, data is presented to initially determine if there is any significant difference between a rural and urban environment or service. This data usually detects differences in terms of utilization of health care services, government spending, and geographic distribution of providers and services. However, the tables may be turning and the focus on rural health is seemingly transitioning to population health.

According to David Kindig and Greg Stoddart, population health is defined as “an approach that focuses on interrelated conditions and factors that influence the health of populations over the life course, identifies systematic variations in their patterns of occurrence, and applies the resulting knowledge to develop and implement policies and actions to improve the health and well being of those populations.” In a recent survey amongst rural health experts and physicians, “access to health services” was overwhelmingly ranked as the number one priority; conversely, the survey participants also ranked diabetes, mental health, oral health, and tobacco higher than ever before and as serious health concerns too. I don’t think the issue of “place” will ever completely go away as a priority in medicine and health care, but it is clear that the focus of many health care professionals is shifting from the differences between urban and rural health to population health. I guess we will just have to watch and see as more research is conducted and reforms and policies are brought forward regarding interventions and rural regions.



Week 5: Environmental Injustice and Inequality

This weeks articles and video clip all revolved around the idea of environmental injustice and inequality. I particularly liked the video clip “Bad Sugar”, part 4 in the video series “Unnatural Causes.” The video began by introducing some unnatural, powerful determinants of health such as economic, social, and political structures in today’s society. The title of the video, “Bad Sugar”, comes from the nickname given to type 2 diabetes by members of the Native American tribes interviewed in the video. Type 2 diabetes is a serious epidemic in populations such as the ones interviewed in the video. In fact, research shows that certain ethnicities around the world are twice as susceptible to type 2 diabetes than others. Currently there is no known cause OR cure for type 2 diabetes, but studies have provided links between the disease and genetics.

The part of the video I found the most interesting, however, was when they discussed the “unnatural causes” of type 2 diabetes and the scientific research behind these causes.

“If you’re in an impoverished community, and you don’t have healthy choices for food and you don’t have safe places to exercise, you are tremendously disempowered when it comes to a disease like diabetes.” -Donald Warne, M.D.

One of the main, and perhaps obvious factors attributing to the unstable health of many tribe members (as well as individuals in other impoverished areas around the world) is the lack of access to produce and/or natural, whole foods. In addition, stress from living in poverty has been directly linked to blood sugar control. When researchers observe and measure stress, they look at levels of stress hormones, such as cortisol and epinephrine. Studies show that as these stress hormones increase in the body, so too does blood sugar. And as a result, when high stress levels are maintained, glucose levels remain high and diabetes begins to develop. This seemingly hopeless pattern created by the harmful relationship between health and poverty should cease to be overlooked. It is significantly important for thousands of impoverished people not only in our own country, but also around the world.

Week 4: “Is Inequality Making Us Sick?”

This week’s material included part 5 of the video series “Unnatural Causes” called “Place Matters”. It discusses the important question, “is inequality making us sick?”. Watching this video reminded me of the spring break mission trip I went on last March to the impoverished neighborhood of Brentwood in Jacksonville, FL. We spent a week in the heart of the one of the most segregated, poorest neighborhoods not only the in Jacksonville, but also in the United States. Our group of 16 college students collaborated with a local organization called 2nd Mile Ministries and spent a week helping the community in various ways. 2nd Mile’s mission is to see individuals empowered and the community transformed through mission and volunteer work. In the state of Florida, the Brentwood neighborhood is statistically highest in instances of family poverty, child poverty, infant mortality, low-birth weight babies, little to no prenatal care, child deaths, teen pregnancy, HIV/AIDS, sexually transmitted diseases, births to unwed mothers, single parent households, homicides, and high school dropouts. For many years, Brentwood was also known as “the murder capital” of Florida.

Before leaving our safe, liberal and beloved city of Madison, WI, our group met a few times over the course of a couple months. Our meetings consisted of educational videos and general information about Jacksonville to inform us of what kind of culture and community we would be entering into. In “Place Matters”, they examine a variety of different locational, causal health factors such a neighborhood and geographic location.  A given place determines a person’s accessibility to resources, such as health care and food, and the environment by which they are surrounded. Place also determines a person’s level of exposure to environmental factors such as chemicals, and to social situations and relationships with neighbors. One of the main points of the video, which also applies to Brentwood in Jacksonville, FL, is that quality of housing and an individual’s neighborhood has a direct impact on his/her health. Many studies only consider the individual risk factors, such as diet, physical activity, and smoking, when looking at chronic diseases. However, it was very obvious while visiting Brentwood that there was more attributing to the poverty and illness in the community than just individual factors. When you look at the demographics of different chronic diseases compared to poverty levels and crime rates across a geographical area such as Jacksonville, FL, it is evident that place really matters.    

Week 3: Causation

This week’s readings proved to be interesting, informative, and challenging at the same time. Each discussed causation of disease and/or causal inferences in public health in some way, along with including a good amount of opinionated and theoretical content. I’d have to say my personal favorite was “Social Conditions As Fundamental Causes of Disease” by Bruce Link and Jo Phelan. First, Link and Phelan introduce their opinion on epidemiological research and how successful it has been recently in identifying risk factors of major diseases. However, most of these risk factors are individual, such as diet, cholesterol levels, and exercise, and tell us little about social conditions in relation to disease.  Hill and Phelan argue that more research attention should be focused on basic social conditions, such as socioeconomic status and level of social support, as risk factors of disease. They also claim that this type of research focus is necessary in order for health reforms and policies to reach their full potential in the future.

“Individual-based risk factors must be contextualize, by examining what puts people at risk of risks, if we are to craft effective interventions and improve the nation’s health.” (80)

I agree that by completely overlooking social conditions as “fundamental causes” of disease, we risk applying only individual-based intervention strategies that will result in ineffective solutions. However, although I see the point Hill and Phelan are trying to make, I don’t think they are putting enough emphasis on the individually-based risk factors in addition to the contextual and situational risk factors they so excessively allude to. Of course, every individual case is different, but both types of risk factors can play a significant causal role in the methodology of disease. I think it is important to not overlook any possible causal aspects of disease, including both situational and individual, because it could lead to the development of ineffective intervention methods.   

Week 2: Determinants of Health and Analyzing Trends

The chapter begins by discussing the deceivingly simple question, “why are some people healthy, and others not healthy?” To answer this question, Skolnik explains different determinants of an individual’s health, such as genetic makeup, sex, age, social and cultural issues, amount and extent of social support, environmental factors, education, individual health practices and behaviors, access to healthcare, and governmental control regarding health policies and programs. The influence “personal and inborn features”, as Skolnik describes them, have on individual health may seem fairly obvious at first . However, I also found it interesting to read about how Skolnik describes factors such as culture, social settings, and environment having an affect on individual health. The chapter then goes into examining different statistical health indicators, such as life expectancy, maternal mortality ratio, infant mortality rate, neonatal mortality rate, and child mortality rate. These analyses are deeply dependent on the individual health determinants discussed by Skolnik in the first chapter. I also found the graphics and figures to be very helpful with visualizing the statistical data.

The rest of the chapter deals with health related data regarding different countries, comparing both high and low income countries as well as different age groups and different demographics for these populations. I liked how Skolnik touched on not only the “10 leading causes of death” regarding different populations and age groups, but also demographics on risk factors, global health, and the burden of disease. I particularly liked the conclusiveness of Table 2-12 and found it very interesting to compare all this information side by side. Overall, I think Skolnik did an excellent job informing his readers of individual health determinants, indicators of health status, global burden of disease, and other statistical data regarding fertility and mortality rates for different countries around the world.  

I was also very enlightened by Gonick’s comic. It reminded me of good ‘ole statistics class in high school, only I wish I would have learned about statistics via those comics (they would have made the class more interesting and easier to sit through…). It served as a nice review of simple data analysis topics such as regression lines, regression analysis, ANOVA, scatter plots, hypothesis testing, sum of squared errors, and multiple linear regression.   

Week 1: Defining Public Health

This week’s readings explore the idea of health and the various ways it is and has been defined. In “Rethinking the WHO Definition of Health,” Bok discusses the outdated definition of “health” provided by the World Health Organization within the Preamble to the Constitution of the WHO from the early 1940’s. The WHO definition illustrates “health” as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (1). Although this definition may have been applicable and appropriate for the time period during which it was written, implementing this definition in today’s society is difficult. As Bok alluded to, including “a complete state of well-being” in the definition of health today would be very problematic. This is because most people who consider themselves to be “healthy” also suffer from a variety of minor ailments such as allergies (7). This definition also conflicts with underlying moral and political issues (2); it was written during a time period with different health conditions, epidemics, and mortality rates, with much less medical knowledge than available today.

Rothstein’s article, on the other hand, focuses on the newer, alternative definitions of health and public health. He discuses three different types of more relevant definitions of public health, including “human rights as public health”, “population health as public health”, and “government intervention as public health.” The idea of “human rights as public health” involves social factors such as war, crime, poverty, illiteracy, and injustice (144). This definition is tricky, however, because it covers a very broad spectrum of social problems and creates a problematic method of training for public health officials. “Population health as public health” focuses on the health of the whole population and not just an individual (145). By this definition, public health includes insuring access to healthcare and providing preventative information. Yet it is inclusive of both private and public divisions, creating a broad approach to public health. “Government interventions as public health”, as Rothstein confers, is probably the most sensible and applicable definition for today’s society. It involves government officials taking appropriate actions to protect the health of the public while balancing private and public rights and interests (146). 

After reading all of this week’s articles, it seems to me that the definition of health has been flexible in the past due to the ever-changing world around us. Although the definitions provided by Bok and Rothstein contradict each other and are from two very different times in history, it is interesting to compare and contrast them, and to notice that some facets of the idea of health have scarcely changed over time.