More communities need to integrate health care and public health programming: Prince George's County, DC, etc.
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Update: Not only did DC announce ("Bowser strikes deals for new Howard hospital and new Southeast D.C. hospital," Washington Post) that they have inked an agreement with George Washington University Hospital/Universal Health Services to build and manage a new hospital in Southeast DC, they've agreed to pay $300 million toward a new hospital for Howard University, which is becoming integrated into the Washington Adventist health system ("Adventist HealthCare and Howard University Hospital Sign Management Services Agreement," press release).
According to the article the GWU project will include some East of the River clinics beyond the hospital.
One of my "complaints" about DC is that as the nation's only real city-state, not having to kow tow to conservative state legislatures, it has tremendous opportunity to be innovative, but it rarely avails itself of those kinds of opportunities.
Sure, Congress has oversight, but for the most part, the city can do what it wants unfettered (not on debt, and Republicans often pass restrictive legislation as it relates to particular culture war matters).
Health and wellness care is one area where the city could be truly innovative, and really isn't. This new deal is an example. It will do a bit more than the current setup, with the outreach clinics, but it could do so much more.
As I wrote in the comment stream, in 2007 I laid out a concept I called "HealthyDC" community clinics to deal with chronic disease management and wellness. It was inspired by the then new clinics being put in pharmacies.
But the reality is that in A Pattern Language: Towns, Buildings, Construction, Christopher Alexander et al. (List of patterns) outlined the same concept in the late 1970s as item #47 (Community) Health Centers, based on the Pioneer Health Centre experiment in Peckham, England.
========
Partly because
- my first DC job was for a public health related organization
- the closure of DC General Hospital during the Williams Administration around when I started getting more involved in DC issues and when I started blogging
- a searing article in the no longer published Suburban Maryland Gazette newspapers in 2003 ("Shouldering the burden"), about the impact on Prince George's County with special negative impacts on Prince George's Hospital, from the forced displacement of poor DC residents to that county from the redevelopment of DC's public housing which also when it was rebuilt, was with fewer units than before;
-- "Health planning vs. hospital planning redux," 2006
-- "Piling on the hospital issue," 2006
-- "An opportunity for rethinking health and wellness care in the District of Columbia," 2006
-- "Speaking of rethinking how to offer "public services" and medical care," 2007
In 2018, I wrote a series outlining how a rebuild of United Medical Center in Ward 7/East of the River could be transformational both in terms of health care and public health outcomes as well as an economic development initiative, by marrying it with the simultaneous development of an advanced medical education and research program next door at the St. Elizabeths Campus, which the city has been trying to redevelop for more than a decade, with little to show for it.
-- "Ordinary versus Extraordinary Planning around the rebuilding of the United Medical Center in Southeast Washington DC | Part One: Rearticulating the system of health and wellness care East of the River
-- "Part Two: Creating a graduate health and biotechnology research initiative on the St. Elizabeths campus"
-- "Part three: the potential for donations around an expanded program"
-- "Update on DC's plans to build a new United Medical Center"
-- "Community Health Improvement Planning"
-- "A glaring illustration of the need for comprehensive health and wellness planning in DC: Providence Hospital"
The influences on that program were far and wide, and as I come across other great programs new to me, I enter them in the comments on the various articles.
A few weeks ago, I wrote about how there was something I missed in that series, the need when building that hospital to plan in extra functions and potential capacity in case of epidemic or terrorism, the way that Rush Medical Center in Chicago was reconstructed after 9/11.
-- "Rush Medical Center (Chicago) clues us into a gap in state and regional health care planning: planning for disaster and epidemic response"
As I said, the economic and health outcomes problems faced by DC General, Howard University Hospital, and Prince George's Hospitals at the same time made me realize that this issue was regional, not jurisdiction specific. But I chalked that up mostly to poverty.
-- "When the problem is defects in the structure of "the market", financial incentives won't do much good: Maryland's health enterprise zones," 2013
Health disparities for people of color aren't just about income. But the issue of health disparity is more than just poverty, it can also be an issue of race, as indicated by the Washington Post article, "Covid-19 is ravaging one of the country’s wealthiest black counties."
Another example was outlined previously in reporting by the New York Times about black women and pregnancy complications, which affect women at all income levels ("Why America's Black Mothers and Babies Are in a Life-or-Death Crisis").
Minorities in Prince George's County dying from coronavirus aren't "just poor" or people with serious underlying health conditions, they are also healthy people with high incomes who happen to be people of color.
To deal with the problems of PG Hospital, the state facilitated its merger with the University of Maryland Medical System, which because the medical school is in Baltimore, has been less focused on the DC side of Maryland.
The program is now called UMMS Capital Region Health and the linchpin is a new hospital under construction in Largo, which will replace the existing PG Hospital.
-- "Prince George’s health system names permanent chief," Washington Business Journal
-- "New empire in Prince George's: The road ahead for UM Capital Region Health," Washington Business Journal
Probably every new hospital project needs to add capabilities to deal with epidemics and other potential health disasters. But like with my recommendations for United Medical Center and the recognition that the program should be expanded even further, along the lines of what the Rush Medical Center has done, my sense is that the UMMS program for the new hospital in Largo doesn't link health care and public health programming, and the hospital isn't likely to being outfitted in extranormal ways to deal with epidemics, terrorism events, and other threats.
(And yes, I know many hospitals, at least with catastrophic response to mass casualty events, are already doing some of this.)
PG County needs to do what I recommended DC do. Looks like Prince George's County, and presumably other communities with high population of people of color need to develop similar programs marrying health care and public health programming more directly.
For example, the Post writes about a similar situation in Milwaukee, "Covid-19 is ravaging black communities. A Milwaukee neighborhood is figuring out how to fight back," and there have been many articles about the hollowing out of the rural health care system ("Closed Hospitals Leave Rural Patients ‘Stranded’ as Coronavirus Spreads," New York Times; "1 In 4 Rural Hospitals Are At Risk Of Closure And The Problem Is Getting Worse," Forbes). These communities need better care as well as more care.
Like how UMC probably isn't being built the same way that Rush Medical Center was, to be of special use in times of pandemic, the same is probably true of the new UMMS hospital in Largo.
Transformational Projects Action Planning as an approach
This approach, oriented to wringing out every possible benefit from a large project as a way to transform a functional "service" like health and wellness care and public health, is an example of what I call "Transformational Projects Action Planning" applied to health and wellness planning more generally, and specifically to large scale projects, like the planning, development, construction and operation of a new hospital.
-- "Why can't the "Bilbao Effect" be reproduced? | Bilbao as an example of Transformational Projects Action Planning," 2017
-- "Downtown Edmonton cultural facilities development as an example of "Transformational Projects Action Planning"," 2018
-- "A "Transformational Projects Action Plan" for a statewide passenger railroad program in Maryland," 2019
-- "A "Transformational Projects Action Plan" for the Metrorail Blue Line," 2020
The Purple Line series in toto is an example of TPAP. All the relevant articles are linked within this update:
-- "Revisiting the Purple Line (series) and a more complete program of complementary improvements to the transit network," 2019
Labels: change-innovation-transformation, health and wellness planning, hospitals, provision of public services, public health
posted by Richard Layman @ 9:47 AM&Permanent Link
68 Comments:
excellent post.
I'd say we need to look at Baltimore and BC; for what ever reasons they have been more successful here.
Do I know why? No. But worth asking that question.
There will be federal money for building out hospitals more. Hospitals are actually a huge driver in expenses but yes I'd see a lot of money flowing in there. So both Howard and SE medical center have some chances now.
Here is my question -- how effective has been "networking" within DC. Looks like DC is still constrained and the DC area hospitals may not be working so well together. Again hard to evaluate that claim right now.
You've also got a lot of federal resources here : VA, Bethesda naval, and we could probably use another one.
Can public health outreach to elderly be part of medicaid? Medicare? There are specific programs that do that with children. Likewise there are other program that drive it to special communities (Whitman walker). What is needed is something on that level.
Pharmacy deserts:
https://www.nationalacademies.org/news/2020/04/exploring-the-importance-of-pharmacies-to-public-health
DK if JHU and UMD having great medical schools is an issue.
At the same time the independent, Bon Secours, and to some extent LifeBridge (formerly Sinai, and in the poorer area because it had been Jewish before outmigration) deal with the lower income communities more than the big systems, maybe?
Bon Secours was doing a lot of community work, including building affordable housing. But with the recent merger, they've exited the Baltimore market. Allegedly the community work will continue, and LifeBridge bought the facility, but it will be downgraded to not have hospital beds.
Another thing about Baltimore City, I guess because of ongoing heroin problems and maybe STDs, they have (or at least had) a strong public health unit. Directors have gone on to high profile positions.
But probably, in terms of the difference of what I call health and wellness vs. health care, probably JHU and UMMS are no more forward than anyone else.
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I don't know enough about the medical field to know how important networking is/can be.
I know in other areas (higher education, commercial district revitalization, ANCs) it's almost no networking.
At the sub city level of ANCs, community groups, historic preservation, and commercial district revitalization programs, for going on 15 years I keep calling for networking and sharing resources.
But the higher education institutions do have their consortium, which shares resources, allows students to take classes at other institutions, etc. (like the consortium in Amherst, Mass.).
As I said in other comments, a large part of this reaction is predicated by your familiarity with infection disease. On a national and sub-national - and personal scare.
One reason I've been downplaying it. My mother is a virologist. I've literally had to go in a bio-hazard virus lab as a kid after school. My grandfather died of the bubonic plague. (Long story). On my father's side, the majority of his extended family was wiped out in 1918. My father had to become a doctor because his grandfather -- the only survivor -- saw how important it as to have a doctor around.
For the vast majority of americans, infections disease is something to happens to black/brown people and not a real concept anymore. Strong moral element to it -- if you catch something it is because of morality, not science.
D/K enough about Baltimore and hospital systems to asses. But make everything else equal, it should be ripping through Baltimore more.
From what I can tell, DC is relying on its own pubic health lab, one university lab, and private results 6 labs total. they've been limited with reagents and swaps like everyone else, and DC only doing testing on its own in Ward 7 and 8. (could be mistaken on the last)
And yes that lack of networking is probably an endemic problem.
Going back to the national level on familiarity, you see that with HK, Singapore , south korea. They ran this game 20 years ago. Easy model, no sign that we're duplicating it. Do you think quarantine orders are being followed in DC? Bowser did ban visitors to senior public housing but not to regular PH --- which is also primarily old people.
Manchester UK reports 1/2 of homeless put in hotels left b/c they didn't like the lifestyle. It isn't optional.
What we are really seeing her is how important metabolic health is and those are the easiest interventions.
Like I mentioned in comments, I went through a period where I read a bunch of stories by John O'Hara, and he was a doctor's son and had second hand experience I think with his father's work during the 1918 epidemic. (He wrote about families in mining towns in Pennsylvania being wiped out, among other things, Poles and Welsh, etc.)
Plus Andromeda strain, plus reading about leprosy, TB, AIDs, hantavirus, Legionnaire's disease, vaccine issues, Ebola, cholera, etc. over the years.
I had chicken pox. Not measles. Don't think I knew anyone who had polio. But I just can't remember.
And working for CSPI introduced me to public health. I even considered doing grad work, but then I didn't continue in the field.
So what you're saying is the US was lucky vis a vis first hand experience, for about a century.
So we had structural complacency.
Yes, the Asian countries have to be constantly on watch given the likelihood of new viruses like SARS, now this.
But eventually, luck runs out as it did in this case.
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Yes, reiterates the value of basic health, and wellness.
Not a surprise about Manchester (I'll look it up.)
There was a Reel South documentary a few days ago about removing a homeless tent camp in Nashville. I wanted to watch it because the blurb said it was about "gentrification" etc.
It had nothing to do with gentrification, but did have to do with dealing with homeless policy (which they didn't address) and the use of public space for informal tent communities.
Anyway, from the interviews, no question that every person in the camp had mental and/or substance abuse issues.
That being said, it was a rare example of such a camp where the people had a sense of collective responsibility, maintained the general areas, etc.
But they had wacked ideas that if they did a nice job maintaining it that the city would leave them be...
Reading the post article on PG county, what strikes me is how many of those cases are just being handled by emergency rooms.
Again may be misreading this, but I'd say the issue is lack of a doctor to talk to.
The public health / metabolic health issue is in another box. I don't think Doctors are the best ones to say how to lose weight and exercise. You need incentives.
In japan if your waist size is over 35" you don't get insurance.
https://www.nytimes.com/2008/06/13/world/asia/13fat.html
Remember I worked at CSPI. In 2007, really intrigued by the introduction of the Minute Clinic concept, I wrote a blog entry suggesting the creation of "HealthyDC" "stores" that would be clinics/wellness centers focused on this and other chronic medical conditions.
http://urbanplacesandspaces.blogspot.com/2008/02/dispuptive-innovation-once-again.html
Putting this together with the other stuff that I have written since, I realize now that my approach about linking planning and mechanisms for change has a lot to do with what I learned while working at CSPI, even though it wasn't a "direct service" group, what I called indirect service, focused on structural change. But it was a self-help oriented group in terms of publishing Nutrition Action Healthletter, while at the same time, working for structural changes in policy and regulation.
(But it's also related to stuff I learned and tried to apply in college, concerning "action research" and organizational development.)
My 2006 piece on Arlington's commuter stores, the Idea Store library-workforce centers in Tower Hamlets, and one other program I don't remember, makes similar kinds of points.
... how I have advocated for a teaching kitchen at Eastern Market for more than one decade.
... how I argue for providing programs for assisting people in making the switch to biking and other forms of active transportation.
Of course, the PL series or the hospital series originally.
It's a form of the "nudge" thesis. (Another complaint, about kids being not allowed to go to school without shots. I said, "set up a time before the start of the school year with a doctor and nurse and do it production line style.)
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CSPI did some educational films. A couple years I exhibited at the Am. Home Economics Assn., and a teacher from Eastern High School asked me to show the film to her classes. I did. In our talking about it, she said that for many of her students, having a group meal in class was one of their only experiences eating a meal together. Etc.
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But as great as my HealthyDC idea was, it turns out that Christopher Alexander has a similar concept in _Pattern Language_. Then again, it's not rocket science.
But the HealthyDC clinic/"stores" are basically creating the kind of GP practice that marks the NHS set up, at least as it is portrayed on "Doc Martin."
Moving it away from the emergency room.
It wasn't just not having insurance that sent people to ERs before ACA, it was not having doctors. And obviously that is still mostly the case in these kinds of communities.
https://hbr.org/2006/12/disruptive-innovation-for-social-change
https://www.washingtonpost.com/local/dc-politics/bowser-strikes-deals-for-new-howard-hospital-new-southeast-dc-hospital/2020/04/29/8483ffea-8a69-11ea-9dfd-990f9dcc71fc_story.html
https://on.ft.com/2SlG7FE
https://www.statnews.com/2020/04/29/we-need-the-real-cdc-back-and-we-need-it-now/
he FT story is great.
“When we look back, we will see this as a moment that laid bare some of the dysfunctions and inequalities in the American healthcare system,” says Adam Gaffney, an instructor of medicine at Harvard Medical School, and a pulmonary and critical care doctor. “We have a completely fragmented, privatised health system that continues to fail us.”
But yes, I started learning that at the Academy of Health Services Marketing conference I exhibited at in something like 1990 or 1989...
One of the things that I thought was really wrong about Obama's approach to health care, was a failure to lay out some parameters of the ideal.
It's easy for me to say that though, me not being focused on what was possible politically.
Especially with the tea party counterattack which moved Congress to Republican control.
While so many criticize "Medicare for All" the issue really is do we want a catastrophic care system or a health and wellness system.
... and a care system vs. a set of disconnected markets.
Except Medicare for all is still insurance focused. Maybe with such a system, we'd start getting community based physician practices again. Maybe not.
(I presume you saw the Post article about doctor practices being seriously economically impacted by the pandemic. Like hospitals postponing elective procedures, not seeing patients means no income.)
BUT without people laying out the alternative/an alternative ultimately things won't change much.
... and when I was processing this a.m., speaking of your point about metabolic health,
https://www.nytimes.com/2020/04/20/well/eat/coronavirus-diet-metabolic-health.html
wrt the CDC piece. Yep. Wow. They were thought of as the consummate professionals. Everyone looked up to them.
Again, this idea I laid out of reshaping the Public Health Service, CDC, schools of public health, and state and local departments of public health as an integrated system on the extension model is key.
It's somewhat on those lines already. But with a huge gap in funding.
And obviously, there needs to be some independence, given how f* up our politics are.
In the old days, it wasn't like that so much.
https://www.bizjournals.com/washington/news/2020/05/01/d-c-is-getting-a-pair-of-new-hospitals-here-are-5.html
Article about what the funding for the new hospitals means.
Poor state of metabolic health demonstrated as a result of coronavirus hospital admissions:
https://www.bostonglobe.com/2020/05/07/opinion/link-between-coronavirus-deaths-those-french-fries/
Michael Marmot, director of the UCL Institute of Health Equity
https://www.ft.com/content/5e6330de-1e95-4343-8424-184d19dc34b9
2. Another area for a program like the one outlined here appears to be the area served by the University Hospital in Brooklyn (SUNY Downstate Medical Center).
https://www.nytimes.com/2020/04/26/nyregion/coronavirus-new-york-university-hospital.html
WSJ, "Rethinking the Hospital for the Next Pandemic"
https://www.wsj.com/articles/rethinking-the-hospital-for-the-next-pandemic-11591652504
6/8/2020
Other WSJ articles in the same section:
"Wanted: Doctors to Treat Addiction" -- many doctors lack the certification to use drugs as part of addiction treatment
"The High Cost We Pay for Crowded ERs" -- reports on research that crowded conditions in ERs leads to worse outcomes and more death.
"A Multipronged Strategy for Obesity" looks at addressing obesity more directly and with a wider range of treatments.
A few things from a NYT Magazine article, "Why we're losing the battle with covid-19," focused on Texas.
https://www.nytimes.com/2020/07/14/magazine/covid-19-public-health-texas.html
Public health isn't so much a system. Underfunded. CDC lacks ability to require data collection. Politics overrules public health.
As PH interventions successful in the 19th and 20th century, e.g., re tuberculosis, STDs, polio, water systems, sanitation, etc., disconnect over PH ability to mandate actions.
National Institute of Medicine, two reports on lack of investment in, support of public health. Not a system.
_The Future of the Public's Health in the 21st Century_, 2002
https://www.ncbi.nlm.nih.gov/books/NBK221239/
Trust for America's Health rates states, addresses PH matters:
https://www.tfah.org/
More on the revival of Jackson Health System, the public hospital in Miami-Dade.
https://www.miamiherald.com/news/health-care/article74816342.html
Making it a hospital of choice. Management and labor cost improvements.
Public bond to support the Jackson hospital system.
https://www.miamiherald.com/news/local/community/miami-dade/article1967074.html
Maternal care deserts:
https://wtop.com/health-fitness/2020/09/maternity-care-deserts-found-to-be-serious-issue-in-dc-md-and-va/
https://www.marchofdimes.org/materials/Nowhere_to_Go_Final.pdf
Washington Post has article about Rand study of health disparities in Prince George's County.
https://www.washingtonpost.com/local/md-politics/prince-georges-health-report/2020/09/29/534facbe-0262-11eb-b7ed-141dd88560ea_story.html
One comment on the article, by William T. Hopkins, is particularly good:
I would direct County Council Chair Todd Turner to look toward CA who instituted health-in-all-policies strategy in 2012 and revised their policies in 2013. Richmond, CA has also been innovative in healh-in-all-policies. NY State started this approach in 2017. CA's Office of Health Equity insures these policies are adhered to; I would NOT follow DC's Dept of Health's Office of Health Equity that has soaked up millions in salaries and has yet to produce ANY strategies that the District Gov't has incorporated.
Inner city Philadelphia has hospital economic problems comparable to those of UMC and Howard University.
https://www.inquirer.com/business/health/einstein-jefferson-hospital-ibc-klasko-childrens-hospital-ftc-philadelphia-market-20201005.html
Jefferson Hospital/Medical School aims to acquire Einstein, boxing out other competitors.
St. Joseph's Hospital closed in 2017, Hahnemann in 2019, and in March Mercy Philadelphia eliminated most of its in-patient care programs.
https://www.theguardian.com/us-news/2020/oct/23/covid-19-battering-black-chicagoans
https://www.washingtonpost.com/graphics/2020/national/george-floyd-america/health-care/
Financial Times series on response to the coronavirus. One article is on the massive failure in New York City and State:
https://www.ft.com/content/a52198f6-0d20-4607-b12a-05110bc48723
https://www.nytimes.com/2020/11/03/us/dr-philip-lee-dead.html
Dr. Philip Lee Is Dead at 96; Engineered Introduction of Medicare
Professor David Barton Smith of Drexel University, author of “The Power to Heal: Civil Rights, Medicare and the Struggle to Transform America’s Health System” (2016).
https://www.vanderbilt.edu/university-press/book/9780826521071
https://www.washingtonpost.com/graphics/2020/health/covid-race-mortality-rate
‘I just pray God will help me’:
Racial, ethnic minorities reel
from higher covid-19 death rates
A Post analysis shows that communities of color continue to
die from the coronavirus at much higher rates than Whites.
11/20/2020
Tennessee is prioritizing areas with high social vulnerability (CDC social vulnerability index) and high covid rates for the vaccine.
https://www.washingtonpost.com/health/2020/12/18/covid-vaccine-racial-equity/
CDC social vulnerability index
https://www.atsdr.cdc.gov/placeandhealth/svi/index.html
"Mortality rate for Black babies is cut dramatically when they’re delivered by Black doctors, researchers say"
https://www.washingtonpost.com/health/black-baby-death-rate-cut-by-black-doctors/2021/01/08/e9f0f850-238a-11eb-952e-0c475972cfc0_story.html
Black barbershops help men with health - The Washington Post
https://www.washingtonpost.com/people/courtland-milloy/
Great article about the creation of "community health centers" in the 1960s, as a medical response to civil rights organizing in the South. They are in both rural and urban areas.
https://www.washingtonpost.com/outlook/2021/01/28/health-care-was-central-civil-rights-movement/
Sinai Urban Health Institute at Sinai Hospital, Chicago.
https://sinaidevmt.sinai.org/content/sinai-urban-health-institute-0
SUHI conducts community health surveys and aims to address chronic health conditions and disparities resulting from poverty.
-- Improving Community Health Survey, 2004,
http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.673.4726&rep=rep1&type=pdf
They published a book, Urban health: combating disparities with local data, which outlines the "Sinai model" which is based on the idea that by collecting health data at the scale of neighborhoods, effective responses can be developed to reduce health disparities.
The Guardian: For Black Americans, Covid-19 is a reminder of the racism of US healthcare.
https://www.theguardian.com/commentisfree/2021/feb/22/black-americans-covid-19-racism-us-healthcare
Black Americans should face lower age cutoffs to qualify for a vaccine
https://www.washingtonpost.com/opinions/black-americans-should-face-lower-age-cutoffs-to-qualify-for-a-vaccine/2021/02/19/3029d5de-72ec-11eb-b8a9-b9467510f0fe_story.html
https://www.nytimes.com/2021/03/07/opinion/racism-public-health-emergency.html
The deadly covid-19 pandemic is obscuring another — obesity
Opinion by Leana S. Wen
https://www.washingtonpost.com/opinions/2021/04/11/deadly-covid-19-pandemic-is-obscuring-another-obesity/
Separately I've written about EMS, but not so much in this context of the rearticulation of hospital organization and the integration of public health programming.
e.g., http://urbanplacesandspaces.blogspot.com/2016/02/dc-ems-medical-directorassistant-fire.html
WTOP: Arlington Co. EMS crews will now take some patients to urgent cares instead of hospitals.
https://wtop.com/arlington/2021/04/arlington-co-ems-crews-will-now-take-some-patients-to-urgent-cares-instead-of-hospitals/
Emergency medical crews in Arlington, Virginia, can now start transporting some patients to urgent care centers instead of hospital emergency rooms and could, later this year, start treating some patients at home via telemedicine under an “innovative” program to lower costs and streamline EMS operations.
Arlington County announced the shift in a news release Friday.
The county’s EMS department is one of 250 nationwide selected by the Centers for Medicare and Medicaid Services to roll out the Emergency Triage, Treat and Transport program, known as ET3.
2. Orthodox Jewish women volunteer ambulance service in Brooklyn.
https://www.nytimes.com/2021/04/19/us/ezras-nashim-womens-EMT.html
New York City and State have a fair number of such volunteer services. This service was developed to "complement" an Orthodox Jewish male EMS service that refuses to accept women as EMTs.
wrt covid public health measures, of course a key element should be financial support for isolation and quarantine, paid sick days/income support, etc.
This was a key element in China, South Korea (they provided isolation but I don't know about income support), and Taiwan.
https://jamanetwork.com/journals/jama/fullarticle/2762689
Criticism of Ontario's failure to do so:
https://www.thestar.com/politics/political-opinion/2020/06/08/unpaid-sick-days-are-what-ails-doug-fords-recovery-plan.html
New thinking on long term care:
https://www.thestar.com/politics/political-opinion/2021/04/10/long-term-care-needs-fresh-thinking-and-new-money-not-old-excuses.html
Lack of continuity of care.
https://www.washingtonpost.com/opinions/2021/04/22/what-weve-learned-chauvin-trial/?outputType=comment&commentId=efb96c54-b92c-493e-8b49-2697273700ee
Yahoo Finance: New proposal to lower Medicare age to 50 could be a lifeline to millions
https://finance.yahoo.com/news/proposal-lower-medicare-age-50-130000091.html
https://news.yahoo.com/blacks-face-four-times-higher-125731802.html
The chances of having a stroke in middle age are at least four times greater for Blacks than for Whites in the United States, according to research
UMC is still the odd man out:
D.C. Council refuses to raise funding cap for United Medical Center, triggering oversight board.
https://www.washingtonpost.com/local/dc-politics/dc-council-cannabis-bill/2021/05/03/b3677b12-ac1d-11eb-b476-c3b287e52a01_story.html
The New Yorker: The Death of Hahnemann Hospital.
https://www.newyorker.com/magazine/2021/06/07/the-death-of-hahnemann-hospital
https://www.bostonglobe.com/2021/06/02/opinion/generation-pandemic-is-interested-public-health-we-should-take-advantage/
http://www.regionalprimarycare.org/prince-georges-county/
Regional Primary Care Coalition
report, Transformative Change: Our Role in Achieving Health Equity for PG County
http://www.regionalprimarycare.org/wp-content/uploads/2018/10/Prince-Georges-County-Health-Equity-Forum-Report-June-2018-Final.pdf
Adventist HealthCare Fort Washington Medical Center
The pandemic rocked this small hospital in a mostly Black suburb. Now it’s trying to grow..
https://www.washingtonpost.com/dc-md-va/2021/06/21/hospital-black-fort-washington-prince-georges/
WRT rural health and the addiction crisis, in this case opioids, this article, focusing on health professional Nikki King, from Rural Kentucky is quite interesting in discussing the lengths to which someone went to create a drug treatment program in Ripley County (Batesville), Indiana at her hospital, working with the court system, how opioids repattern the brain and so require "medically assisted treatment" but there are many barriers to providing such, etc.
When the state medicaid program said they wouldn't pay for the drug treatment program, because it was located not at the hospital, but at the county courthouse, she got the idea to "buy" (in this case rent) the space from the Courthouse, so that they could say it was part of the hospital.
Fighting the Opioid Crisis in Indiana and Appalachia
https://www.theatlantic.com/magazine/archive/2020/05/nikki-king-opioid-treatment-program/609085/
They also did a video.
https://www.theatlantic.com/video/index/609679/small-town-plague/
It's relevant, I think, to urban settings as well.
wrt facilitating care for the aged
https://www.nytimes.com/2021/04/23/health/elderly-medical-equipment.html
Many Older Adults Lack Even Simple, Helpful Equipment
A team at the University of California, San Francisco, combed through national data and came up with an estimate, recently published in JAMA Internal Medicine: About 12 million people over 65, living in their own homes, could use equipment to help them safely bathe and use the toilet, two of the activities disabled older people most commonly struggle with. But about five million of them don’t have those items, even though they generally cost less than $50.
... a program at Johns Hopkins called CAPABLE (Community Aging in Place — Advancing Better Living for Elders) sent a nurse, an occupational therapist and a repair person to provide some inexpensive assistive devices. “It made a tremendous difference in my life,” Mr. Hancock, a retired school cook, said. ....
CAPABLE, deploying its multi-specialty team and a modest budget of $1,300 per household for repairs, equipment and installation, offers low-income residents not only bathroom equipment but also kitchen grabbers, well-anchored banisters and other useful articles.
And it pays off. “On average, people’s disability is cut in half,” Dr. Szanton said. “Their pain decreases. Their ability to bathe and dress improves. People stuck on the second floor of their houses for years can go on family trips.”
CAPABLE reduced Medicaid spending and could create Medicare savings as well. Participants reported that it helped them remain at home, made their homes safer and helped them care for themselves.
https://www.dallasnews.com/opinion/editorials/2021/11/14/dallas-healthcare-is-a-tale-of-two-cities/
https://www.beckershospitalreview.com/public-health/how-chicago-hospitals-health-systems-are-tackling-their-top-public-health-concerns.html
How Chicago hospitals, health systems are tackling their top public health concerns
11/18/2021
Nursing home deaths rose 25 percent after Hurricane Irma, study finds
https://www.washingtonpost.com/health/nursing-home-deaths-hurricane-irma/2021/12/03/3863d5d4-52ce-11ec-8927-c396fa861a71_story.html
Mostly due to power failures.
Super fail to not have mentioned drug addiction specifically as an element of public health programming
The rising homicide rate in D.C. is nothing compared with what fentanyl is doing
https://www.washingtonpost.com/dc-md-va/2022/02/07/opioid-fentanyl-addiction-narcan-racism-health-equity-gun-violence-dc/
"The Philadelphia Inquirer: Penn receives record $125 million to offer free tuition to nurse practitioners to work in underserved communities."
https://www.inquirer.com/news/penn-nursing-gift-leonard-lauder--20220214.html
2. Jackson County Michigan has a "community integrated paramedicine" program where EMS personnel are utilized as a way to provide "continuity of care" between hospital release and home, with the aim of increasing care compliance and reducing readmissions.
http://ippsr.msu.edu/sites/default/files/SOSS/CIP%20Pres%20Leg%20Edu%202.8.21.pdf
3. Regions Hospital, Minnesota, community paramedicine program.
https://www.regionsems.com/cp
We must reimagine how to address D.C.’s persistent health inequities
https://www.washingtonpost.com/opinions/2022/06/17/we-must-reimagine-how-address-dcs-persistent-health-inequities/
Perception of quality of existing facilities and services can be an issue.
NBC4 Washington: Adventist HealthCare Plans to Relocate to Prince George's.
https://www.nbcwashington.com/news/local/adventist-healthcare-plans-to-relocate-to-prince-georges/3116795/
7/27/2022
https://www.sltrib.com/news/2021/03/05/what-pandemic-has-taught/
"What the pandemic has taught us about science, society and our own selfish ways"
- funding matters
- social disparities become catastrophic in a crisis
- value of communication
- half-measures don't work
- don't rely on Americans to think about anyone but themselves
USA Today has a six part series on obesity.
https://www.usatoday.com/web-stories/obesity-rate-in-america/
Re public health and covid
https://us.macmillan.com/books/9781250796639/theviralunderclass
The Viral Underclass: The Human Toll When Inequality and Disease Collide
Having spent a ground-breaking career studying the racialization, policing, and criminalization of HIV, Dr. Thrasher has come to understand a deeper truth at the heart of our society: that there are vast inequalities in who is able to survive viruses and that the ways in which viruses spread, kill, and take their toll are much more dependent on social structures than they are on biology alone.
Told through the heart-rending stories of friends, activists, and teachers navigating the novel coronavirus, HIV, and other viruses, Dr. Thrasher brings the reader with him as he delves into the viral underclass and lays bare its inner workings. In the tradition of Isabel Wilkerson’s Caste and Michelle Alexander’s The New Jim Crow, The Viral Underclass helps us understand the world more deeply by showing the fraught relationship between privilege and survival.
Not unlike Latino Health Access in Santa Ana, California.
"To Sway the Unvaccinated, Latino Teens Deputized as Health Educators"
Kaiser Health News
https://www.usnews.com/news/health-news/articles/2023-01-24/latino-teens-deputized-as-health-educators-to-sway-the-unvaccinated
Alma earned her reputation as a trusted source of information through her internship as a junior community health worker. She was among 35 Fresno County students recently trained to discuss how COVID vaccines help prevent serious illness, hospitalization and death, and to encourage relatives, peers and community members to stay up to date on their shots, including boosters.
When Alma’s internship drew to a close in October, she and seven teammates assessed their work in a capstone project. The students took pride in being able to share facts about COVID vaccines. Separately, Alma persuaded her family to get vaccinated. She said her relatives, who primarily had received COVID information from Spanish-language news, didn’t believe the risks until a close family friend died. ...
Community health groups in California and across the country are training teens, many of them Hispanic or Latino, and deputizing them to serve as health educators at school, on social media and in communities where COVID vaccine fears persist. According to a 2021 survey commissioned by Voto Latino and conducted by Change Research, 51% of unvaccinated Latinos said they didn’t trust the safety of the vaccines. The number jumped to 67% for those whose primary language at home is Spanish. The most common reasons for declining the shot included not trusting that the vaccine will be effective and not trusting the vaccine manufacturers. ...
Some training programs use peer-to-peer models on campuses, while others teach teens to fan out into their communities. FACES for the Future Coalition, a public youth corps based in Oakland, is leveraging programs in California, New Mexico, Colorado and Michigan to turn students into COVID vaccine educators. And the Health Information Project in Florida, which trains high school juniors and seniors to teach freshmen about physical and emotional health, integrates COVID vaccine safety into its curriculum.
In Fresno, the junior community health worker program, called Promotoritos, adopted the promotora model. Promotoras are non-licensed health workers in Latino communities tasked with guiding people to medical resources and promoting better lifestyle choices. Studies show that promotoras are trusted members of the community, making them uniquely positioned to provide vaccine education and outreach.
The teens participating in Promotoritos are mainly Latino, immigrants without legal status, refugee students or children of immigrants. They undergo 20 hours of training, including social media campaign strategies. For that, they earn school credit and were paid $15 an hour last year.
“Nobody ever thinks about these kids as interns,” said Celedon. “So we wanted to create an opportunity for them because we know these are the students who stand to benefit the most from a paid internship.”
Mississippi has underinvested in public health for so long, that now that they have more money because of federal programs, they lack the capacity to spend and invest it.
https://www.nytimes.com/2023/02/13/us/politics/covid-public-health-departments.html
Why Mississippi, a Covid Hot Spot, Left Millions in Pandemic Aid Unspent
Stop-and-go federal funding floods public health agencies with cash during crises but starves them of funds afterward. The coronavirus pandemic shows the pitfalls of that approach.
Mississippi’s woes are an acute example of a larger public health failure that is reprised nearly every time a major health threat grabs headlines. The problem, experts say, is that Congress starves state and local health agencies of cash for even basic needs in quiet times. Then, when a crisis hits, it floods them with millions or even billions of dollars earmarked to battle the disease of the moment. And the sluggish machinery of Capitol Hill often ensures that most of the aid arrives only after the worst of the crisis has passed. ...
It is impossible to measure how much the staffing shortages worsened the pandemic’s toll, said Dr. Judith Monroe, who leads the C.D.C. Foundation, an independent nonprofit organization that tried to plug Covid staffing gaps.
But “at the end of the day,” she said, “it cost Americans their loved ones.”
At the root of chronic underfunding of public health, experts say, is a fundamental lack of understanding of its mission.
orkers at state and local health departments monitor and strive to limit a host of threats, including preventable injuries, infectious diseases and chronic ailments like diabetes. Those duties come atop a drumbeat of other more routine but essential tasks, such as restaurant inspections.
Success produces no headlines. And in lean times, health departments are easy targets for government cutbacks.
“Public health at its finest is prevention — it’s invisible to the public,” Dr. Monroe said, adding, “Nobody wakes in the morning saying, ‘I feel so grateful today I don’t have smallpox.’”
Public health is so overlooked that no one knows exactly how much money the nation’s roughly 2,800 state and local health departments spend or how many people they employ. Some states like Mississippi centralize their operations, while in others, counties exercise more control.
The result is a giant patchwork of services and systems. But experts generally agree on one point: In the run-up to the pandemic, public health agencies took a hit.
One study by academic researchers found that state public health spending either stagnated or declined from 2008 to 2018. The de Beaumont Foundation, a nonprofit health advocacy group, estimated that state and local health departments shed about 40,000 jobs between 2008 and 2019. ...
But experts say state and local agencies need far more — $4.5 billion more per year just to meet basic public health needs, the Trust for America’s Health says. The de Beaumont Foundation estimates that those agencies need to hire 80,000 more workers.
https://fortune.com/well/2023/12/01/flu-covid-rsv-syndemic-tripledemic-winter-2023-respiratory-virus/
About the UK but of course fully relevant.
https://www.theguardian.com/commentisfree/2023/dec/16/the-observer-view-on-the-nations-poor-health
The Observer view on the nation’s poor health
Britain cannot fix its growth problem without reducing the number of people who have left the labour market altogether because of ill health. This is also key to tackling not just health inequalities – the gap in life expectancy for the most and least affluent has increased in recent years – but also to reducing the UK’s gaping economic inequalities between the regions; the more deprived an area, the higher rate of working-age ill health it is likely to have. The growing numbers of younger people with long-term health conditions, including mental health concerns, who have many years of their working lives left, suggests that if this issue goes unaddressed, the problem will get worse.
This is on children and family services but relevant. Hennepin County Minnesota has made great gains.
Multipart series.
https://www.startribune.com/minnesota-hennepin-county-reforms-child-protection-system-investments/600324597/
Hennepin County reduced repeat abuse of kids. Are there lessons for the rest of Minnesota?
12/17/2023
More money, more caseworkers, better training, fewer clients per caseworker.
... Hennepin County's Parent Support Outreach Program (PSOP). A social worker with the program found them a hotel room and delivered food. During the next two months, the county put them up in hotels and helped the family find a home.
PSOP is a voluntary statewide program that serves families in need. County workers connect people with resources, from job training to mental health or addiction services to the basics, such as food and clothing. It aligns with a national movement to prevent neglect or abuse by devoting more resources upstream.
... About six years ago, the county examined reasons families were entering the child protection system, Hennepin County Commissioner Debbie Goettel said.
"A lot of it was because they were in poverty and they were trying to just survive," she said. "You can't stabilize kids, can't have a great family life, when everybody in the whole family is always in crisis mode."
Since then, the county has more than doubled its PSOP staff. They still have a waitlist of families seeking aid. The program served more than 2,500 people in 2022, and about 80% of families that got help did not have a subsequent screened-in child protection report, according to the county.
Goettel hopes to next add community resource centers where "a family can walk in with no judgment and say, 'I need help with this to keep my family together.' "
For many families, the "this" is treatment resources, she said, such as the in-home family recovery pilot program the county launched last year. It helps people struggling to get to outpatient treatment. A team provides a family with substance use and mental health treatment, connects them with services and does several drug screens a week.
https://www.ft.com/content/d4d289a7-e1a5-4848-8e7e-b592f7018722
Novo Nordisk CEO person of the year, potential success of obesity drugs.
12/21/2023
https://www.bostonglobe.com/2023/12/21/metro/covid-19-vaccine-holiday-surge
Super low take up on covid, other vaccines. Income disparities.
https://www.bloomberg.com/news/articles/2024-01-05/ozempic-s-cost-weight-loss-drugs-will-be-billed-to-us-taxpayers
Ozempic Mania’s Billions in Bills Are Coming for Taxpayers
State and local governments across the US are grappling with a growing problem: Expensive drugs to treat diabetes and obesity are threatening to drain their health-care budgets.
State health plans and Medicaid offices are seeing eye-popping bills for Novo Nordisk A/S’s Ozempic, its sister drug Wegovy and similar medications known as GLP-1s. They’re a breakthrough for treating two of the most complex chronic health conditions. But with list prices stretching above $1,000 a month, the costs threaten to empty government coffers.
“It’s not sustainable,” North Carolina Treasurer Dale Folwell, who oversees state workers’ health insurance, lamented at a recent board meeting. “It’ll sink the plan.”
... Demand for the drugs is poised to explode. Public attention has focused on the well-off looking for a quick way to lose a few extra pounds, but the reality is that type of customer represents a tiny fraction of the potential market for GLP-1s. More than one in 10 Americans have type 2 diabetes, and upward of 100 million suffer from obesity. Those rates are higher among the 19% of Americans who rely on Medicaid, the public health-insurance program that on average accounts for more than a quarter of state spending.
... So far, data suggest it’s diabetes, not weight loss, driving the surge in Medicaid spending on GLP-1s. Doctors don’t consistently disclose why a patient is prescribed a drug. But reimbursements for diabetes drug Trulicity, which hasn’t been shown to cause the same dramatic weight loss and Ozempic or Mounjaro, accounted for 62% of the increase in Medicaid spending between 2020 and 2022. Incomplete claims data for 2023 suggest reimbursements for GLP-1s continued to rise, driven especially by the newer drugs.
... Increasing popularity of newer diabetes formulations, new studies about health benefits beyond diabetes and the likelihood that the medicines will soon come in pill form (instead of injections) is likely to drive more patients to take GLP-1s. If all type 2 diabetics on Medicaid who would likely benefit from the drugs got a prescription, the annual cost would be some $41 billion, Bloomberg’s analysis showed, or close to half the money the program spent on all prescription medications in 2022.
... Obesity costs the US health-care system some $173 billion a year, and the condition is now so prevalent that 25% of young people are too heavy to be eligible to join the US military.
... Faced with the prospect of spending $30 million on GLP-1s last year, Connecticut Comptroller Sean Scanlon introduced a trial program that requires those who want the drugs to lose weight to first enroll in a lifestyle management program. Scanlon says data suggest growth in prescriptions has moderated, but not enough to seriously reduce the state’s costs.
Obamacare has been unable to save money on U.S. health care
https://www.washingtonpost.com/opinions/2023/10/02/obamacare-money-health-care-save/
Yep. What the ACA did is expand access to health care, particularly for the poor. It didn't change how care was organized and delivered, especially wrt wellness, prevention, and chronic conditions. Hence, more cost.
https://www.bostonglobe.com/2024/01/11/nation/covid-surge-2024-jn1/
It seems like hardly anyone still cares about COVID. Does it matter?
Doctors differ on the question, with some saying long COVID remains a significant risk, while others say that concern is overblown
What are the potential consequences? The answers vary depending on which public health expert you ask.
With more than 95 percent of Americans now carrying antibodies against some forms of the virus, either from a vaccine or previous infections, the risk of serious illness and death is low for most of the population. The elderly, immunocompromised, and those with preexisting conditions are the most likely to pay the price. Their vulnerability constitutes the most urgent reason for the young and healthy to take precautions, most public health experts agree.
... But there’s another compelling reason for the young and the healthy to get boosted and consider following precautions: long COVID. The little-understood condition is broadly defined as a set of symptoms that are present four weeks or more after an initial infection, often consisting of brain fog and extreme fatigue. Dr. Ziyad Al-Aly, chief of research and development at the VA St. Louis Health Care System, has been studying long COVID for close to four years. He compared the casual attitude of some to playing “Russian roulette.”
“Out of a hundred times, yes, you’re going to emerge unscathed about 96 percent of the time,” said Al-Aly, who estimates the risk of getting the condition is between 3 and 4 percent. “But in some cases this leaves people — people in their 20s, 30, and 40s — significantly disabled.”
... Al-Aly and his collaborators recently compared the long-term outcomes of 81,000 patients hospitalized with COVID-19 between 2020 and 2022, to that of about 11,000 hospitalized with seasonal flu between 2015 and 2019. They found that patients were at a significantly increased risk of death, hospital readmission, or health problems in both cases. But those with COVID-19 were roughly 50 percent more likely to develop the chronic condition.
... Dr. Peter Hotez, a vaccine expert and dean of the National School of Tropical Medicine at Baylor College of Medicine in Houston, noted that new studies have found that boosters significantly reduce the risk of long COVID.
He also pointed to studies linking repeated COVID infections to a host of other problems, including a greater risk of heart attack and stroke in adults, and of Type 1 diabetes in children.
Hotez attributed people’s apathy in part to a failure of public health messaging. Since the Biden administration declared the public health emergency over last May, he noted, it has been largely silent.
“People don’t understand that there’s urgency to get this new vaccination,” Hotez said. “To me, that’s the single most important piece that’s missing right now.”
Denver Health on brink of breaking point due to uncompensated medical care costs
https://www.cbsnews.com/colorado/news/denver-health-brink-breaking-point-due-uncompensated-medical-care-costs/
1/12/2024
In 2020, the hospital had about $60 million in uncompensated care, within two years that number doubled to $120 million and last year that number increased to $136 million with a quarter of that cost coming from non-Denver residents.
"It comes here because of something called EMTALA which requires to take anybody who comes into our emergency room, regardless of where they live by county, by state or by country," said Lynne.
By law, Denver Health must provide care for patients regardless of their ability to pay.
"While I have tremendous compassion for what's going on, it's heartbreaking, it's going to break Denver Health in a way that we didn't even anticipate," said Lynne.
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