Second year, Kristen Audet, reflects on 2012 APHA conference

Reflections on the American Public Health Association’s Annual Meeting

Last month I traveled to the American Public Health Association’s Annual Meeting. The convention was held in San Francisco, California, a city that lives and breathes public health; you walk down the street and see the mandated composting bins at every establishment and signs proclaiming that vendors are no longer able to bag your purchases in plastic, but would you like to use a re-usable bag? I learned about a myriad of health issues, from “street medicine,” which provides healthcare to our homeless population, to lasting impacts from oil spills on the Gulf Coast. I also tried to listen in on the national conversation surrounding immunizations.
 I attended a packed, standing-room-only panel presentation, “Vaccination Controversies in Historical Perspective.” Dr. Robert Johnston, Heidi Lawrence, and Dr. Elena Conis presented three thought-provoking papers discussing the way vaccination programs and “vaccination-skeptics” have been viewed throughout history. Lawrence drew the distinction between the various exigencies of vaccination campaigns in American history, for example, polio was a potent and palpable risk to the American public and it was thus easy for public health professionals to demonstrate the need for the vaccination. In contrast, the 1976 National Influenza Immunization program had a harder go of it because the disease was not as visible, indeed they did not have the visuals of polio-stricken children to use in their campaign. Lawrence described polio and the 1976 flu as different “rhetorical situations.” This idea of differing rhetorics came on the heels of Dr. Johnston’s paper urging current practitioners to be more respectful of “anti-vaccinationists,” arguing that indeed some scientists that were high respected in their time were in fact anti-vaccine and it may be beneficial to the current “pro-vaccine movement” to engage further with their assumed counterparts. Finally, Dr. Conis explored comparisons between the anti-vaccine movement and earlier environmental and feminist movements. In sum, all three speakers encouraged what seemed to be a room full of “pro-vaccinationists,” to consider a broader perspective when fighting for their cause.
At the end of the presentations and Dr. James Colgrave’s summing up perspective as discussant, a county health officer stood up and offered that while all this information was excellent in context of cultural competency and other ideations of theoretical complications surrounding the controversy, he was struggling to translate this into the actual, every day practice of raising immunization rates. I too, struggled with this question. One panelist later suggested we shift to calling the movement “vaccine-skeptics” instead of “anti-vaccine,” as many members of the movement are merely questioning the safety of vaccines, and not the overall efficacy of inoculation. The suggestion to reconsider what we call “the other side” gave me pause and I wondered how we may use these considerations in our practice in rural Wisconsin.
The Southern Wisconsin Immunization Consortium has always been open to anyone concerned about vaccinations in the region. Our mission and goals relate directly to raising immunization rates across the population, but we have always held an open door policy. If anyone wanted to join our meetings who were “skeptical” of vaccines, they would not be turned away. Yet- no skeptics have emerged. However, I have begun to think that we may need some. Listening to these panelists present made me consider how to best “fight” the “other side,” and the difference between silencing and “dialoging,” (a word which in this instance I will not shy away from saying for me is closer to “discrediting”). I would welcome some further pushback. I think that our initiative can only be strengthened from learning from the vaccine skeptics. Instead of completely shutting each other out, I encourage us to learn from each other. 

Second year fellow gives an update of her summer activities at the Great Lakes Inter-Tribal Epidemiology Center


Bemidji Area Tribal Environmental Health Assessment

Over the summer I spent most of my time at Great Lakes Inter-Tribal Epidemiology Center (GLITEC) working on an assessment of environmental health priorities and resources among the 34 Tribes in the Bemidji area, an Indian Health Service area that covers Minnesota, Wisconsin, and Michigan.  This is part of a larger effort by GLITEC to start addressing environmental health in addition to the established focus areas of behavioral health, maternal and child health, and chronic disease. 

The assessment had three parts: a review of Tribal websites to see if there were any environmental services or resources identified, a survey completed by Tribal health directors and environmental staff, and key informant interviews.  Raymond Allen, a NARCH intern and student at Ripon College, and Alex Cirillo, an MPH student at the University of Michigan, were both extremely helpful in conducting the assessment.  We received 28 surveys from health directors and environmental staff and conducted 17 key informant interviews with staff from the Environmental Protection Agency (EPA), Great Lakes Indian Fish and Wildlife Commission (GLIFWC), and staff from the Department of Natural Resources and Department of Health in Minnesota, Wisconsin, and Michigan.
  
I shared the assessment results with staff at the IHS Bemidji office in September and am wrapping up the final report, which will be reviewed by a sample of health directors and Tribal environmental staff, then shared at Tribal health director meetings and posted on the GLITEC website.

Second year fellow, Rashonda Jones accepted into CityMatch CityLeaders program

Rashonda Jones, Wisconsin Population Health Service Fellow, was accepted into the 2012 City Match City Leaders program. City Match is a national organization for urban leaders in maternal and child health, with the mission of improving the health and well-being of urban women, children and families by strengthening the public health organizations and leaders in their communities.  Each year, the program selects emerging leaders in maternal and child health to participate in this intensive eight-month training on the core competencies of maternal and child health leadership. Rashonda will utilize the opportunity to strengthen her contributions to maternal and child health in Milwaukee.

Second Year Fellow, Tyler Weber writes about public health and determinants of peace


Public Health and Determinants of Peace

Peace is not an imaginary distant utopia; it is a measureable, designable, and achievable human outcome. Thanks to the Institute for Economics and Peace (IEP), we now have an evidence-based platform to critically and meaningfully introduce the determinants of peace into our research and practice in public health.

Discussions of peace and public health, although sparse, have existed for some time. In 2002, Laaser and colleagues suggested that public health professionals could play a role in promoting peace by utilizing multiple approaches to mitigating violence.1 Around the same time, others noted that health and peace can’t exist without each other,2 and that “peace through health” should become a new discipline in health sciences.3 These editorials and commentaries highlighted important issues, however, a critical point was made--the growing interest and movement in peace through health needed evidence.4

Established in 2009, the IEP is a non-profit, independent, non-partisan research organization that creates conceptual frameworks and metrics for defining and measuring peace.5 It was formed after the Global Peace Index (GPI) found strong correlations between peacefulness and national wealth.5 Since then, the GPI has enabled IEP to create an evidence-based framework of the determinants of peace.

Structures of Peace is a notable publication by IEP that lays out a statistically grounded conceptual framework for peace.6 Figure 1 highlights eight key determinants associated with peace,6 some of which are also found in public health models:

Figure 1: Institute for Economics and Peace Conceptual Framework
http://economicsandpeace.org/wp-content/uploads/2011/09/Structures-of-Peace.pdf
Determinants in the IEP conceptual framework, such as high levels of education and good relations with neighbors, have also been found in the public health literature to benefit individual and population health.  In contrast, the role the business environment plays in health doesn’t often enter the public health discourse even though it is a prominent determinant of peace. It has already been suggested that achieving public health objectives may be paramount for successful peace building in a post conflict setting,7 but it would be limiting to think that peace can be defined only as the absence of conflict. Peace isn't merely the absence of violence or conflict, but rather it is a condition that exists in the presence of attitudes, institutions, and systems that foster peaceful communities and environments.6

Similarly, the World Health Organization specifies that health isn't merely the absence of disease, but as a state of complete physical, mental and social wellbeing.8 Consequently, we must continue working towards the elimination of violence, poverty, hunger, and disease, but we may only be successful when we simultaneously build structural peace.

This framework presents an opportunity for those of us in public health to explore the symbiotic relationship between peace building and public health efforts. We are in a position to collaboratively and collectively work across sectors and disciplines to build and sustain healthy and peaceful communities and environments.

In closing, I'll share a quote from IEP found in the Structures of Peace: Identifying What Leads to Peaceful Societies publication.

"Peace is statistically related to better business environments, higher per capita income, higher educational attainment and stronger social cohesion. Therefore, by establishing the appropriate environment to support peace many other benefits will flow. In this light peace can be seen as a proxy for creating the optimal environment for human potential to flourish."6

An important question remains—where do we go from here?

Thoughtful comments and questions are most welcome.

Tyler Weber, MPH
Wisconsin Population Health Service Fellow
Population Health Institute
University of Wisconsin - Madison
tylweber@gmail.com


References

1.      Laaser, U., Donev, D., Bjegoviæ, V., & Sarolli, Y. (2002). Public Health and Peace. Croatian Medical Journal, 43 (2), 107 - 113.
2.      Levy,  B. S. (2002). Health and Peace. Croatian Medical Journal, 43(2), 114 -116.
3.      Macqueen, G., Santa-Barbara, J., Neufeld, V., Yusuf, S., and Horton, R. (2001). Health and Peace: Time for a New Discipline. The Lancet, 357, 1460 - 1461.
4.      Vass, A. (2001). Public Health Through Peace. British Medical Journal, 323 (7320), 1020.
5.      Institute for Economics and Peace. (2012). Institute for Economics and Peace: Quantifying Economics and its Benefits. Retrieved from http://economicsandpeace.org/.
6.      Institute for Economics and Peace. (2011). Structures of Peace: Identifying What Leads to Peaceful Societies. Sydney, New York, & Washington, D.C: N. A.
7.      Tasi, T. (2009). Public Health and Peace Building in Nepal. The Lancet, 374, 515 - 516.
8.      Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.

Fellowship presents at Leading the Way conference 2012



On Thursday, September 27, 2012, the Wisconsin Population Health Service Fellowship  Program presented at the Leading the Way conference in Milwaukee, WI.  The conference was hosted by the Medical College of Wisconsin’s (MCW) Advancing a Healthier Wisconsin (AHW) and the University of Wisconsin School of Medicine and Public Health (UWSMPH) Wisconsin Partnership Program (WPP).

Two current Fellows, Kristen Audet and Tyler Weber, and one past fellow, Traici Brockman, spoke about their experiences with the fellowship and how those experiences have shaped their work in the public health field.  Fellowship staff and faculty also spoke about their experiences working with and serving as mentors to fellows.

Congratulations on a presentation well done!

Meeting: Tribal Health


Geof Swain, Medical Director and Chief Medical Officer for the Milwaukee Health Department, as well as Preceptor for Fellows placed in Milwaukee, explains his drawing during an introductory activity in Keshena, Wisconsin
September's two-day monthly meeting on Tribal Health was held in Keshena, WI.  This meeting kicked off with an introduction activity, in which fellows and fellowship staff were asked to draw/write three things that represented their culture. 

David Grignon, Director of Historic Preservation for the Menominee Indian Tribe of Wisconsin, gave an overview of the termination and restoration of the Menominee Tribe.  Later, we heard from Jerry Waukau, Health Administrator of the Menominee Tribal Clinic, and Wendall Waukau, Superintendent of Schools for the Menominee Indian School District.  Jerry and Wendell gave an inspiring talk about community engagement and discussed how they raised their high school graduation rate from around fifty percent up to ninety-five percent.

Fellows and fellowship staff spend time sharing stories and roasting marshmallows over a campfire


Later that evening, fellows and fellowship staff spent time bonding over a campfire and making smores.  One of our fellows, Erica LeCounte, even ate her very first smore.

First Year Fellow, Erica LeCounte eating her very first smore
Day two began with Kristen Audet, second year fellow, who gave an awesome CALs presentation on the emergency response to the heat wave that occurred this past summer.  Then, Kristin Hill, Director of the Great Lakes Intertribal Epidemiology Center, gave the Fellows an overview of Indian Health Services.

Isaiah Brokenleg shares some of the culture and history of the Menominee tribe with the fellows
This was followed by Isaiah Brokenleg, Epidemiologist and Program Director with the Great Lakes Intertribal Epidemiology Center, who instructed the fellows on "Indian 101" which discussed the history and culture of the Menominee Tribe.  Lastly, the fellows participated in an activity which served as a lesson on the privilege that many people are unaware that they have, but that continually affects their everyday lives. 


One last group shot


Expedited Partner Therapy toolkit

Fellow Katarina Grande helped develop a toolkit for sites implementing expedited partner therapy (EPT), the practice of prescribing medication to partners of individuals with sexually transmitted infections. The project builds off work by Fellow alum  Marisa Stanley, who helped pass EPT legislation in Wisconsin.


Project description:
Rates of chlamydia and gonorrhea are consistently high in the City of Milwaukee, a problem with is exacerbated by high rates of re-infection. In order to expand the health department's capacity to address these high rates, it is promoting expedited partner therapy (EPT) in medical clinics and pharmacies serving high incidence areas in the city.

In 2010, EPT was legalized in Wisconsin, however it is not yet widely used. Despite survey findings showing that providers view EPT favorably, health department staff have noted reluctance from some community providers to employ EPT. To address this issue, the health department developed simplified guidance sheets for EPT and a 15 minute presentation about EPT to describe the local epidemics of chlamydia and gonorrhea and the purpose of prescribing EPT. These presentations are designed to be given in person by the health department staff, which allows for questions and concerns to be addressed on the spot. The presentation is styled as an informal version of academic detailing, where the MHD representatives "sell the idea" of EPT to small groups of clinicians and pharmacists at their clinics and pharmacies. The health department also provides medication and support, such as informational resources, to providers and clinics prescribing EPT.

Throughout development of this initiative, the health department engaged a variety of partners, including medical students, a fellow from the state health department, and colleagues at local healthcare providers.

Fellows make waves at WI Public Health Association Conference

Fellows and Fellow alums attended, presented, and led the 2012 Wisconsin Public Health Association Conference. The event, held at the Kalahari Resort in the Wisconsin Dells, gave us a chance to share our research and initiatives, hold trainings, and learn about public health across the state. Here's an overview of our involvement:

Paula Tran Inzeo is the WPHA Secretary and leads the WPHA Health Impact Assessment Committee. She also conducted a Pre-Conference Session: Health Impact Assessment: From Start to Finish; presented a Panel Presentation: The Wisconsin Health Impact Assessment Collaborative: Promoting Healthy Community Design Through Diverse Partnership, and presented a Poster: Health Impact Assessment of Treatment Alternatives to Incarceration in Wisconsin.

Emma Hynes co-chairs the WPHA Maternal and Child Health Committee. During the conference, Emma led a section meeting at the conference to do strategic planning for the section. She also presented a poster about the Wisconsin Healthiest Women Initiative.
Fellow Emma Hynes' poster for the WPHA conference: "The Wisconsin Healthiest Women Initiative: A Collaborative Effort to Improve Women's Health Across the Life-Course"
Anneke Mohr presented a poster on Acceptance Journeys

Kristen Audet presented a poster on the Southern Wisconsin Immunization Consortium.

Current Fellow Kat Grande and past Fellow Marisa Stanley co-presented a talk entitled, "The Changing Face of Hepatitis C in Wisconsin and Network Diagramming as a Tool for Public Health Partnerships, Evaluations, and Investigations."
Kat's WPHA presentation [soon to become available in webinar format!]
Kelli Stader helped create a poster about the Wisconsin Public Health Improvement Initiative and its focus on accreditation and another poster about the accreditation process with the Institute for Wisconsin's Health, Inc.

Fellows Tyler Weber and Katherine Vaughn-Jehring co-presented a poster about the acclaimed Wisconsin Population Health Service Fellowship.

Fellow alum Raisa Koltun, Chair of Policy Development Committee, briefed conference attendees about the 2011 WPHA Policy Resolutions.

Fellow alum Kate Konkle leads the Early Career Professionals Committee and hosted a networking dinner alongside the Health Impact Assessment Section.

Fellow Akbar Husain moderated the discussion “The Road to Accreditation in Wisconsin – Three Early Travelers.” This presented an opportunity for local and tribal health departments interested in applying for accreditation to ask questions of representatives from three departments that have submitted their applications. In addition, Akbar played giant connect four in the Kalahari arcade and spent a considerable amount of time in the lazy river.
Fellows Tyler, Akbar, and Paula relax after a day of conferencing

Meeting: Refugee and Immigrant Health

Abdistaar Doon, Refugee Services Assistant with Workforce Resources Inc. speaks to the group as Fellow Akbar Husain listens. Here, Doon shows the group a traditional toothbrush from Somalia.
April's monthly Fellowship meeting, held in Eau Claire, focused on refugee and immigrant health. Abdistaar Doon, Refugee Services Assistant from Workforce Resources Inc., spoke to the group about life in Somalia prior to arriving in the U.S. as a refugee. 

We discussed the book, Enrique's Journey, UW-Madison's 2011 Go Big Read selection. Fellows and staff had mixed reactions to the book, which chronicles the treacherous journey of a young man from Honduras to America. 

Fellow Tyler Weber shared his experiences with the Lindsay Heights Neighborhood Community Research Council for his Core Activities of Learning (CAL) presentation. One or two Fellows give CAL presentations at each monthly meeting. Here, Tyler demonstrated the CALS of Leadership, Community Dimensions of Practice, Cultural Competency, and Communication.
Fellow Tyler Weber presents his work with the Lindsay Heights Neighborhood Community Research Council


Quality Improvement Training

Fellow Katherine Vaughn-Jehring works on a QI exercise
Fellows gathered in Eau Claire, Wisconsin, for a day-long training on Quality Improvement. Led by Fellow alumna Kate Konkle, the group learned numerous techniques for improving processes. 

Fellow alumna Kate Konkle trains the group on Interrelationship Digraphs--a Quality Improvement tool
Kate taught the group the Plan-Do-Study-Act Quality Improvement model. We learned how to write an Aim Statement, which succinctly describes "what the team hopes to accomplish with its QI efforts," (see p.29 of the excellent resource guiding our learning session: http://www.accreditation.localhealth.net/QI%20Resources.html). Kate then lead us through a process mapping exercise and a root causes analysis (see photo above). Lastly, we developed process indicators. Rather than using theoretical examples to walk us through the process, we used existing processes in the Fellowship. As a result, we're already striving to improve processes related to information and idea-sharing. (Check out the blog for updates on this soon!) Kate proved to be an amazingly effective trainer and we all had a learning-filled day.

The group opted to stay overnight in Eau Claire, as we had a monthly Fellowship meeting the next day. We cooked, laughed, and enjoyed spending time together!
Near Eau Claire, WI, Fellows and staff spend time bonding
Fellow Paula Tran Inzeo prepares spring rolls, under the guidance of head chef Lesley Wolf
Fellows Akbar and Tyler entertain the group with guitar music

Fellowship Program Coordinator wins Edible Book Festival Awards



Lesley Wolf's depiction of "The Story of Frog Belly Rat Bone"
She kept it under wraps at the Fellowship orientation, but program coordinator Lesley Wolf harbors a talent for depicting whimsical characters and literary scenes from edible materials. In the 2012 Edible Book Festival, sponsored by UW Librarians' Assembly and Memorial Library, Lesley won both the people’s choice as well as the “most elaborate” awards for her depiction of the book “Frog Belly Rat Bone” by Timothy Basil Ering. The book, which Lesley says she chose in part because of its public health message, “plants the idea that with some strategy, good communication and goodwill, you can grow wonderful things," according to the Portland Press Herald. A pear, kiwi, radishes, tomatoes, strawberries and microgreens, among other edible materials, were coaxed into an ephemeral art experience. Lesley’s partner, Kris Glodoski, helped curate the festival. For more images and descriptions see the blog Eating in Madison from A to Z: http://www.madisonatoz.com/ and the Edible Book Festival website: http://www.library.wisc.edu/edible-book/


"When I have participated in this event before, I worked in sugar and sweet things and this year I wanted to do something to promote healthier food choices so when I came across Frog Belly on my bookshelf it all came together," says Lesley. 


"There is a strong public health theme subtly tucked in to the story of turning cement land into a garden so I decided to make Cement land and the garbage piles out of candy and show the progression of greening the land using only fruits, vegetables and seeds," says Lesley.
photos by Kris Glodoski



Fellowship Director, Marion Ceraso, took home the award for "Most Creative Use of Ingredients" for her depiction of the book "Goat Song"

2012 State of the Tribes

Leaders of the Wisconsin Indian Tribes. From Left: Stewart Bearhart, (St. Croix) Bob Chicks, (Stockbridge-Munsee) Ed Delgago, (Oneida) Craig Corn, (Menominee) Mike Wiggins, (Bad River Ojibwe) Mic Isham, (Great Lake Indian Fish and Wildlife Commission) Front: Tom Maulson (Lac du Flambeau) and Harold "Gus" Frank, (Forest County Potawatomi)
photo source:
Although I grew up in Wisconsin, I knew very little about the American Indian population here until I started the fellowship and was placed part time with the Great Lakes Inter-Tribal Epidemiology Center (GLITEC), based in Lac du Flambeau. GLITEC is an Indian Health Service-funded data center serving the 34 federally recognized tribes in Minnesota, Wisconsin, and Michigan. Eleven of those tribes are in Wisconsin – Oneida, Forest County Potawatomi, Stockbridge Munsee, Menominee, Ho-Chunk, and six bands of Ojibwe, including St Croix, Red Cliff, Lac Courte Oreilles, Bad River, Lac du Flambeau, and Mole Lake Sokaogon. The population of each tribe ranges from roughly 1,000 to 20,000 members. Each tribe is a sovereign nation and has a government-to-government relationship with the State.  Each tribe has a legislature and a chair or president elected every 1-4 years.

Since 2005, all 11 tribes have come together to deliver an annual State of the Tribes address before the Wisconsin State Legislature. I was fortunate enough to attend the 2012 State of the Tribes on March 13, 2012. It began with drumming and an outside procession. This was followed by an unofficial smoke break, thanks to the tobacco industry and religious restrictions that made commercial tobacco more common than traditional tobacco in Indian Country.  The formal ceremony then took place in the Assembly Chamber. One tribal leader is selected each year to deliver a speech on behalf of all tribes. This year, Jon Greendeer, President of the Ho-Chunk Nation, based in Black River Falls, delivered the speech. Some of the issues he highlighted included:
  • Caring for veterans and returned soldiers;
  • Being stewards of the land for future generations and protecting against environmental contaminants;
  • Tribal governments are often the largest employers in their area and help balance the state budget through gaming tax revenue, employee taxes, and buying power;
  • With budget cuts, tribal communities are often the first to feel the effects, especially those physical and mental health concerns;
  • The importance of education in alleviating poverty; and
  • The need for adequate access to health care. 
President Greendeer noted the shift in diet among many American Indians to high fat and high sugar foods and shared that he was able to lose 140 pounds thanks to effective health programs. New initiatives like the Indigenous Games, the Community Transformation Grant, and Let’s Move! in Indian Country help to address this, too.
 
Greendeer also mentioned Act 31, a state law that passed in 1989 to ensure that Wisconsin students learn about American Indian history. This is a small but important step in increasing awareness of the diverse but often hidden cultures in Wisconsin. The State of the Tribes was a good reminder for me that even as an adult, there is always something new to learn. I look forward to continuing my learning this summer, as I prepare to move from Madison to Lac du Flambeau for a few months to work with GLITEC full time.

The Wisconsin Population Health Service Fellowship is an initiative of the UW Population Health Institute’s Mobilizing Action Toward Community Health (MATCH) Group. The Fellowship program is funded by the Wisconsin Partnership Program at the UW School of Medicine and Public Health.