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Population Health in Challenging Times: Insights from Key Domains: Proceedings of a Workshop (2023)

Chapter: 2 Academic Public Health and Population Health

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Suggested Citation:"2 Academic Public Health and Population Health." National Academies of Sciences, Engineering, and Medicine. 2023. Population Health in Challenging Times: Insights from Key Domains: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26143.
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2

Academic Public Health and Population Health

Joshua Sharfstein introduced the panelists, all of whom were drawn from schools and programs in public health and population health. He first invited them to share their thoughts about what academia can do at this moment of crisis for the field and the nation, both in terms of how institutions respond to crises in partnership with communities and other sectors, and how they transform their internal structure, culture, and processes. Key points from the panelists are provided in Box 2-1.

Dora Hughes from The George Washington University Milken Institute School of Public Health began her remarks with a quote from James Baldwin: “Not everything that is faced can be changed, but nothing can be changed until it is faced.” The current crises—and in addition to those outlined in the introduction, she included wildfires, floods, and climate change more broadly—reveal the consequences of not facing or acknowledging key public health issues such as “avoidable, unfair, and remediable differences in health.” She highlighted three key roles for academia in times of a public health crisis: advocacy for science and transparency, supporting or facilitating coordination on the marshalling of data and evidence in responding to the crisis, and providing support for governmental public health officials.

Regarding the first role, Hughes offered a specific example of lack of transparency: the delay on the part of the Centers for Disease Control and Prevention (CDC) in reporting demographic data that it was gathering about the pandemic’s disproportionate impact on Black, Latino, and low-income populations. She noted that the void of federal data was filled in by data and analyses from universities, adding that reliance on academic

Suggested Citation:"2 Academic Public Health and Population Health." National Academies of Sciences, Engineering, and Medicine. 2023. Population Health in Challenging Times: Insights from Key Domains: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26143.
×

partners to highlight a data gap was not unprecedented. Her university, she stated, had determined the accurate number of casualties from Hurricane Maria in 2017—an effort that ultimately helped replace Puerto Rico’s official total death toll of 64 with an estimate of nearly 3,000 deaths, and was followed by a commitment from the territory’s government to improve its preparedness and response capabilities.

The second role for academia, Hughes remarked, is that its dedication to teaching, research, and service ought to include advocacy for science and transparency. An additional role of academia in a public health crisis is to facilitate and develop an infrastructure for coordination and collaboration, perhaps under the auspices of public health organizations.

A third potential role for academia, Hughes asserted, in a similar vein to what she called truth telling about science and evidence, is supporting and providing cover for public health officials operating on the front lines of a crisis. Hughes made note of the 49 public health leaders who resigned or were fired during the unfolding pandemic.1 Sharfstein agreed, stating that public health leaders in academia do not face some of the pressures

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1 See https://khn.org/news/public-health-officials-are-quitting-or-getting-fired-amid-pandemic (accessed December 5, 2022).

Suggested Citation:"2 Academic Public Health and Population Health." National Academies of Sciences, Engineering, and Medicine. 2023. Population Health in Challenging Times: Insights from Key Domains: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26143.
×

faced by leaders in government agencies, and should be “willing to lean forward and push to make sure we are highlighting and promoting science and transparency.”

Marc Gourevitch from New York University Langone Health offered reflections on academia’s role in responding to the pandemic and to racial injustice. With regard to the state of the science and evidence, he listed several examples of areas where the evidence is already available to inform action and policy, such as approaches to reversing chronic disinvestment in Black and Brown communities. In addition to implementing known evidence, truth telling and narrative shifting also are needed to help inform public attitudes and health-related policy, Gourevitch added. He described, as an example, the findings over the past decade about how obesity affected military readiness, and how messaging about those findings was persuasive to a broader range of decision makers (Gollust et al., 2013). What is needed, he added, is a research and action agenda on how to inform the public and decision makers about what produces health that “infuses all of our work and language.”

In her remarks, Sheri Johnson from the University of Wisconsin–Madison School of Medicine and Public Health called for addressing the conflation of race and racism in teaching and scholarship and the erroneous use of race, instead of racism, as the explanatory factor for health disparities (Hardeman and Karbeah, 2020). “Unfortunately, in academia” Johnson stated, “we still have an imbalance of how we understand race as a social construct, [how] we teach about it, how we craft the questions that we ask in our scholarship,” and academics must face these issues in a comprehensive and direct way, “not as an extracurricular pursuit.” Research indicates, added Johnson, that members of the general public as well as medical students and residents have erroneous beliefs that there are biological differences between Blacks and Whites, and these beliefs influence decisions made by public health and health care practitioners. The recognition that racism is an organized and hierarchic social system “based on an ideology of inferiority” strips racism of the power it has to influence the allocation of societal resources, Johnson stated. The recent executive order and related memo from the U.S. Office of Management and Budget that question the use of critical race theory in academia and other organizations makes these reflections timely, Johnson added. Critical race theory is a framework that has been around since the 1980s to examine society, culture, and the intersections with race “pervasive across all aspects of society including housing, employment, education, public health, the law, and it explicitly probes racism’s influence on both outcomes and processes.” The work of applying these concepts is not aiming to demonize some groups compared to others, Johnson stated, but to serve as a framework for telling the truth about the historical context in which some groups received opportunities and advantages denied to other groups. These truths are the real drivers of

Suggested Citation:"2 Academic Public Health and Population Health." National Academies of Sciences, Engineering, and Medicine. 2023. Population Health in Challenging Times: Insights from Key Domains: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26143.
×

differences in health and health outcomes, including the disproportionate burden of COVID-19 in communities of color.

Johnson shared a specific example for how the medical school curriculum reinforces false assumptions about race, describing one university’s analysis of medical school lectures, which identified 102 slides that mentioned race. Only 4 percent acknowledged social determinants of racialized disease disparities, compared to 58 percent that implied biological difference (Tsai et al., 2016). Johnson underscored Gourevitch’s observation about the need for new narrative framing: the field needs new narratives that decouple race and racism and integrate into teaching and scholarship a fundamental acknowledgment of the societal structures that drive differences in health and health outcomes. Hughes asked if universities have the necessary resources and tools to integrate this information into their curricula and teaching. Johnson replied that the field is still in the early stages of comprehensively interrogating and overhauling curricula and scholarship, and that some approaches, like teaching about cultural humility and implicit bias, are easier to implement than others.

Sharfstein spoke about integrating trauma-informed practices in the curriculum and classroom experience and thinking about the current moment as an opportunity to teach more about responding to crisis, and to do so in a broad-based way, connecting to other disciplines and sectors. It is one thing, said Sharfstein, to conduct epidemiologic work quantifying the pandemic’s impact on Black and Latino communities. It is a different matter to be able to respond to these questions of the specific interventions needed, for instance, in the transportation sector or with regard to low-wage jobs. What is the role of public health in these areas? Sharfstein added that leaders in academia need to think of public health as a field that becomes activated in crisis.

Little things, began Ziad Obermeyer from the University of California, Berkeley, can matter a whole lot, and a small, technical issue can put in motion a series of larger actions that can have enormous negative consequences. Obermeyer said that researchers use health care costs to measure health care needs, but recent research he and colleagues conducted showed how an algorithm based on that assumption and used by many health systems around the United States was found to be facilitating “large-scale racial disparities.”2 The algorithms predict how much a patient’s care will cost and allocate extra resources for help (e.g., home visits from a nurse practitioner to manage medications), to people who are projected to cost a lot. That means that when people who need health

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2 Obermeyer and colleagues published the Algorithmic Bias Playbook, based on their research findings, in June 2021. See https://www.chicagobooth.edu/research/center-forapplied-artificial-intelligence/research/algorithmic-bias/playbook (accessed December 20, 2022).

Suggested Citation:"2 Academic Public Health and Population Health." National Academies of Sciences, Engineering, and Medicine. 2023. Population Health in Challenging Times: Insights from Key Domains: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26143.
×

care do not get health care, they “cost” less (as measured by medical claims) than people who have access to health care. When Obermeyer and his colleagues studied this issue, they learned that this algorithm builds in inequities toward populations of color, those with lower incomes, rural populations, and anyone who lacks adequate health care access or who “is treated differently when they get access to [the] health care system.” Obermeyer and colleagues worked with the company that develops the software to change the algorithm to remove the built-in inequity.3 A similar bias, Obermeyer noted, is built into some government policies. For example, the 2020 Coronavirus Aid, Relief, and Economic Security (CARES) Act included a provision that allocated funding based on an algorithm formulated on the basis of past revenue, which built in racial biases similar to those described above. Because the field does not always have appropriate measures to identify who needs help, there are often no mechanisms or incentives to distribute resources equitably.

Hughes asked how difficult it is to identify alternate measures that do not deepen inequity. Obermeyer said that although the main measure (cost) is available from claims data and other data sets, there is a wealth of additional measures in those data sets that may be more reflective of patient needs, and there also are national data sets that can be used (e.g., blood pressure data that is available from a survey program that gathers the data in people’s homes). The data are available, and researchers and practitioners need to understand that these data are valuable both for achieving equitable outcomes and for ensuring effectiveness.

Shreya Kangovi from the University of Pennsylvania shared her reflections on society’s and the discipline’s inadequate acknowledgment of the current state of inequitable conditions and resulting health disparities. “We are in denial,” Kangovi said, and there is evidence that indicates health inequity is a psychological disease that affects the privileged but with symptoms found in the disadvantaged, she noted. Researchers and practitioners study, pathologize, and aim to “improve” people’s hemoglobin A1Cs and other measures, but those “experts” need to understand the root cause, which is their own “perverse psychology of the privileged” that manifests itself in inequities. Kangovi added that the field needs to build an implementation science to further critical race theory by partnering with people who experience disadvantage. Community health workers (CHWs), for example, share life experience with the people they serve, Kangovi stated, and the emerging model for the work of CHWs is built on an empowerment framework (Rifkin, 2003). CHWs, Kangovi stated, should not be viewed as a means to the health care system’s own targets. Accordingly, health system leaders ought not to say “use” or “get them to” when referring to the roles and contributions of CHWs, but rather, to

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3 See https://science.sciencemag.org/content/366/6464/447 (accessed December 5, 2022).

Suggested Citation:"2 Academic Public Health and Population Health." National Academies of Sciences, Engineering, and Medicine. 2023. Population Health in Challenging Times: Insights from Key Domains: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26143.
×

reflect a model of true partnership analogous to how a CHW would ask a community member “what do you think you need?” Such a shift in framing and mindset reflects a transfer of power and control.

Johnson asked Kangovi to reflect on how science is placed on a pedestal, seen as never being wrong or needing to self-correct. Kangovi stated that it is important to first define what is meant by science. If this is about the essence of science as truth telling, as asserted by Hughes, that is indisputable, but the culture of science—its elitism, the blind spots when science is only done by one kind of person—that is problematic. Kangovi stated that the field needs more participatory science or people science.4 Sharfstein asked Kangovi what she thought about COVID-19 vaccine uptake in the context of the American public’s thinking about it. A top-down science way of doing things will not work, and a public relations campaign may not work, she responded. It is necessary to employ an empowerment framework rather than a target-oriented one to engage communities in the implementation of a COVID-19 vaccine.

Sandro Galea from the Boston University School of Public Health outlined what he called three distinct traumas that the nation is experiencing—COVID-19, economics, and the “reckoning with centuries of structural racism”—and these traumas call for strategies for the academic enterprise to deal with them. Galea underscored other speakers’ comments calling on academia to speak the truth, to bear witness, and to serve as a moral compass. However, simple and quick solutions will not adequately respond to the traumas that the nation is facing, but academia needs to act on all three planes, Galea stated, specifically to:

  1. articulate academia’s role in generating the science and evidence to move society forward;
  2. rethink the economics of academia, which previously may have allowed (some) academics to feel separate from macroeconomic forces, with secure livelihoods, and to consider who gets to have those roles and benefits; and
  3. reckon with centuries of racism, bringing what has long been known to greater public attention.

This calls on academia to look inward and outward to guide how it responds when people are marginalized; how it brings a “stabilizing constructive voice to conversations” both to react to urgent short-term questions and to long-term considerations, such as what is being learned

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4Participatory science is sometimes used interchangeably with citizen science, referring to engaging a broader range of people in conducting research. See, for example, the discussion in the National Academies report Learning Through Citizen Science: Enhancing Opportunities by Design (NASEM, 2018).

Suggested Citation:"2 Academic Public Health and Population Health." National Academies of Sciences, Engineering, and Medicine. 2023. Population Health in Challenging Times: Insights from Key Domains: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26143.
×

and what can be done better in response to COVID-19 and racism. Galea asserted that it is the job of academia to contribute the ideas toward building a better world. Sharfstein added that there are flaws to the academic model, even as society can benefit from its positions and advocacy, and invited others to weigh in about flaws and opportunities.

Reflecting on the then impending election, Kangovi remarked that there is a need to act to help get out the vote. Sharfstein mentioned Vot-ER as one effort in health care to register people to vote.5 Galea added that voter registration is part of educating Americans about the core responsibilities of a citizen—the nonpartisan notion of civic participation not just in the world of ideas but the in world of action—to vote. Johnson commented on ongoing work to develop measures of civic engagement that are comprehensive and include attention to structural factors, such as the number of election polling stations, voter suppression efforts, and “looking at effects on overall health and differences in health by group,” and ultimately making these drivers structural and normative.

DISCUSSION WITH AUDIENCE INPUT

Sharfstein relayed an audience question about recruiting, engaging, and supporting students, especially students from disadvantaged backgrounds, at a time when learning is largely virtual, and students may face many logistical, economic, and public health issues. Sharfstein shared an example about his school’s program that has redesigned course offerings.6 The school additionally provides full scholarships for public health training for 50 people who are working in other sectors to respond to public health challenges, and who may not otherwise be able to receive formal public health training.

A viewer asked if people in the field could put the science that calls for physical distancing in context for people for whom this behavior is impossible because of their living and work circumstances. Johnson spoke about existing solutions for responding to inequities—the direct evidence, or evidence that can be extrapolated, supporting implementation of guaranteed income and increases in Supplemental Nutrition Assistance Program food assistance, the earned income tax credit, and the Great Smoky Mountain Study (Costello et al., 2016). “These are some of the strategies we know can respond to the inequities in society,” Gourevitch said. Some of these solutions, such as the economic interventions that could take the pressure off lower-income families, Gourevitch noted, are stuck in con-

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5 See https://vot-er.org (accessed December 28, 2020).

6 See the Bloomberg American Health Initiative at Johns Hopkins University at https://americanhealth.jhu.edu (accessed December 18, 2022).

Suggested Citation:"2 Academic Public Health and Population Health." National Academies of Sciences, Engineering, and Medicine. 2023. Population Health in Challenging Times: Insights from Key Domains: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26143.
×

gressional gridlock. Academia does not think about the political sphere much and avoids entering the political fray. However, he added, this is not about being partisan, but about framing the messaging and narrative to have a greater effect. Obermeyer shared his thinking that the failure to implement testing innovations could have contributed to more targeted stay-at-home policies that could have caused less harm. Hughes reflected on academia’s potential role in informing the COVID-19 vaccine rollout to give equitable access to different communities on the ground, but she acknowledged the short time frame available to prepare in this way.

Galea asserted that academia has not had “a trustworthy partner in the public sector.” In normal times, the public sector is the best forum to bring society together for problem solving, he noted, but because the sector has not been functioning optimally, the academic inputs have not been weighed by public-sector partners among all inputs and perspectives, and something important has been lost in terms of collaborating to identify solutions. Is there a way for academia to take on some public functions when public-sector entities—such as CDC—are not working effectively, Sharfstein asked. Gourevitch agreed that there is a role for academia to step in and then step back when things improve in the public sector—there are many efforts unfolding to collect COVID-19 data, such as the Johns Hopkins COVID-19 website, and to tell stories about the data being collected. He added that academia has in some ways stepped into the vacuum. It is important to articulate where it can step back again. Sharfstein asked Kangovi to speak about the role of academia to elevate people’s lived experiences. The trajectory of inequity in health starts with the psychology of the privileged, she responded, and that shapes the distribution of wealth and power and community, which in turn influences living conditions, behavior, and health. At each step along the way there are possibilities to intervene, and at each point, Kangovi stated, the contributions of people with lived experience should be brought in to inform the interventions.

This discussion raised the issue of the “rules of academia,” said Johnson, and ways in which people in academia obtain power through tenure, promotion, and leadership positions. Forms of research that require deep listening and time may not align with the ways in which academics are recognized, Johnson added, and that type of research is needed to inform thinking about the workforce and the nature of academics in public health and population health. In a similar vein, Kangovi commented on the need for leaders in academia to ask themselves what it means “to be a public health student and who can afford to be a student in public health and who gets to do science?” Hughes concluded with a reflection on the fact that schools of public health cannot do it alone; they are dependent on other schools, other sectors, and people with lived experience.

Suggested Citation:"2 Academic Public Health and Population Health." National Academies of Sciences, Engineering, and Medicine. 2023. Population Health in Challenging Times: Insights from Key Domains: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26143.
×
Page 5
Suggested Citation:"2 Academic Public Health and Population Health." National Academies of Sciences, Engineering, and Medicine. 2023. Population Health in Challenging Times: Insights from Key Domains: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26143.
×
Page 6
Suggested Citation:"2 Academic Public Health and Population Health." National Academies of Sciences, Engineering, and Medicine. 2023. Population Health in Challenging Times: Insights from Key Domains: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26143.
×
Page 7
Suggested Citation:"2 Academic Public Health and Population Health." National Academies of Sciences, Engineering, and Medicine. 2023. Population Health in Challenging Times: Insights from Key Domains: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26143.
×
Page 8
Suggested Citation:"2 Academic Public Health and Population Health." National Academies of Sciences, Engineering, and Medicine. 2023. Population Health in Challenging Times: Insights from Key Domains: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26143.
×
Page 9
Suggested Citation:"2 Academic Public Health and Population Health." National Academies of Sciences, Engineering, and Medicine. 2023. Population Health in Challenging Times: Insights from Key Domains: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26143.
×
Page 10
Suggested Citation:"2 Academic Public Health and Population Health." National Academies of Sciences, Engineering, and Medicine. 2023. Population Health in Challenging Times: Insights from Key Domains: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26143.
×
Page 11
Suggested Citation:"2 Academic Public Health and Population Health." National Academies of Sciences, Engineering, and Medicine. 2023. Population Health in Challenging Times: Insights from Key Domains: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26143.
×
Page 12
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The year 2020 presented extraordinary challenges to organizations working to improve population health - from public health agencies at all levels of government to health systems to community-based non-profit organizations responding to health-related social needs. To improve understanding of how different domains in the population health field are responding to and being changed by two major crises (racial injustice and the COVID-19 pandemic), the Roundtable on Population Health Improvement of the National Academies of Sciences, Engineering, and Medicine held a workshop from September 21-24, 2020, titled Population Health in Challenging Times: Insights from Key Domains. The workshop had sessions organized by themes: academic public health and population health; the social sector; health care, governmental public health; philanthropy; and cross-sector work. Each panel discussion highlighted difficulties and opportunities, both internal to the respective institutions and sectors, and at the interface with peers and partners, especially communities. This publication summarizes the presentations and panel discussions from the workshop.

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