Adonis Diaries

Archive for May 27th, 2011

What is the future of public health in Chicago?

Commissioner Choukair said in the commencement address: “During my tenure at the Chicago Department of Public Health, which has been about a year and a half so far, I have stressed the importance of focusing on public health strategies that effectively address the actual causes of death, rather than what is found on a death certificate.

Groundbreaking work done by McGinnis and Foege at CDC in the early 1990’s, and fine-tuned since then, demonstrated that the actual causes of death are largely related to individual health behaviors and social circumstances — not genetics, not access to health care.

Dr. Thomas Frieden, Director of CDC, looked at these, took it all in, but then went further and asked:  “now that we have a better understanding of the actual causes of death, how can public health, charged with improving the health of the population, best intervene?”

The most effective interventions, at the base of the pyramid, address the social determinants of health and the way that our society is structured.  Taking this approach to heart, I challenged our team at the Chicago Department of Public Health to develop a draft of a public health agenda that best meets this current understanding of effective public health interventions. And while our emphases have been near the bottom on the pyramid, I recognize that there is a need for effective programs at each level.

If you follow Chicago government, you might know that Mayor Emanuel committed to releasing a public health agenda for the City of Chicago in the next 100 days.  Our public health agenda is a blueprint for action intended to serve as a framework for a focused, yet comprehensive, approach to how the Chicago Department of Public Health will lead and work with partners to improve the health and well-being of the people in Chicago.

Our public health agenda:

  • identifies priorities to guide our public health work over the next five years;
  • sets measurable targets, achievable by 2020, to improve the health and well-being of Chicagoans;
  • sets policy, programmatic, educational, and public awareness strategies that can be measured and monitored; and
  • serves as a vehicle to engage communities, partners, and other public health stakeholders in health improvement efforts.

The priorities presented in this agenda were identified through an assessment of public health data and resources, as well as current or potential stakeholder involvement. Reflecting a multi-tiered public health approach, for each priority area, this agenda presents strategies organized into three sections:

  • ·      Policies, including regulatory changes and laws that will be pursued to improve the public’s health;
  • ·      Programs and services that will be delivered, and
  • ·      Education and public awareness

I am sure it is no surprise to anyone if I share our priorities with you. I am talking about Obesity Prevention, Tobacco Use, HIV Prevention, Teen Pregnancy Prevention, Cancer disparities with a use case on breast cancer disparities in Chicago. I am also talking about heart disease and stroke, about violence prevention and about access to healthcare among others.

These are exciting times in Chicago. In 97 days, our City will have a clear public health agenda. We will have a focused set of priorities. We will make our targets public. We want the public to hold us accountable.

Chicago invests around $200M every year in our public health system. We owe it to Chicagoans to do our best to stretch those dollars and get the best return on investment. This is my commitment to you today. As you get ready to start the next phase in your career, I call on all of you to join me in this journey. I guarantee you it will be a lot of hard work but a lot of fun and we will get a healthier city.

 There are many ways to have an impact on health:

  • ·      Treating the sick –
  • ·      Preventing the illness in the first place through screenings
  • ·      Population-based prevention strategies

I hope in your work in public health, regardless of the setting, you keep in mind the concept of the “third revolution” (Breslow) in public health. Now that we have made significant progress in addressing communicable disease (first revolution) and made progress in chronic diseases (second revolution), we are poised to embark on the third, where communities are healthy and the goal is promoting health and not just preventing disease: “Health promotion reaffirms considering not only how to avoid being sick, a negative concept, but also how to expand the potential for living, a positive view: The main difference between health promotion and disease prevention is the premise of health promotion regarding health as a resource of everyday life”.

We all know the impact of clinical medicine on public health.  To promote health, we need to think beyond just clinical medicine. We have to be involved in social policy.  All social policy is public health.  Fiscal policy is health policy.  Education is public health. Housing is public health.

Perhaps in your schooling, or on your own, you saw the film “Unnatural Causes: Is Inequality Making Us Sick?” Through four hours of excellent documentary film making, it makes crystal clear what needs to change in our society if we are going to be truly healthy:

  • ·      It’s less poverty
  • ·      It’s quality housing
  • ·      It’s quality education
  • ·      It’s viable communities filled with resources geared to the needs of the particular population

I grew up in Lebanon in the midst of a civil war. I saw the impact of violence on individuals, on families, on community and on the whole country. I suffered the impact of violence myself.  I saw the impact on my own family, in my own community.

In medical school at the American University of Beirut, I spent time seeing patients in Palestinian Refugee camps in Beirut. I talked to so many people who lived their whole lives in an environment where I might not choose to live.  I saw firsthand the impact of forced migration on health.

In Houston, at Baylor College of Medicine, I trained in a community health center serving mostly Mexican immigrants who struggled to make a decent living. I learned about homelessness by providing clinical services to people living in shelters, under bridges, in cars and on the streets.  I saw firsthand the impact of poverty and lack of housing on individuals.

In Rockford, at Crusader Community Health, I served as a medical director of a community health center network. I learned about more migrant communities. I learned more about public housing. I learned more about HIV/AIDS.  I saw firsthand the impact of poverty on different communities.

At Heartland Alliance for Human Rights and Human Needs, I worked with immigrants and refugees on the North side of Chicago. I also worked with many of the Heartland Alliance global health team:

  • ·      the team working on HIV Prevention among Men who have sex with men in Nigeria
  • ·      the team working on sexual and gender-based violence in Sulaymaniyah, Iraq,
  • ·      the team working on torture and trauma treatment in Momostenango, Guatemala
  • ·      the team working on Maternal Child Health in Patzcuaro, Mexico
  • ·      the team working on child soldier reintegration in Srilanka

I visited with some of these sites and learned from the Heartland staff and most importantly I learned from the participants in these programs.  What I learned from all of these experiences is simple.

To empower individuals to achieve their human rights, and to empower communities to achieve their potential, we cannot think about health care alone. We have to think about healthcare. We also have to think about housing. We have to think about economic security. We have to think about legal protections.  This is what public health is all about.  This is what we need to address as public health people.

I hope that with your public health education and approach you will keep in mind that a healthier society is a society where healthier choices are the default choices.  A healthier society is a society where children have good schools to attend, and safe neighborhoods to play in.  A healthier society is a society where parents have enough resources to provide their children with a rich experience in life.

What do you need to do to be a better person?  What will you do to build a healthier society?  How can you contribute to social justice?  What role will you play to advance human rights?  Join me today in dreaming big for our communities.  I always did. I always will.

Note:  This is the third part of a commencement address of Chicago Commissioner Choukair.

Speakers lucubrations at TEDx meeting at LAU Beirut, May 26, 2011
I attended another gathering of TEDx.  This time, Patsy, William, and the committee for organizing a TEDx Beirut this September, have decided to hold it at LAU Beirut, the new business school building.  The idea was to expose, promote,disseminate, and associate as many participants in the coming TEDx event.  Thus, once a month, a major meeting, called TEDxBeirutSalon, showing a few TEDx speakers and commenting on the topics will be in a university campus.  The three other Thursdays will be at Patsy house in Awkar.  Reine, a teacher of English and Ethics at LAU, facilitated and coordinated this first “Salon”.  Over 100 showed up, among them 30 LAU students.
I felt a good vibe among these young people, and refrained from commenting as I wished to do on many topics.

The first speaker, (I tend to forget names, though many in the small auditorium considered him top in statistics and adulated him), exposed by animated graphs the trends of the US, England, Japan, India, and China since 1858 in life expectancy versus average income.  The speaker said that in 2048, India and China will surpass the US, Japan, and Western Europe States in life expectancy and average income. 
Apparently, these countries have preserved data since 1858 and could be compared.  Anyway, the  year 1858 coincided with the defeat of Indian uprising against the British colonial power, the defeat of China in the Opium War (opening China market to European product in exchange (bartering method) of opium manufactured in India, and the coertion of japan to opening its harbors to US and European merchant ships.  And in 1858, Queen Victoria talked to the US President via the new invention the Telegraph.
First, the speaker didn’t clarify whether data on life expectancy were homogenous among all countries.  For example, were children dead before age of 5 included in the samples?  Were people living to be 60 and over, functional, relatively healthy, or practically dead and needed to be fed in their bed for another ten years?
Second, how average income were computed?  Were income standardized to match the cost of living?  Is $100 in India of the same worth as $1000 in the USA from 1858 till now?…  Anyway, if we standardize the notion of income, we can conjecture that the trend for the lower 20% classes is a flat line to all countries.  We can also conjecture that the trend for the richest 1% of the population is basically the same among all countries.  What make a difference in the trend are principally the lower middle-class section that represent 60% of any population. 
Third, average income is not a good indicator.  For example, poor Bangladesh, neighboring India, with half the average income is better than India on human development indicators as defined by the UN.  A couple of years ago, I had read an extensive article in the French monthly “Le Monde Diplomatique”, showing exactly the same graphs.
Derek Sivers’ funny 3-minute speech “How to start a movement” could have been a basis for heated opinions, but we were ready for a coffee break. Derek showed a video of a group of people on the beach.  A youth, top naked, starts dancing alone.  Another clothed youth join in the dance.  Pretty soon, most of the viewers hurry to participate in a haphazard dance, just not to feeling left out from the crowd.  Derek said: “If no one joined the first dancer he would be labeled a nut case; but, as another fellow joined in and another, then the top naked dancer is a leader, and worse, a movement was set in motion!
This is the kind of speech that get people “excited”, as if a new discovery was invented.  Youth who does not demonstrate to be a nut-case is usually not a normal youth.  Youth not joining the first nut-case is not a normal youth.  The notion of leader in that context is not applicable.
If someone did his due diligence, studied, read a lot, went on adventures, reflected on his experiences and constituted “expert convictions or opinions”, and then, decided to recall his youth craziness and energy and acted out a nut-case scenario, and happened to have youth join in, then he is promoted a leader momentarily.
The irony is that, although youth are the backbone for any movement, it is the “matured” new followers who grab the administrative and managerial positions.  The youth are expected to just “follow” and stop acting crazy!

As William wrote: “I don’t believe a leader is someone that people follow. In Derek’s talk, what the first lone nut did is simple. He showed everyone that nothing bad will happen to him if he danced on the beach. No consequences. Of course this by itself doesn’t start a movement. People will not get up and start dancing just because he did. There’s another secret ingredient.

Everyone got up and started dancing because they all really wanted to dance in the first place. And because they were afraid… no one did it.  A leader is born when he does something that a lot of people already want to do. He uses himself as an example and abolishes the fear. People do what he’s doing not because he’s telling them what to do. It’s because he’s showing them that it’s OK to do what they’ve always wanted to do. He creates a safety net. If something goes wrong, he’s the one most likely to suffer the consequences. And so the followers feel safe.

And so this changes the concept of a leader and follower. A leader doesn’t lead, and a follower doesn’t follow. They’re just people doing what they’ve always wanted to do, but wouldn’t (Mostly out of fear).  The TEDxBeirut team isn’t doing this because our curator Patricia is telling us what to do. We’re doing it because each one of us already wanted to do it so much.”

The third speaker demonstrated that car technology is advancing:  We can let the car drive us wherever we want, at any dangerous road, and be safer than if we decided to be in control.  He said: “The number fatality for youth is car accidents.  One day, we will be wondering why we drove car.”  Indeed, if there are efficient and inexpensive public transports, why anyone but nut drivers would purchase, maintain a car, pay traffic tickets, be exposed to humiliating policemen, be incarcerated in prison for reckless driving, and spend half his income on a private car?

Feudal system adopting modern financial schemes:The case of Island vote on referendum.

In 2007, the average income of the around 350,000 “citizens” of Island was 60% higher than the average US citizen, and was ranked 5th in the world.  The gas guzzling 4*4 were crowding the streets.

Iceland was a feudal system for 600 years, an extension of the kingdom of Danmark. Cold-water fishing was the main income generator.  Before 1940, 14 families represented the feudal system: They supplied the elite classes for the political, economical, and financial institutions.  The 14 families were known as “the Octopus”.

During WWII and after, the economy of Iceland boomed, thanks to the US “Marshall” economic and financial plan, the establishment of an US military base to servicing the NATO in Western Europe, and for enjoying a highly educated small population.

By 1980, the government had instituted vast public social services, financed by taxes, and competing in quality with Norway, Sweden, Danmark, and the Netherlands.  The local oligarchies was taking care of the “citizens”.

The “Octopus” dominated all the major sectors in transport, import, fish export, banks, insurance… The Octopus was represented by the “Independence” political party that controlled the medias, the army, the police force…

In the 70’s, students in law and business published the daily “Locomotive” and this daily managed to break through the Octopus monopoly in politics.  After the fall of the Berlin Wall in 1989, the Locomotive brought to power David Oddsson.

In 1998, Iceland had three public banks.  Oddsson reigned for 14 years as PM:  He privatized the three major banks.  The banks were headed by members of the Octopus families: The Landsbank representing the IP party, the Kaupthing  representing the CP party, and the Glitnir, servicing the small enterprises.  The banks acquired assets over 100% of Iceland GNP in 2000.  The assets jumped to over 800% of the GNP in 2007, second after Switzerland. 

Oddsson carried out a “liberal” economy, lowered the tax and TVA rates, and the citizens could borrow up to 90% of their income.  The financial oligarchy took over the political structure.  In 2004, Oddsson headed Iceland central bank!

Iceland was vying to become a major international center for financial transactions.  The three banks borrowed from one another to repurchase shares in their own societies. 

In the decade 1990 and 2000, Island political regime facilitated the job of private interests to enacting public laws and regulations that encouraged financial institutions to balloon the financial sphere of activities.  This financial system imploded even before the financial crisis of 2008.  The dynamics of Bubble economy was taking hold.

In 2006, the financial press started criticizing the stability of the financial institutions in Iceland: The three banks were having difficulties getting loans from the financial world market to sustain growth and maintaining liquidity.  Iceland deficit grew to 20% of GNP in 2006.  The stock exchange “capitalization” in 2007 was 5 folds the level of 2001.  The central bank could not have rescued the banks in times of crisis.

The financial crash of 2008 pressured the government to re-nationalize the 3 banks.

The hot question is: “Is there a legitimate institution linked to popular sovereignty that is capable of opposing financial institutions supremacy?”

April 10, 2011:  60% of the citizens of Island answered “NO” in the referendum for paying back deposits made by British and Netherlands depositors into the private bank “Icesave” in Iceland.  They had answered “NO” in 2010 by 93%.  The Financial Times wrote: “It is now legitimate to advancing the citizens’ interest before banks.”

What is the financial Icesave scheme? 

In 2006, the three banks were hard-pressed generating fresh money to resume new acquisitions and reimbursing their debts.  Icesave is basically an internet service attracting deposits, at lucrative interest rates that traditional banks would not offer.  Over 300, 000 British and Netherlands private depositors were lured into this scheme. 

Within 18 months, universities, police associations, and even the Audit Commission of London were enjoying early high income.  The entities of Icesave were agencies and not affiliate and thus, under the control of Island authority and not the European Union economic Space.

Another financial tool used was what was known as “Love letters” since the credits are simple promises for repay.  The mechanism is for the three big banks to selling credits to smaller regional banks, which they deposit at Iceland central bank for fresh guaranteed loans.  This tool is generalized internationally and the big banks opened affiliates in Luxemburg and use the EU central bank.

Two weeks after the fall of Lehman Brothers, Iceland is facing a serious situation:  the currency is in free fall, the government buy 75% of the shares of Glitnir Bank, and Britain freezes the assets of Landsbank.  Joblessness climbs to 9% and Iceland witness a reverse immigration of the workforce, back to their country of origin.  The IMF imposes the constraint of reimbursing the debts of Britain and the Netherlands for any further loan extensions.

In October 2009, the Parliament of Iceland agrees to repay $5.5 billion, or 50% of the GNP, in the years 2016-2023.  But the government changes tactics and demands a referendum for validating the parliament decision. 

Basically, what the referendum said: “Send the bill back to whoever made your finance deficit worse”.  I could understand that logic if the international financial institutions made loans to the poorer States governed by oligarchies, dictators, and absolute monarchs who never mean for the money to be invested in society and human development. 

The case of Iceland is highway robbery:  It was intentional never to pay back the deposits, and it was done by the government who had nationalized the three major banks.

Note:  The information were taken from a thorough article published in the French monthly “Le Monde Diplomatique.  The article was written by Robert Wade and Sila Sigurgeirsdottir.




May 2011

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