Adonis Diaries

Feinberg PPH: Commencement Address given by Bechara Choucair, May 4, 2011

Dr. Bechara Choucair is Commissioner of public health of the city of Chicago.  I liked his Commencement Address at Feinberg School of Medicine at Northwestern University and decided to publish it on wordpress.com.  This speech covered all the grounds and it is impressive.  I found it acceptable to edit out sentences that are not closely related to the subject matter in order to shorten the message.

“Today is about you. You decided to invest in your education. You decided to focus on public health. You worked hard. You read many articles. I am sure you wrote many papers. You participated in many work-groups. You sat for many exams. You gave many presentations. It is all paying off today. Congratulations.

My mom, dad, my sisters and my grandfather came along to my college graduation. I was so excited to have made it through College. At that time, I was accepted into Medical School at the American University of Beirut. I was really happy with the progress I made. My grandfather, who graduated from the same school 60 years earlier, gave me a big hug and said: “I could not be any more proud!” To this day, these are the words that come to mind anytime I think of him. He passed away a few years later. I am so glad I made him proud.

I have no doubt that many of your loved ones could not be any more proud today. To your loved ones: Thank You. Thank you for your support. Thank you for your love. And most importantly, thank you for being there.

As I reflect back on how my career has evolved, I can’t help but wonder if I would be here today if I did not work with Dr Hamadeh as my community medicine project mentor in my second year of medical school. Dr Hamadeh is a Family Physician with a Masters in Public Health. I worked closely with him and I realized that there is a lot more to Medicine than seeing patients. I saw the potential power that public health has, to truly make our population healthy. Every time I go back to Lebanon to visit with family, I make sure to stop by his office. I hope he knows how critical his role was, in shaping my career.

Today, I wanted to do 3 things:

1. I will briefly describe the history of public health in Chicago
2. I will talk about the intersection between public health and medicine
3. I will tell you about the future of public health in Chicago

The population-based approach of public health has had a tremendous impact on the health of our communities for almost two hundred years.  In Chicago, the formal establishment of public health took place in 1834, when the Board of Health was established to fight the threat of cholera.

During this Early Sanitation era, sanitation and quarantine were our best tools for fighting disease. The first sanitation regulations were passed and required all men over 21 years old to help clean the city’s streets and alleys. We conducted home visits to persons with infectious diseases and boarded ships in Chicago’s harbor to check on the health of crewmen.   Our deepest public health roots can be traced to disease control.

[Slide 1]   Earliest public information efforts.

Starting in the 1850’s,efforts in the era of sanitary reform, focused heavily on sewers, water and food and dairy. During this period, the Health Department issued regulations governing the drainage and plumbing of new buildings (1889); we initiated meat inspections at Chicago’s Union Stock Yards (1869), and; full milk inspection activities began (1892).

We saw some of our highest death rates during this era due to diphtheria, typhoid and scarlet fevers, measles and whooping-cough. Using his regulatory authority, the health commissioner at the time, Dr Oscar Coleman De Wolf required the reporting of contagious diseases by physicians in 1877.

[Slide 2]   By 1887, our advancements in medical understanding helped us see that typhoid would continue to kill unless we stopped the flow of contaminated water into Lake Michigan–the source of the water we drank, the water we cooked with, and the water in which we bathed.  Building the 28-mile Sanitary and Ship Canal, which reversed the flow of the Chicago River by 1900, was a major medical/public health intervention.

With the advent of the Hygiene Movement (1880’s-1950’s), and continued advances in understanding disease and medical practice, the focus of public health shifted to individual hygiene and medical care, particularly children’s health.

In 1890, a Chicago child had only a 50% chance of reaching 5 years of age. By 1900, the odds of surviving to age 5 had increased to 75%.   In 1899, with the support of 73 physician volunteers, the City initiated its first campaign against infant mortality.

Service delivery focused on the provision of dental services in schools in 1915, public health nurse home visits to infants in 1925 and educational campaigns against venereal disease in 1922.   These remain among our priorities today.

[Slide 3]  Early public health nurses at work.

On the bottom is one of a group of nurses known as “finders of sick infants.” These nurses would seek out sick babies and refer them and their mothers to Tent Camps where they would receive medical treatment and hygiene education.

[Slide 4]These pictures are from 1956 when 516 persons were stricken with polio. Public health authorities assigned 90% of the city’s health workers to reach a goal of one million inoculations in 2 weeks. One year later, Chicago had only 28 cases, and in 1959 when the U.S. went through a record breaking year for polio, Chicago had only one case.

The 1950’s saw the beginning of dramatic growth in medical interventions which prompted the era of health care services. During this time, the delivery of personal health care services, primarily to low-income populations, was becoming the primary public identity of public health in Chicago.

In 1959, the Health Department opened the Mid-South Mental Health Center, the first of what would become a network of community mental health centers by the early 1970’s.

[Slide 5]The first half of the 1970’s also saw the development of several Department neighborhood health centers under the federal Model Cities Program. The first of our centers, in the Uptown community, was established in 1970. Here you can see our clinics in Lakeview and the 1987 groundbreaking for the expansion of our West Town clinic.

The 1960’s and 1970’s brought significant changes at the federal level as well. The passage of Medicare and Medicaid in 1965 greatly expanded access to care for some of our most vulnerable populations.

Since that time, CDPH has greatly expanded its capacity in Epidemiology, Policy, Planning, Resource Development, and more recently, Information Technology, while maintaining its efforts in critical public health functions such as disease prevention and control, and in the last decade, emergency preparedness.

We have a public health history to be proud of. From the early days of the sanitary reform era to running medical care facilities, I can’t be any prouder of our history as a City. We always invested in building a healthier and a safer Chicago.

The intersection between clinical medicine and public health. These two worlds are often seen separate. We often see them as different disciplinary silos in which many of us spend entire careers. Ted Schettler, the Science Director of the Science and Environmental Health Network, frames both disciplines with respect to focus, scale, ethics, education and the nature of the science.

Clinical medicine focuses primarily on the individual while public health focuses on the community. Relevant time frames in Clinical Medicine are usually single lifetimes, while public health thinks in terms of generations.

From an ethics perspective, clinicians advocate for individual people. Public health practitioners advocate for the community, for a group of people. In clinical medicine we focus on individual patient rights. In public health, we think about human rights, social justice, and environmental justice.

From an education perspective, in clinical medicine we focus on the biomedical model with more emphasis on cure than prevention (although this is shifting now). In public health, we learn more about sociology, epidemiology, cultural anthropology, economics and more.

Think for a moment about the evidence of the science. In clinical medicine we love to talk about controlled, double-blind clinical trials. We don’t find that type of approach often in public health.

Have you ever asked yourself where do you fit better? Have you ever seen yourself in one of the two worlds?

Clearly, there are differences: differences in focus, differences in scale, differences in ethics, differences in education and differences in the nature of science.

But the reality is that the health of the individual and the health of the community are inter-related and inter-dependent. Maintaining two disciplinary silos is NOT the answer. Bridging the gap is critical if we are serious about improving the quality of life of our residents.

Bridging the gap starts right here. It starts with education. We have to enhance the understanding of public health principles among our students in the clinical field and we have to enhance the understanding of clinical medicine principles among our public health students.

Bridging the gap happens in research. We have to expand our research portfolio to focus on health disparities and other population level research.

Bridging the gap will not be successful unless we translate what we learn in research all the way into public policy.

And finally, it is people like you, like the faculty here and like me, who will take the lead in bridging this gap. The good news is that here in Chicago, there are great people who have done great work in bridging this gap. I am forever grateful for their contributions.

At the Chicago Department of Public Health, we are exploring how to fully exploit the intersection of public health and medicine. We are excited about having the opportunity to use, as the foundation of such efforts, the proliferation of HIT initiatives, particularly in under served communities. A major federally-funded initiative to help us achieve this goal is CHITREC, housed here at Feinberg and funded through stimulus funds (American Recovery & Reinvestment Act).

CHITREC (Chicago Health Information Technology Regional Extension Center) provides technical assistance to primary care providers serving predominantly uninsured, under insured, and medically under served populations in developing an Electronic Health Records system that will improve health outcomes. CHITREC is collaboration between Northwestern University and the Alliance of Chicago Health Center Services, a health center-controlled network. It builds upon extensive collective Electronic Health Records implementation and clinical informatics experience.

We anticipate that as the participating providers come on-line, there will be wonderful opportunities to use the wealth of data available through an Electronic Health Record to measure population health and be able to pinpoint where particular interventions are needed to improve outcomes.

Other federal funding, including the 2010 Patient Protection and Affordable Care Act, has provided additional opportunities for investments in the electronic data infrastructure supporting population health. Your Chicago Department of Public Health (CDPH) is positioned to become a leader in the public health applications of Health Information Technology. Current CDPH activities include:

•  Funding of 26 acute care hospitals in Chicago to assist in their efforts toward establishing capacity to transmit data of public health significance to CDPH;
• Partnering with the Centers for Disease Control and Prevention (CDC), GE Healthcare and the Alliance of Chicago in a pilot evaluation the feasibility of targeted, pubic health-oriented clinical decision support for ambulatory providers, delivered at the point of care through Electronic Health Records;
• Supporting Stroger Hospital of Cook County and two major Federally Qualified Healthcare Center (FQHC) networks (ACCESS Community Health Network and the Alliance of Chicago) in their efforts to establish robust transmission of immunization administration data to the Illinois immunization registry;
• Engaging with the Illinois Office of Health Information Technology in statewide efforts to build a sustainable Health Information Exchange (HIE);

What is the future of public health in Chicago?

[Slides 6 and 7]

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?”

[Slide 8]

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 (well, 97 days by now since he’s been in office for 3 days already!) 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 and educational & 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.

From being a little kid playing on the beach of a small Mediterranean town in Lebanon, dreaming about a safer Lebanon to the conversation I had the last week with Mayor Emanuel when he asked me to stay as part of his Cabinet, I always dream big for our community.

Today is a milestone in your career. Please join me in dreaming big.