Can innovation thrive in the culture of U.S. public health systems

Amazon, despite its critics, has been an innovator in the private sector.

Amazon, despite its critics, has been an innovator in the private sector.

The business press and the communications teams in the private sector work hard to show that innovation mingles in the air like oxygen  at successful businesses. The theory goes, innovation breeds success, which creates profits, which spurs new products and services and wealth, which of course is good for the economy and thus all of us.

Forbes, for instance, showcases business innovators, like Starbucks and Amazon, by highlighting metrics that the magazine considers to be markers of innovation. According to the Forbes’ Sept. 2, 2013, piece on innovation, Amazon’s CEO Jeff Bezos says he looks for traits in innovators in his company and allows for innovation to occur three ways:

  • Rewarding innovators who are relentless in their on their vision but flexible on the details of how to get there.
  • Fostering a decentralized work culture for new products or services, so that the majority of employees feel like it is expected of them (Amazon’s now famous “two-pizza teams”). 
  • Third, teaching teams how to experiment their way to innovations.

But once we start talking about government, talk of innovation gets tossed out the door. In fact, the prevailing wisdom among many in the private sector, and likely in the public sector too, is that government is the ultimate death machine to innovation.

Not only does innovation die still-borne in public agencies, government regulations themselves kill innovation in the private sector, many writers and politicians claim ad infinitum.

Do any public agencies have capacity to innovate?

Government still funds innovation and research and development, particularly in defense and health care. But as a culture, government is not the incubator, goes prevailing wisdom. One global survey completed this year puts trust in government around the world below 50%, behind trust in business at about 58%, for its ability to demonstrate change and new leadership.

Public health, as a public endeavor in the United States, is by definition a public undertaking. Thus it remains government-funded, government-run, and thus, be default, the inheritor of government’s best and worst traits.

As someone who has now worked at the international, state, and local levels of government, including in public health, I can attest to government bureaucracies’ failure in many instances to embrace change, inability to stimulate ideas, and poor track record in adopting new ideas to improve how government does business.

One recent research paper by British researchers Geoff Mulgan and David Albury on the lack of innovation in the public sector noted: “Most service managers and professionals spend the overwhelming proportion of their time dealing with the day-to-day pressures of delivering services, running their organisations [sic] and reporting to senior managers, political leaders, agencies and inspectorates [sic]. They have very little space to think about doing things differently or delivering services in ways which would alleviate the pressures and burdens.” In short, government culture lacks innovation.

The pair argue that innovation should be a core activity of the public sector. They claim this helps public services improve performance and public value, respond better to the public’s needs, boost efficiency, and cut costs.

Geoff Mulgan and David Albury 's diagram how public bodies do no innovate.

Geoff Mulgan and David Albury ‘s diagram how public bodies do not innovate.

What are people saying about innovation in public health and health care

In Europe, in 2010, the Association of Schools for Public Health in the European Region’s Task Force on Innovation/Good Practice in Public Health Teaching developed a plan that called for seven action items, two of which focused on innovation:

  • Developing more coherence between policies in the fields of education, research and innovation.
  • Measures to develop an innovation culture in universities.

Back on this side of the pond, the Harvard Business School held a conference on innovation in the massive health care sector in October 2012, and then published a study in February 2013 on how innovation was seen as critical to health care and health education, which includes public health.

The report found that 59 of the CEOs of the world’s largest and most innovative health-sector organizations most frequently used the word “innovation.” According to the discussion of the attendees, innovation in its broadest sense was even seen as the “only way that change will happen and that creative solutions will be found for our current problems in health care.”

The most important characteristic for a company according to leading health care CEOs is innovation.

The most important characteristic for a company according to leading health care CEOs is innovation.

Recent evidence shows that innovation can lead to better outcomes. A 2013 study  published in the Journal of Multidisciplinary Healthcare, on technological innovation and its effect on public health in the United States, found a correlation regionally in parts of the country where it was perceived that technological innovation was occurring. The study reported that “relationships between the technological innovation indicators and public health indicators were quantified,” and it was found “that technological innovation and public health share a fairly strong relationship.”

Will innovation remain a dirty word in public health departments at all levels of government?

But does anyone working in a local health jurisdiction, hard-strapped for cash in the post-Great Recession era of downsizing, see innovation taking place in their work environments? As hierarchical bodies, modeled originally after the military since their original inception in the United States, public health bodies are seldom discussed in organizational behavior literature as “innovative.” They are organized hierarchically and often divided by departments with no interchange, and their managers may be unable to allow for information sharing and promote collaboration seen in many for-profit firms.

Yes public health jurisdictions, to win much-coveted accreditation by the national Public Health Accreditation Board, must prove they are committed to quality improvement and a competent workforce. But this by no means is the same as encouraging a culture of innovation to adapt to tremendous change, particularly financial downturns and the challenges posed by chronic disease and the increasing wealth disparity among the top wage earners and the majority at the bottom, which is leading to great health disparities.

One local health jurisdiction that is trying to innovate, the Spokane Regional Health District, developed a strategic plan that calls out as its top two strategic priorities: increasing awareness about the role of public health and securing more stable funding. I think these are spot on and demonstrate how this agency has moved its focus upstream and is adapting itself to succeed in that bruising political arena.

innovation not

More of Tom Fishburne’s artwork can be found on the web site: http://tomfishburne.com/.

But my own sense of public health jurisdictions, small and large in the Pacific Northwest at least, is that other jurisdictions may not wish to emulate Spokane because of agency rivalries and personal jealousies among upper management. I would love for one day to learn that some of the traits of private sector organizational behavior practices, such as rewarding innovators, promoting a culture of innovation, and teaching workers how to innovate take root. Right now, I’m not seeing that within the sector, and the talk is not matching the walk.

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Making the case for public schools, the highest-stakes poker game around

Recently I posted a link on my Facebook page to a Slate blog piece by Allison Benedikt: If you send your kid to private school, you are a bad person. It drew some negative feedback as well as a very positive response. Benedikt, who is a parent, provocatively suggests if you do this, you are “not bad like murderer bad—but bad like ruining-one-of-our-nation’s-most-essential-institutions-in-order-to-get-what’s-best-for-your-kid bad. So, pretty bad.”

Benedikt then goes on to argue that people who abandon public K-12 education undermine the foundations that make for a healthier, more democratic society. In defense of her seemingly provocative view, she claims that the bad things she did with bad kids during her public school days taught her more about life than reading Walt Whitman. In the end, she pleads with the middle-class moms and dads of the country reading her piece to go to bat for public schools in the most visceral way.

There’s a big public health story here too, but first, let me give some personal background and why this resonated profoundly with me.

How I endured then cherished my public school experience

I have friends who send/have sent their kids to private schools, and I do not think they are bad. But having attended K-12 public schools my formative years, I am very biased to Benedikt’s point of view. It’s my tribe, those public school grads. You might call me a bulldog on this point. My mother was a public school teacher as well, so I know the exhausting and harsh down sides from the perspective of such educators.

The most important things I learned about life are the ones I clawed together in that often chaotic petri dish, and at times it was chaos too. While I think many aspects of U.S. public schools truly stink, mainly the large mega schools and school systems that reward jocks and criminally fail to prevent abusive bullying of all stripes, I cannot deny the value of socializing in this publicly-funded mosh pit provides.

A seen from my graduating class of 1983 from University City Senior High School--yes I'm in there, bad hair and all.

A snapshot from my graduating class of 1983 from University City Senior High School; yes I’m in there, bad hair and all.

The system I attended til 1983 in University City,  next to St. Louis, was good (in some ways), but very divided in terms of who was on the fast track to say a great music college and who was on the fast track to say joining the armed forces. Both paths seem good to me now, and I was among those without a clear path. People came from respectable professional families (the ones whose parents were high-earning types like doctors) and from those living on the margins. The realities of race, and in my mind class, were omnipresent. During my years in that system, grades 3-12, the student population was roughly 70% black, 25% white, and 5% all other (Latino, Asian, Middle Eastern).

There were great teachers, and awful ones. There were clicks, stoners, nerds, punks, jocks, super achievers, motorheads (people I respected the most), future criminals, future drop-outs, future business people, musicians, and hip hop artists. Violence lurked in many places, too. I saw three extremely violent and criminal assaults (two on campus, one off) during a several-year stint. I experienced more than my fair share of racial harassment, and I was hospitalized after being cold cocked on a school setting—a crime I partially brought on myself, but also with racial undertones. But hey, who says high school is supposed to be walk through the flowers?

A group shot from my 1983 graduating class; I am not seen in this one.

A group shot from my 1983 graduating class; I am not seen in this one.

In the end, I would not trade this for anything. All of this gave me the tools to deal with an increasingly diverse country, where skills at communicating cross-culturally matter in every professional setting, and in most personal interactions too. In a more fundamental way, I felt equipped to stand my ground and hold my own anywhere in the world, and really appreciate people on their own terms. It gave me a window to really get to know people.

Schools becoming less diverse and more segregated

Today, however, it is more likely students finishing their K-12 education will not have experienced something like what I did—a school that has true racial and cultural diversity without deep segregation at the district level. According to a 2009 report by the University of California at Los Angeles’ Civil Rights Project, schools in the United States are more segregated today than they have been in more than 40 years. Worse, millions of non-white students are trapped in so-called “dropout factory” (public) high schools, where large numbers do not graduate and remain unprepared for the challenges of an increasingly knowledge-based economy of technological haves and have-nots.

While our nation has come a long way since the Brown v. Board of Education Supreme Court case of 1954 made it illegal to segregate schools based on race, there are still many problems. A typical example is in Richmond, Va., where a recent news report found that 40 years after the U.S. Supreme Court rejected consolidation of public school districts to achieve racial integration in the Richmond area, one in every three black students in the Richmond-Petersburg region attends a school with a population that is at least 90 percent black and 75 percent poor.

So what right-minded parent, black or white or brown, would want their child in a school that is segregated and all but likely underfunded? It is a non-starter, really.

School Enrollment comparison

The U.S. Department of Education’s data show private school enrollment has dropped, mostly due to declining attendance at Catholic schools.

Public vs. private schools by the numbers

According to the U.S. Department of Education in 2008, the number of public schools in the United States outnumbered private schools (including religious schools) by about a 5-1 margin (65,990  vs. 13,864). In the past 15 years (1995-2009), private school enrollment actually dropped from 12% of all enrollment to less than 10%. The main reason is attributed to the drop in Catholic school enrollment.

Economic downturns also led to falling enrollment. Due to the increasing decline of the U.S. middle class and the concentration of all wealth in the hands of a few Americans, the disparities have even worsened. Between 2009 and 2011, the mean net worth of the wealthiest 7% of households rose 28%, while the mean net worth of households in the lower 93% slipped 4%, according to a Pew Research Center.

According to Jack Jennings, founder and former president of the Center on Education Policy, the real issue remains how well the nation will educate the 90% majority—the ones with increasingly less wealth—who are not privileged and have less resources and who comprise the majority of our public school student population. They will be the future soldiers, medical professionals, politicians, scientists, engineers, construction workers, and more. “If we want a bright future, we must focus national attention on making public schools as good as they can be,” Jenning says.

At last count, about 49 million kids were enrolled in K-12 education, or nearly or a sixth of the U.S. population. So the debate about where we educate these youngest citizens and our up-and-coming leaders is about as important issue as any we face as a nation, and as citizens of our communities and country.

Jessica Strauss, in a June 2013 New York Times piece on the country’s growing education divide, pointedly notes: “The truth is that there are two very different education stories in America. The children of the wealthiest 10% or so do receive some of the best education in the world, and the quality keeps getting better. For most everyone else, this is not the case. America’s average standing in global education rankings has tumbled not because everyone is falling, but because of the country’s deep, still-widening achievement gap between socioeconomic groups.”school_choice

Education, health, and ethnic diversity–fused at the hip

So where should kids get the tools they need to prepare them for their life challenges, a turbulent economy that is divided by knowledge and technology, and the diversity in a country that will be less than 50% white by 2043. Navigating the nation’s ethnic and linguistic diversity will be as critical for someone running a small business as it will be for a highly trained medical professional serving patients with different ways of dealing with health care.

Research over the past 20 years has generated countless studies consistently showing how a person’s health is driven largely by underlying factors, or the social determinants of health. In short, one’s education will predict a child’s future health as good as any other causal factor.

So as a nation, if we also want to promote opportunities for everyone to achieve good health, as well as good jobs, there must be a public policy imperative to ensure that the poor, underachieving, increasingly non-white public schools do not get short-changed. Does that mean more blog posts and rants chastising liberal middle-class parents and taunting them? Perhaps that’s one way to raise awareness, as Benedikt tried and I think succeeded.

But I’m less convinced parents of any race who want their kids to be learning Mandarin by age 8 and making high-def feature movies by grade 10 (like students do at the elite Annie Wright School of Tacoma, Wash.) will dare risk their child’s well-being for the larger social good. If parents are fortunate to be economically well off in that narrowing minority of “haves,” they will choose the high-price, high-quality schools like this leafy campus and pay tens of thousands of dollars for that rare privilege. Because I am not a parent, I can avoid this very hard decision, so I am very lucky.

Such advantage-bestowed kids will undoubtedly go on to be successful leaders. But I am less inclined to believe they will be the right leaders, who have a visceral sense of what’s best for all of us, though many of them will be the ones driving the agenda in many of the organizations that impact us the most.

The crowded, congested, contested road: unsafe at nearly every speed

Seattle traffic

Seattle traffic is among the worst in the nation, and it can be downright deadly, according to those who track road-related fatalities.

Every day that I drive to work, I am literally putting my life on the line. I commute roughly 80 miles daily, round trip, from Seattle to Tacoma, navigating one of the most harrowing urban traffic corridors in the Untied States, on Interstate 5 and two state highways. (My story why I am commuting this way will be for another day, but there are good reasons.)

Routinely, erratic drivers dangerously pass me, putting our lives at risk, in order to gain a few extra minutes by speeding. I have seen many accidents, some fatal, on this route over the years, and I am glad that I have my will and living will in proper order in case a truck jack-knifes near me in the rain—and yes I’ve seen that happen twice before on the freeway system around Seattle.

Seattle Road Kill 2001-2009

How deadly are roads in the Puget Sound–take a look at the roadkill on this data map showing types of mortality by form of transportation for 2001-2009.

Judging by this map, we get a fair share of road kill in the metro area I call home.

The Centers for Disease Control and Prevention (CDC) put the number of road deaths annually in my home state at nearly 500 (2009). Nationally, in 2012, the United States reported that 34,080 people died in motor vehicle traffic crashes in 2012, a 5.3% jump over 2011. This ranks as 10th leading cause of death in the United States, if one pulls this form of death from all accidental deaths, in which it is grouped by the CDC epidemiologists.

So by all counts, getting in one’s car (or on one’s bike or in a bus or other form of transportation) and hitting the road can be deadly business in my country, especially given the proliferation of mobile-device users and drunk drivers.

In 2011, cell phone use in the good ole’ U.S.A. was a contributing factor in more than 3,300 deaths and for the previous year, in 387,000 motor vehicle injuries. These are very sobering numbers, and I actually expected there would be more given that I have seen far too many texters during peak travel times in vehicles moving 70 mph. Normally I move over a lane or lay on my horn to snap them out of it.

But this is nothing compared to the perils that passengers and drivers experience globally. According to the World Health Organization (WHO), road accidents claimed 1.2 million lives globally in 2011, ranking as the No. 10 cause of death, on a list that has some pretty nasty company, including respiratory infections (3.5 million), tuberculosis (1.3 million), and the big killer of children ages 0-5 years, diarrhea (2.5 million).

The Institute for Health Metrics produced this data table showing how road deaths globally compared to other causes of death (it's No. 10); go to: http://www.healthmetricsandevaluation.org/gbd/visualizations/gbd-heatmap

The Institute for Health Metrics produced this data table showing how road injury globally compares to other burdens of disease (it is No. 10); go to: http://www.healthmetricsandevaluation.org/gbd/visualizations/gbd-heatmap

A typical story that one sees with mind-numbing frequency overseas are bus collisions with motorcycles and motor scooters. This November 2012 story, 19-yr-olds crushed to death by bus, notes two aspiring young men were run over by an errant bus driver and dragged 40 feet in Chandigarh, India; the driver then fled the scene. Both of the men’s heads were crushed by the bus’s wheels.

I saw no less than three similar road maulings on the island of Java in 2009, when I visited Indonesia. That island, one of the most densely populated locations in the world, is overwhelmed with low-income and middle-income residents on  scooters competing for space with trucks and army of loosely and unregulated van taxis and buses.

Indonesians who use these highly efficient and inexpensive 100-125cc motor scooters are frequently killed on the island nation's infamously unsafe and crowded roads.

Indonesians who use these highly efficient and inexpensive 100-125cc motor scooters are frequently killed on the island nation’s infamously unsafe and crowded roads.

Road accidents alone in Indonesia account for more than 48,000 deaths annually, the 9th leading cause of death in the world’s largest Muslim nation.

The United States Department of State offers this stern warning to would-be American visitors to Indonesia–a country I really loved by the way: “Air, ferry, and road accidents resulting in fatalities, injuries, and significant damage are common. … While all forms of transportation are ostensibly regulated in Indonesia, oversight is spotty, equipment tends to be less well maintained than that operated in the United States, amenities do not typically meet Western standards, and rescue/emergency response is notably lacking.”

During my two-week visit in 2009 to the island nation, I rode about a dozen different buses and equally as many microbuses, not to mention the country’s crash-prone domestic air carriers once, their local train service (also unsafe at times), and the far less safe inter-island ferry services. I saw about a half dozen crashes from my bus window, most fatal and usually with motor cycle riders as victims, and from my hotel room I heard one multi-vehicle crash in the middle of the night that clearly claimed many lives. I learned the next day it was between a bus and truck. The bus was totaled.

Roads can really kill you overseas, and so can planes, boats, and trains too

Buses like these are cheap in Indonesia, but your life can be as some locals would say, insha-Allah, or at the mercy of God.

Buses like these are cheap in Indonesia, but your life can be as some locals would say, insha-Allah, or at the mercy of God.

The writer Carl Hoffman, author of the book The Lunatic Express: Discovering the World… via Its Most Dangerous Buses, Boats, Trains, and Planes, documents the horrendous conditions of ferries, public transportation, trains, planes, and other forms of transport. The book’s online promotion notes that it offers a “harrowing and insightful look at the world as it is, a planet full of hundreds of millions of people, mostly poor, on the move and seeking their fortunes.”

Anyone who has travelled in developing or “middle-income” countries (like, say, Chile or Turkey) knows their life is literally in the hands of drivers who may have no proper training, in busses with no proper maintenance or even reliable brakes. Worse, the drivers of buses and microbuses in countries from Uganda to India to Mexico may trust their fate to Allah, Saint Christopher, the Virgin Mary, or Krishna. Those who have travelled in such places know this to be true, by the many religious deities dangling at the front of public transportation by the drivers’ seats.

Worse, the drivers will often play chicken with their competitors by speeding into oncoming traffic at high speeds while passing other vehicles or simply to “have fun.” I swear I thought I would die on many occasions in: Mexico, Guatemala, Nepal, Peru, Uganda, Indonesia, Egypt, Turkey, Chile, Argentina, India, and other places that I’d rather forget just now.

accident or more by Birn

When is an accident really an accident, or when it is linked to larger systems issues? This analysis is provided by Anne-Emmanuelle Birn in her description of the social determinants of health (SDOH).

Three separate times, after I lived through the near mishap, I swore I would never, ever take a bus again in a developing nation. Yet I threw caution to the wind, as I needed to get around, and I could not afford to get around any other way. Not seeing the country I was visiting was not an option.

Is it really  “just an accident” or something more?

Anne-Emmanuelle Birn, international health professor at the University of Toronto, and co-author of the widely used global health tome called Textbook of International Health, points out the deeper connections that road-related deaths have to poverty and social inequity in undeveloped and middle-income countries. Birn writes that road traffic accidents are the second-leading cause of death for children between 5 and 14 years of age globally, and that poor and working classes are disproportionately affected in most countries. In high- income countries, most of those killed are drivers and passengers, whereas in low- and middle-income countries pedestrians, cyclists, and public transport passengers make up nine out of every 10 road-related deaths.

In Haiti, for instance, the word for local transport is molue (“moving morgue”) and in southern Nigeria locals say danfo (“flying coffins”).

Duncan Green, an Oxfam policy adviser and development blogger, recently wrote an article asking when road traffic injuries would finally be recognized as a priority by the international development community.

In fact a major report released in June 2013 by the Overseas Development Institute, the United Kingdom’s leading development think tank, notes that transportation is not recognized as a human right like access to water, yet it still is a fundamental factor for many to achieve basic human rights. Well-run transportation systems, for people and for goods and services, promote benefits, while unsafe and weak transportation systems harm the most vulnerable citizens.

Given the debate emerging now for future sustainable development post-2015, the deadline set for the Millennium Development Goals, road safety may finally find a way into the broader public health, development, and environment agenda, as a way to tackle this clearly documented major global killer. Perhaps the threat may finally be treated as the international epidemic that is is, globally or closer to home in the United Sates. For me, this includes the roads in the Puget Sound where I spend more than two hours daily to and from my public health job.

Project Homeless Connect provides ‘disaster relief’ close to home

On May 17, 2013, I participated with other employees in my public health department working at Project Homeless Connect.  This is, at present, a quarterly endeavor to provide a range of medical and social services to the estimated 2,000 homeless individuals of Pierce County, Washington.

However, the people who line up as early as 7 a.m. for a range of needed services are not entirely the homeless. Many have jobs, but lack health and dental insurance. They basically are coming for primary or even emergency care that they cannot access elsewhere.

The Washington State Department of Social and Health Services is one of many organizations participating in Project Homeless Connect.

The Washington State Department of Social and Health Services was one of many organizations participating in Project Homeless Connect, held on May 17, 2013 at Calvary Community Church, in Sumner, Wash.

Project Homeless Connect, in its communications for its volunteer-run event, said it offered the following:

  • Medical and urgent care
  • Urgent dental care
  • Mental health services
  • Social service referrals
  • Vision/glasses
  • Haircuts
  • Child/adult immunizations
  • Veterinary care
  • Legal and financial advice
  • Housing, shelter, employment and education information
  • Tobacco cessation
  • Homeless assistance
  • Veterans services
  • Chemical dependence and assessment

This was no small effort. Months of planning went into pulling off this disaster-relief style engagement that is more associated with hurricanes and tornadoes than with meeting the basic needs of Pierce County, the second most populous (pop. 812,000) in Washington State.

Large, converted vans/trucks lined up providing veterinary services, dental care, and other interventions. Yet, oddly, there was no media present to put the story on the 5 p.m. news or in the daily newspaper the following day. (I checked but found nothing doing Google searches.) Why? Everyone who was homeless in Pierce and most social service and medical service providers likely was aware the event was taking place, for months in advance.

I did see not any elected officials (they may have come, and they may even have volunteered). All of this took place in a county whose hospitals are making profits of $1,000 per patient visit more than the state average and in a county where nonprofit hospitals are earning up to and more than $500 million in profits.

I saw all kinds of people—young, old, white, black, Asian, Latino, Pacific Islander, disabled, able-bodied, veterans, you name it. Volunteers came in all stripes as well. There were military personnel, dental assistant students from Pierce County community colleges (Bates and Pierce ), trained medical providers, church volunteers, hair stylists, and more. The list goes on. What struck me the most was how polite and appreciative the attendees were. Many drove or were driven from remote parts of the county to this somewhat semi-rural area in Pierce, southeast of Tacoma.

One of the providers, Medical Teams International, had one of its full-service converted mobile home vans providing dental care.

Medican Teams International brought one its converted mobile home vans to Project Homeless Connect on May 17, 2013, in Sumner, Wash.

Medical Teams International brought one its converted mobile home vans to Project Homeless Connect on May 17, 2013, in Sumner, Wash.

That program boasts a fleet of 11 mobile dental clinics in Oregon, Washington, and Minnesota that use 38-foot converted motor homes. Each clinic contains has two full medical stations and all necessary equipment, instruments, and supplies. The organization claims it has helped more than 200,000 adults and children with its mobile medical program since 1989.

Medical Teams International defines itself as a christian global health organization “demonstrating the love of Christ to people affected by disaster, conflict, and poverty.” The group works globally, including in Africa, South America, Asia, and North America.

Yet, it was in Pierce, addressing what clearly that organization perceived as akin to disaster and conflict.

In Washington State, 14 percent of all residents are without health insurance, according to the Kaiser Family Foundation. In Pierce County, the percentage is roughly the same.

All of this I find remarkable. Less than five miles from this revolving quarterly circus of human need there was a major shopping center, South Hill Mall, with about every major electronic gadget and consumer good on the market. Truck and car lots were also close by, with products selling from $25,000 and up. The disconnect to me was palpable, particularly the same week the Republican-led U.S. House of Representatives passed its 37th legislative measure to repeal or defund the market-driven health care reform known to its detractors as “Obamacare.”

I recall what one of my University of Washington School of Public Health colleagues—the one I respected more than nearly all others—told me when we talked about our peers who had worked or would work in public health in Africa or in developing nations. My friend asked somewhat ironically, why don’t they work at home. We have plenty of problems here. Given what I saw at Project Homeless Connect in Pierce County in mid-May 2013, I could not agree more.

Rally to ban assault weapons lays out strategy for Washington State activists

I attended a rally today (Jan. 13, 2013) in Seattle that included a march through downtown to the Seattle Center. The event called for an immediate ban on assault weapons and better laws to require background checks on all weapons sales. The march was organized by the non-profit called Washington Ceasefire, a state-based group founded in 1983 and dedicated to reducing violence from guns in the United States. (See my photo essay below.)

The event attracted somewhat lukewarm media coverage as of this evening, with stories picked up by most of Seattle’s major broadcast media, including the major TV news stations. The event was competing with the story that mattered most to Seattle–the playoff game that saw the Seattle Seahawks fall in a heart-breaker to the Atlanta Falcons. Still, approximately 400-500 participants attended the rally that marched about a half mile from Westlake Center to the Seattle Center.

The event began with a speech by mayoral candidate and current City Councilman Tim Burgess, a former Seattle police officer who called for attendees to focus their advocacy on immediate actions that could be taken by the Washington State Legislature. No specific state-level legislation or bills were identified, and Burgess’ rallying cry noticeably did not call for any specific federal action, perhaps because such proposals are still being formulated by the Obama White House.

Nor were any of the state’s congressional members referenced in public remarks or acknowledged in any event promotional material I am aware of. (Note I left the rally before it ended.) To my knowledge, no member of the state’s congressional delegation officially participated in the speaking activities, nor did their staff. I found that omission intentional and noteworthy. I am sure many attending noticed this also.

Washington Ceasefire President Ralph Fascitelli specifically called on an outright ban on assault weapons and sensible gun legislation. The web site created to promote the event quoted the group’s executive director, Beth Flynn: “We want to send a clear message to our legislators that we want to ban semi-automatic assault weapons.”

It was refreshing to me, as a public health professional, to hear Councilman Burgess make reference to the public health threat posed by firearms in his remarks. I spotted at least one retired University of Washington School of Public Health faculty member in attendance and holding a sign, which was very encouraging. I also met other public health professionals in the audience. Again, nice to see.

A list of the dignitaries who were invited to speak can be found here. I spied Seattle Mayor Mike McGinn, Councilman Nick Lacata, Councilmember Jean GoddenState Rep. Reuven Carlyle (D-Seattle), and other civic and religious leaders on the Mural Amphitheater stage at the Seattle Center, where remarks were made.

Also noteworthy was the presence of gun-rights activists. I saw two men wearing handguns in their holsters at the Westlake Center. So, I took their photographs. No doubt groups opposed to firearms legislation were monitoring the event and were mixing with the crowd. I observed very peaceful exchanges between those for greater legislation and those opposed to it. I included a photograph of the two men who were armed below to highlight how they communicated their views–at least through a visible display of their guns for the TV cameras and for those seeking legislation to control firearms violence.

Photographs of the StandUp Washington rally, January 13, 2013 (click on each thumbnail for a larger image)

A primer on the futility of buying health insurance in the open market

On Sept. 19, my University of Washington graduate student health insurance plan expires. I paid $607 a quarter last year, four quarters a year, for two years for this plan. It was OK. I never really “used” it for anything. I did have my knee looked at, and a finger was inspected once that got dislocated that I actually fixed, but no real “medical care” was ever provided except consultation. Only one visit really required a specialist’s expert analysis, but I actually deduced a similar conclusion from online research. Short of a medical test, even that expert opinion was just that, an opinion. So I am left wondering what this investment served. It did not cover in-house physical therapy, massage, or chiropractic care—all forms of medical care that I truly believe promote health and wellness without expensive, harmful pharmaceuticals and that use non-invasive techniques to promote healing through touch and manipulation of the body’s muscles and skeletal system.

Massage should be covered at higher levels by all insurance plans, as it provides excellent health outcomes with few negative effects and no medication.

I was supposed to cover those expenses “out of network” at 60%. As a former graduate student, I had to weigh medical care versus, well, paying for food and rent, and I simply put off the care I needed the most and used to get when I had a plan with my former employer in Alaska – chiropractic care and massage therapy. There were times I was in excruciating pain that simply had to be ignored because my insurance did not cover it, and those problems could have been addressed if I paid for much of it, after my deductible.

So now I am in the open market of insurance again. This is that wonderful place where the “invisible hand” of Adam Smith is supposed to provide solutions without “government interference.” Well that is not the case. The market is somewhat regulated by the Washington State Insurance Commissioner. They put together a good web site to help consumers understand the nine companies that offer health insurance plans in this state and the types of plans available to them. I think they did a good job.

Such communication for consumers is critical, as insurance companies prefer to communicate in “insurance speak” language involving legalese and jargon such as “co-pays,” “deductibles,”  and let’s not forget “pre-existing conditions.” Here’s just a taste of one clause from one plan on how they try to limit coverage for a “pre-existing condition”:  “Pre-existing conditions: these plans contain a nine-month pre-existing condition clause that excludes coverage for any condition for which there has been diagnosis, treatment (including prescribed drugs), or medical advice within the six-month period prior to the effective date of coverage, for which a prudent person would have sought advice or treatment. Section 6 of the application for our individual and family plans will help us determine whether you have creditable coverage, which would allow [COMPANY NAME REMOVED BY AUTHOR] to waive pre-existing conditions/exclusions for you and/or your dependent(s).

No, choosing insurance is never easy because the language is often confusing and many non-experts cannot decipher the fine print of the  brochures with happy, smiling people used to lure in customers.

Such language is not simple or easy to understand, and in theory, the Patient Protection and Affordability Care Act (health insurance reform passed by Congress recently) will make it impossible for insurance companies to deny persons health insurance in the future because of a pre-existing condition. It is not clear if non-English speakers can understand this information at all. While many people have fought with insurance companies, many lower-income or less-educated persons may not have significant experience navigating complex legal documents that, quite frankly, I think people with MBAs or law degrees do not fully understand. Here are two companies’ plans that offer health insurance to individuals in the state of Washington (there are exactly nine corporate players in this limited market): LifeWise, Group Health.

I chose LifeWise. I am waiting for them to approve my plan. I will have to have proven I actually had coverage before (I did as my UW plan was owned by them) and am likely not a deadbeat. I am sure they are probing my legal, credit, even personal records as I write this to determine if I have been an actuarial risk to providers, if I have some terrible health condition that would harm their profit margins, and if I am generally on the up and up as a possible customer to help them make a “reasonable rate of return,” which is really all a company can hope to do. This all is, of course, unlike other developed democracies, because our country continues to refuse to adopt a single payer plan that other countries like Canada and France have taken up with better population health outcomes for their citizens and less gauging of consumers.

So what will I get if I am approved? I signed up for the basic catastrophic plan called “Wise Simplicity”. I would pay $160 month as a nonsmoker, and have a $10,000 deductible (compared to an $1,880 deductible that would cost me about $370 a month). So if I am hit by a car, I pick up the first $10,000 out of pocket? Great, eh?

So what do I get with the barebones plan? Well, basically a plan that tells me not to get sick and certainly don’t have an accident that costs $9,999.

I simply cannot afford another plan now. And this deeply worries me, until I get a job with coverage (and that is coming soon – yeah!). Two people I know in my immediate circle of friends just had enormous medical bills. One friend had elective knee replacement surgery. I cannot imagine that is less than $50,000 to $100,000 in costs (surgeon, anesthesiologist, several nurses, equipment, rehab, etc.). Another friend had a horrible and likely allergic reaction to a standard immunization and developed a syndrome that sent them to the hospital, where the same issue ensued with specialists, etc. My friend guessed the bills before insurance will be at least $100,000. So as I bike down Seattle’s dangerous roads, avoiding cars that do not know I am there as the driver texts a message about whatever, I contemplate just how flimsy my health care coverage really will be come Sept. 20. I guess the answer is what some running for office suggest – just don’t get sick. You know what I really do not have a choice. Adam Smith’s invisible hand I guess is making that possible, but why do I feel more like the hand is choking off my air supply and giving me a sucker punch when I am not looking.

A trip to Indian country and the Omak Stampede

So what is “Indian country”?

Drummers gather to perform at the Indian encampment at Omak’s Stampede, in August 2012.

A now-deceased doctor friend of mine who dedicated his life to serving the Native community in the Indian Health Service used the expression a lot describing where he worked in New Mexico and Alaska. It is a legal term, codified in treaty rights, federal regulations, and court decisions. Indian country can be a physical place, associated with customs and cultures of the continent’s first peoples. It is also a state of mind. You literally know you are in Indian country when you go there. There are place names and of course the people. I grew up in St. Louis, Mo., which sits on the mighty Mississippi River (Ojibwe for “great river”), and I felt connected to Indian country there because of the great muddy and the phenomenal Cahokia Mounds just east of the city in Illinois. I knew I was living on historic Indian land even as a kid.

The largest Native mound in the United States is located at the historic Cahokia Mounds, just east of St. Louis.

I have lived the last 16 years of my life in what I definitely consider to be Indian Country, Alaska and Washington State. Alaska felt much more like Indian country to me. Anchorage, my home for six years, is very much a Native city in terms of population (about 16 percent). I rarely feel that connection in modern, congested, urban Seattle.  But I recently took a four-day trip to the hot, upper plateau of central Washington, from the Methow Valley to Omak, and indeed felt I had landed four-square in Indian country again.

According to a section of federal legislation pertaining to Native Americans, “Indian country” refers to three specific criteria:

-All land within the limits of any Indian reservation under the jurisdiction of the United States government, notwithstanding the issuance of any patent, and including rights-of-way running through the reservation;

-All dependent Indian communities within the borders of the United States whether within the original or subsequently acquired territory thereof, and whether within or without the limits of a State; and

-All Indian allotments, the Indian titles to which have not been extinguished, including rights-of-way running through the same.

Indian country also implies U.S. federal recognition of tribal bands as sovereign on their lands and capable of enjoying rights that are government to government. As one source notes, recognized tribes “possess absolute sovereignty [that] are completely independent of any other political power,” but also which is shared with other jurisdictions (local, state, and federal).

In Washington state, federal definitions of “Indian country” apply to state law, in addition to provisions acknowledging tribes non-taxable status in some commerce, such as the sale of tobacco products to tribal members on their reservation. In Seattle, there is still a band, the sparsely populated Duwamish, who have lost their sovereign status  and failed to win legal recognition in the city’s limits, on some of the choicest real-estate on the West Coast. Another nearby tribe, the Snoqualmie, regained their status in 1999 and promptly built a casino and became an economic and political player.

The decades-long fight over treaty-protected fishing and subsistence rights by the tribes culminated in the historic 1974 ruling in the landmark U.S. v. Washington case (the Boldt Decision) that unequivocally affirmed 19 federally-recognized tribes’ fishing rights to salmon and steelhead runs in western Washington. That decision gave the tribes rights to half of the salmon, steelhead, and shellfish harvests in the Puget Sound. It was a major game changer, and its impacts are still felt today–particularly legal squabbles if the decision should still be applied to land-use decisions impacting salmon habitat.

Yet, even as I gaze out on the beautiful Puget Sound, I am hard-pressed to think that I am on historic Indian lands, that I live in Indian country, where there are 29 federally-recognized tribes, in all corners of the state (see tribes and locations here).  But this is very much Indian country in a historic and cultural sense.

In fact, more than half of the state was outright taken by military force, illegal land seizures, and treaties (which also provided fishing and resource rights to tribal members) from the 1850s to the 1890s. Many stories of the exploitation of Native tribes come to mind, notably the hanging of Yakima warrrior Qualchan (also called Qualchew) by the reportedly violent Col. George Wright, in his campaign that defeated five tribes in Washington in the eastern half of what is now is the state. 

On Sept. 25, 1858, Qualchan had surrendered with a white flag and was hung within 15 minutes. That was followed with the hanging of six Palouse warriors the next day. Such incidents typified the period of conquest in my home state. Exploitation of tribal rights followed the signing of treaties. The Colville Tribes, for instance, had their lands stolen without their consent, setting off decades of legal battles that continued to the 1930s and ended in historic settlements returning hundreds of thousands of stolen acres of land.  Salmon and steelhead runs in the state were decimated by commercial fishing interests that harmed tribal groups in the upper and lower Columbia River basin. The runs were further extinguished by the dams built on the Columbia River. Only with the Boldt Decision in 1974 did the tide turn, but with numbers that no where near compared to the great runs of 100 years earlier.

Again, all of this is very academic and abstract to me and most Western Washington residents. Only when I traveled to the “World Famous Omak Stampede” rodeo and suicide race, with Native riders who charge down a 200 foot hill on horseback every second weekend of August, did I again realize I was truly in Indian country. Omak, in north central Washington, lies partially in the 1.4 million-acre Colville Reservation, in sparsely populated Okanogan and Ferry counties. The Confederated Tribes of the Colville Reservation number less than 10,000. I found the area to be amazingly beautiful. It’s hot in the summer, and bitterly cold in the winter. During my visit to Omak for the Stampede, the mercury hit 100 F.

Outside of agriculture (on non-tribal lands), there is little industry in this part of the state, but there is gold mining, forestry, and a limited personal use salmon fishery for tribal members.  Forestry is the mainstay for generating tribal revenues. Gaming is also a big moneymaker at the tribes’ three casinos. If you can believe it, the casinos are attracting acts like blues legend Buddy Guy and rock has-beens like Foreigner and Joe Walsh in the next few weeks. I think it’s a bit sad that even stalwart Canadians are driving south from British Columbia to spend their loonies at the tribal gaming tables, but come they do.

Despite the flow of revenues, health issues remain a problem, as they do throughout Indian country. A June 9, 2012, story republished in the New York Daily News about Tribal Councilman Andy Joseph, Jr., profiles his efforts to address Native health funding issues. The story notes his tribal members and others nationally “are dying of cancer, diabetes, suicide and alcoholism. They are dying of many diseases at higher rates than the rest of the population. And instead of those rates getting better, they’re getting worse.” Joseph is the tribes’ representative to the Northwest Portland Area Health Board, which serves 41 tribes in Washington, Oregon, and Idaho, and is that group’s delegate to the National Indian Health Board, which speaks for all 566 federally-recognized tribes in the country. The story notes that, nationally, tribal members die an average of five years earlier than the rest of the U.S. population and are six times more likely to die of tuberculosis or alcoholism, three times more likely to die of diabetes, and also twice as likely to be killed in an accident. What’s more, they are also twice as likely to die from homicide or suicide. Pretty grim data indeed.

According to Joseph, the major health issues associated with diet and nutrition have occurred as a result of conquest and cultural assimilation: “‘Joseph holds up a jar of canned salmon sitting on his desk. ‘Our people crave this,’ he said. ‘It was taken away from us when they put Grand Coulee Dam in.’ He reaches for a string of dried camas root. ‘It’s what our bodies were raised with for thousands of years. Now, we have Safeway and Albertsons and Walmart.'”

In Omak, I got a taste of Native pride during the Omak Stampede Parade, which mainly featured local businesses, rodeo princesses, groups like firefighters, Republican office holders or candidates, and less than half a dozen Indian floats. (I saw no Latino groups in the parade, despite their large presence picking fruit and in agriculture–they “officially” number about 15 percent of Omak’s residents.)

A Native float at the Omak Stampede parade.

Some of the many teepees at the Native encampment at the Stampede.

The Stampede features a tribal encampment with teepees and a performance area where tribal members perform traditional dances and song in gorgeous costumes.  It reminded me a lot of Alaska, particularly the many gatherings I saw there, including the largest conference called the Alaska Federation of Natives Annual Convention. Yup, I was definitely in Indian country.

My only real, true regret was that I missed the Suicide Race, which features some of the state’s finest Native horseman who charge down the steep hill and swim across the Okanogan River on their way to the finish inside the Omak Stampede stadium. You can watch it on YouTube, and note some times, yes, horses have died in this race.