Episode 53: Universities & Public Health with Dr. Joshua Sharfstein

3:11PM Mar 6, 2024

Speakers:

Dr. Ian Anson

Dr. Joshua Sharfstein

Keywords:

public health

people

community

work

health department

umbc

academic institutions

talk

researchers

research

baltimore

community engagement

organizations

community health workers

health

vaccinated

community based participatory

vaccine

students

challenges

Hello and welcome to Retrieving the Social Sciences, a production of the Center for Social Science Scholarship. I'm your host, Ian Anson, Associate Professor of Political Science here at UMBC. On today's show, as always, we'll be hearing from UMBC faculty, students, visiting speakers, and community partners about the social science research they've been performing in recent times. Qualitative, quantitative, applied, empirical, normative. On Retrieving the Social Sciences, we bring the best of you UMBC's social science community to you.

If you really think about it, universities are kind of weird. They are academic institutions where members of the public from all over the world come together to inhabit a variety of new roles. Among them, professor, researcher, students, instructor, administrators, staff, and a whole variety of other professional descriptors. They create new hierarchies, while also working to defeat inequalities. They consume state resources and levy tuition fees. And with those resources, they produce academic research, diplomas, and hopefully members of the public who leave their campus to become more thoughtful, engaged, and productive citizens. But this very blunt depiction of a university is kind of a wishy washy theoretical one, isn't it? Because universities are real, by which I mean that the vast majority of universities have physical campuses that exist within a specific community in a specific location. UMBC, for example, is located just southwest of the Baltimore City political boundary. More specifically, and more derisively, UMBC students can claim to be students at the lofty and prestigious UCLA. If only they can seal the latter actually stands for the University of Catonsville left of Arbutus. At least that's a joke that I once heard from a crotchety neighbor who probably doesn't know that according to the US News and World Report, UMBC is currently ranked number 15 in the United States for best undergraduate teaching, while UCLA is in the top 50. But I digress. The point is that UMBC is a neighbor to our neighbors, specifically to Catonsvillians, and Arbutians?, and of course, Baltimoreans. And as an institution we strive to connect with and empower those communities through our research, teaching and service. But how can academic institutions play a role in promoting public health in the communities in which they exist? That's a question taken up by Dr. Joshua M. Sharfstein, Vice Dean for Public Health Practice and Community Engagement at the Johns Hopkins University. Dr. Sharfstein is also the director of the Bloomberg American Health Initiative, and a Professor of the Practice in Health Policy and Management at Johns Hopkins. In our condensed rebroadcast of Dr. Sharfstein's recent remarks at the Social Sciences Forum at UMBC, we learn a variety of lessons about the practical challenges and opportunities in public and community engagement for institutions of higher learning that aspire to heal the world. Let's listen to in right now.

It is a real honor to be here, I have just a huge amount of excitement coming and respect for UMBC. So I'm going to talk about putting the public back in public health. And I will confess that I work at a school where there are a lot of experts. Like you bump into someone in the hall and they, you know, there were all there they're doing is a particular type of water quality or a particular pathogen. And I'm like, you know, an inch deep and a mile wide. I get involved in all kinds of different things. Partly because my career was in the public sector where you know, the health commissioner of Baltimore, you can't be a specialist in something, or you work at the FDA, or for the state, so that just gives me an ability to take a step back and think more broadly, but it's also a weakness, because by the third follow up question, you'll see how little I know about any topic that I mentioned. So what is public health? This is my favorite definition from the Institute of Medicine in 1988: "What society does collectively to assure the conditions for people to be healthy." And you'll notice that there are three words in here that I particularly like: society, collectively, and people. So it is not clinical medicine. You know, one on one treatment. It's not talking to one person, just isolated, which might be counseling, which can be very important, but that's not really public health. Public health is what society does collectively, to assure the conditions for people to be healthy. And if you've been following the news or awake during the pandemic, you'll notice that there there's a lot of angst right now about this idea that we can do things collectively to assure the conditions in which we can be healthy, right. And so much opposition to different public health measures. Public health officials under attack. People marching around on their, on their lawns with guns or even shooting into their houses or driving them off the road. All those things are at least alleged to have happened during COVID. Hundreds of people fired. And then you have this idea of crisis of trust in public health. Do people believe in the vaccine anymore? Do they believe when you know, public health official says something? I was on a meeting earlier today among the Advisory Committee to the Director of CDC and there's a whole discussion of what can be done for better communication to enhance trust. How can CDC do this better? It's just on everybody's mind. So I just want to frame what I'm going to talk about in a little bit of a broad way to say like, okay, why are we in this situation. And I'm not going to talk about all these different things, but just to kind of situate what I will talk about in this broader discussion of a crisis for public health, a crisis for our ability to do things collectively. And I put the challenges into two big buckets. One is outside public health, which I said it's outside the house, and the other is within public health, there are problems within public health that we have to deal with. And there's a lot of debate right now going on, about these different factors. And I'll just say, outside of public health, what outside of public health is making it really hard for public health to do its job. Political interference, you know, we have governors who are just absolutely nasty to public health officials these days. You have misinformation, which is incredibly rampant, not just on Facebook or Instagram, but you have entire, like circles of WhatsApp, that are like closed circles of communication, which just comes in as information being exchanged. A lot of misinformation all over the world, some of it coming in here. This is just a recent poll, most Americans encounter health misinformation and most aren't sure whether it's true or false. Political polarization. You know, we've we've seen, like vaccines get kind of lined up by which political party you're in. It's sort of very predictive now in some areas of whether you've gotten vaccinated, and that's not a good thing for the field. So there's a lot going on outside in the world, where public health is affected. Sometimes I think of that as that's the dog and we're the tail. You know, we're getting wagged by political interference, by misinformation, by polarization. But there's also, you know, all that can be true, and we can also say, what can we do better? The part that we're the dog, and we have more agency. And there are three different general ideas that have come up, one of which is that public health is suffering from crisis in liberalism, and there's a book to that effect that just came out. Another is that there's been insufficient connection to communities. And the third is that there's been inadequate public engagement. And let me just say that, I don't think I fully agree with the liberalism critique. We're going to have a podcast where I interview the author of the book. You can decide whether you think his, his argument is stronger than mine. I would say he's very focused on social media kind of exchanges and how people can be quite, I don't know, pointed in their social media exchanges, that would be an understatement. And really not be open to hearing what evidence might be on different topics. I don't think though, that that was really a fundamental problem with the vast majority of the field of public health. But that is my view. I want to talk about these last two, which I really do think really fall under putting the public back in public health. One, insufficient connection to communities for the field of public health and the other inadequate public engagement. And my contention to you is that these are really important for public health. I don't know whether it'll be enough. I don't know whether those things that are, you know, where we're getting wagged, where it's the interference, or misinformation, or polarization, whether those are going to be so important, and our society is going to have all these problems that public health really can't do enough itself. So why is there a gap between public health and community? So let me start there, and then I'll talk about some of the solutions, I think. One of them is the legacy of past abuses. This was a headline I think of the Los Angeles Times "We want to study you for black Angelenos, Coronavirus triggers fear of another Tuskegee." So the history of medicine and of public health. This was actually a public health study,Tuskegee, run by the US Public Health Service, is a history of abuses and racism and that impact lingers. And it's one reason that that there's a gap and I'm not even saying that, you know, there are problems today, maybe not as blatant as Tuskegee, but I think that's the that is something that any public health official or public health researcher has to be aware of if you're thinking about how we work with communities. Another reason is inadequate resources for health departments. So between 2009 and 2020, health department's lost 40,000 workers. That means fewer positions for community health outreach, fewer resources for community partners, less time to sit down and really work with communities about issues that they care about. And that really puts a lot of stress. It's very hard if you have a barebones staff and you have to do certain things to be able to do the job of public health well. In the United States, there's a massive amount of variation in the public health system. In Maryland, every county has a health department. Is that true in the rest of the country, that every county has a health department? No. Sometimes there are town health departments. Sometimes there's only a state health department and no county health department. There's total variation. And some of these are reasonably well funded. Some of them are incredibly poorly funded. In some states, you have lots of tiny little health departments that really can't do that much. Sometimes the health departments have boards, sometimes they're appointed officials, it's just a total mismash. And you really saw that during COVID, that some areas were really able to to respond quickly and others have just enormous struggles in doing it. And so we have this very irregular map of public health. And one of the consequences of that is that there certainly are health departments that I think do a better job of community engagement, but there are many that do not. Another major challenge is that the core human resource structures in public health departments, and I'll say not just there, in academic institutions too, don't make it easy to hire community members. So if you were to say like, you know, why is there such a divide? Why can't we work together? Why can't we hire people from communities to do studies or to collaborate on different initiatives? One of the big reasons is there just, there's just not the HR infrastructure. They're not job descriptions, they're not promotion pathways, Also in the United States that people do a lot of community health work, but but in the informal sector. They don't actually have jobs. And so that that also creates a gap. And then you have research. Research project can be done and I'll talk about better ways and worse ways to do research projects. But even today, research projects can be real irritants in and again I'm understating the case here, in relationships between institutions and their communities. You can have a failure to collaborate in a proposal. No clarity in expectations. People can feel exploited, if, you know, the researcher comes in with a big grant and there's a lot of work for the community to do and then the researcher goes off and publishes the paper and gets the aclaim. And then the intervention can end abruptly when the grant does without, you know, the community really being better off. So these are all reasons why this has been a gap and a gap that I think really became clear in many places during the pandemic. Some of you may remember Dr. Leana Wen, now of CNN and the Washington Post. She was a Baltimore City Health Commissioner, in the wake of the unrest following Freddie Gray's murder in Baltimore, she was the health commissioner. And there were parts of the city that got shut down because of all the violence and she sent Health Department workers out. And she reported that when they knocked on people's doors, people asked, Are you here for a candidate? When they said no? And then they asked, Are you here for a study? You know, and you'd say, like what an indictment of public health and academic infrastructure. That's how people think that like, it's just people come and they need something, either free to vote for something or free to sign up to be a subject and something and that's when they show up. So I'm going to talk a little bit about what to do. And in all of these examples, I think I will say that there was a lot to do, and there's a lot that's being done. But I just wanted to start here by saying that the challenges that we have in public health, that lack of trust that got exacerbated during the pandemic, in my opinion, they relate to this underlying and long standing challenge between public health enterprise and communities that were that are supposed to be the the people who are getting better conditions of health. And among the different solutions to that are diversifying health professions in the Public health workforce. And this is a report from the black coalition against COVID. Where they talked about many different initiatives when the Biden administration came in particularly they funded efforts to support community organizations, not just public health departments, with community organizations to go and talk about the vaccine, and actually had a huge impact on closing the gaps in vaccination. Just a little bit of history here initially, when the COVID vaccine became available, there were like immediately, for example, racial gaps in access to vaccination in Maryland, there were huge racial gaps in access to vaccination. And people at one point, the then governor said something to the effect of, you know, we can make them go get vaccinated, I don't want to paraphrase. And so it's sort of like, you know, this has to do with the uptake, it has not to do with access. And that was not true, that it was very much to do with access, they actually, were supposed to be giving out vaccines in proportion to the population basically. And they were giving out a lot fewer vaccines to counties with predominantly black populations for use in their populations. And so eventually, I think they, they changed some policies, but there were huge gaps in vaccination right out of the gate. And people wonder whether they would ever close. And the Biden ministration came in just as the vaccination campaign was starting, and really invested in that, and it absolutely paid off in Baltimore. The Health Commissioner, Dr. Draza, I think did a phenomenal job. She was all over the media. She also hired 300 People from Baltimore neighborhoods, to go door to door to talk about vaccination as part of a community health score, I got to go out with them. It was really great. You know, I remember I learned from one of the community health workers, how to approach vaccination to somebody who is, you know, kind of resistant. And, you know, you might think your first reaction might be, Oh, you got to really explain, you know, let's talk about what the studies showed, let's show them the data or that this particular idea that you have is not based, in fact, but people would come and go, I'm not getting vaccinated. I heard this, I heard that that could be tracking me whatever they said, right? And this, this community health worker would look very kindly in them and say, if you were to get vaccinated, who would you get vaccinated for? And a lot of people said, Well, my mom and say, Oh, that changed the conversation immediately why your mom's like, well, she's not doing so well, I don't want to get sick. And before you know it, they're getting vaccinated, even without getting into like a rebuttal kind of situation. Second, is to actually partner with community organizations, to support community organizations, or bring them much closer to the field of public health. So rather than the health department trying to do everything by hiring people themselves, having like a set of organizations that they can work really closely with.

I mentioned before, one of the big challenges is the ability to have an HR system that supports this kind of integration between public health and community. And there's a lot of work going on to develop tracks. Interestingly, in surveys, community health workers that some of them maybe want to become nurses, or doctors or other things, but a lot of them want to be promoted as community health workers, because they love the job of working in their community, helping it become healthier. And so there's a lot of interest in developing career tracks that people get promoted within that kind of work and ultimately get to management and policy level. But those have not been widely implemented yet. And then finally, and this is what I want to talk more about, there really needs to be a strong commitment to community engagement by academic institutions. And so let's take a quick step back and say, Okay, what do we really mean by community engagement? So we're an academic institution. How do we do that? This is one definition that comes from the CDC. It's the process of working collaboratively with and through groups of people affiliated by geographic proximity, special interests, or similar situations to address issues affecting the well being of those people that were those it's really important in that sentence, right? It's actually working collaboratively with people about their health. And the community can be a geographic community. It can be a community, by religion, by race or ethnicity, by employment, you know, but you're working with that community that is community engagement, says it often involves partnerships and coalition's that mobilizes resources and influence systems change relationships among partners and serve as catalysts for changing policies, programs and practices. So it is not just telling people what they can do To to make, you know, health, it's just never wrong to tell people not to smoke to eat better and exercise like never, I won't, I won't, I won't ever say that. That's bad advice for anyone. But that is not community engagement, right? Engagement is really figuring out what the issue is for help are in the community, by listening to people working with them coming up with an agenda, some of that can absolutely involve research as you try to figure out with them what the key questions are, and then having an agenda for change. That brings us to what academic institutions can do, I'm gonna organize what I say here around what I think academic institutions do, you know, education, research, and practice. To me, those are like three really big things for academic institutions to do. Education, you know, is central to the idea of what an academic academic institution, so let's be doing research, many research institutions are trying to improve the world through research, and practices actually getting out into the world and trying to make it a better place. So under education, a critically important opportunity for academic institutions is critical service learning, which is a kind of learning where people actually are learning from community organizations and working with the new organizations as they're learning about public health. Also, on here, you'll see instruction on structural racism and discrimination. You know, it's, I think it's really important for students to have an appreciation for the communities that around the schools and their strengths, and how those communities have in many ways suffered over time and the School of Public Health, I'll just say that in years past, people have said before my time that the instruction people got on the community was like, which areas not to go in, because it was unsafe, right. And we now have our service learning organization called Source, organise a whole welcome for the students, we have community members who do tours. And some of the community members who were previously protested the school for how it's taught the students about the community are actually giving the tours. And it's just a small stuff. But the hope is that people really see the community much more as a partner. I will proceed here and talk a little bit about research. So there are all kinds of different research studies. And one of the concepts for community engaged researchers, community based participatory research, so this is a really interesting concept. And there are people you will meet, who will say I am a community based participatory research are nobody ever says that, like kind of in a halting way, they say that with a lot of pride, because they really care that their research is being done the right way with the communities that they're working with. And amongst some of the things that they do, there's a whole methodology for doing that kind of research. Recognizing that you're not just finding people in the community, I'm gonna, I'm just gonna tell you, we once had a faculty member who wanted to do a project. And

in Baltimore, and at a student, Google community organizations in Baltimore, in order to find a partner, which is not maybe the highly recommended way of going about it, and a community based participatory researcher would already have connections probably would be able to work through relationships to understand who partners are. But basically, these researchers are developing the project with community members, they're identifying a question that people really care about. And then they are sharing the resources that come with the project. And they are committing to share the results, and to be part of the dissemination with the community. So it may be a question that is of a lot of interest to people. And it involves a lot of work and can be quite hard sometimes. And that can take a long time. So this is sort of like a model type of research that people do and there are people whose entire careers are in community based participatory research. And in at the school public health, we have a committee that oversees the work that happens in Baltimore, because the Baltimore community engagement committee, it has representation from each of our schools departments, as well as some community members on the committee. But we have a set of best practices that we expect projects that work in Baltimore to have including sharing vision and values. This is interesting, because recently, a couple of researchers wanted to help the community organization in West Baltimore, assess its program on research and evaluation. So there's a community organization that wants to know whether what it's doing is working. And they came to us and they said, you know, can you help us and I found some researchers who I thought would be good to work with them. And following this guidance, the researchers wrote out, here's how we're gonna do it. Here's your role. Here's, you know, they said, Does this look right to you? Let's just set the boundaries of our discussion before we get going. And the community organizations leader called me and said, That was a weird discussion. I've never had that kind of discussion before. And I said, Well, how did it feel to you? What do you think? And he said, Oh, it's great. You know, and that really helped us understand what we're doing in that project turned out to be a really big success. And we have a, we've started what I would call a continuous quality improvement effort here, which is that we've interviewed a number of our community partners, a number of the researchers, we've identified things that the school can do better, we recognize there's a lot that we can do better. And our goal is to continue to try to strengthen and develop good collaborations. And then the third area to talk about is practice through education, research and practice. So you are an academic institution, you want to get involved in helping your county or your city or your state do something, you know, how can you do that? Well, certainly, they may call and ask you to consult. One of the great opportunities that exists. It's called a collective impact project. It's it's also a kind of methodology, where you have a broad goal, you bring all kinds of people together with different sets of skills, and you respect everyone who shows up in it. We have helped economists but we also have community organizations that are knee deep in the actual challenges and have a lot of insight on what can be done about that challenge. And then you set a goal, and you then develop programs and policies to try to move that forward. So one of the collective impact projects that exists in Baltimore City is called be more for healthy babies, is the city's infant mortality reduction effort. Yeah, so that started when I was at the health department. And it started because we realized that we weren't making progress on infant mortality. Infant mortality is the number of deaths among babies in their first year of life number rate per 1000. And Baltimore had one of the higher ones for cities, and we had a five fold gap between black and white babies in the city, black babies were dying at five times the rate, awful. In one year, when I was the health commissioner, we did a press release about 27 preventable infant deaths in the city. And nobody covered it. I was just very, very upsetting and what is going wrong, we had a big focus on sleep related deaths. And those are babies who were die facedown in the crib or maybe smashed into the couch cushions or parents rolled over them and and we had a lot in Baltimore. And our strategy had been to really focus on the birthing hospitals. So that parents got the education, the one on one education, to make sure they put their kids to sleep the right way. But we tried everything, okay, we trained all the nurses are definitely sent on the team to train all the nurses in the newborn nursery, we gave every baby born in the city of Baltimore, a little onesie that said, if I'm sleeping, turn me over, sounds super cute, did not work as far as I can tell. The third thing I did was I used to be the chair of a meeting every month called the child fatality abuse cause and Mercy Hospital is the absolute worst meeting reviewed every preventable death child under 18 in Baltimore. And we had multiple agencies and we would look at the autopsy and you talk it over and we'd see what could be done. And every time I had a baby that was died through that of a sleep related death. I would write that day to the hospital where they were born. And I would say, you know, baby Josh died, obviously, you know, sleep related death. And I'm sure you, you know, taught their parents well. But if you could just use this as an example, have an all staff meeting, bring everyone together, say, this is why we're doing it and people would write me back. We don't take it personally. Thanks for letting us know. We remember baby Josh, you know, we're so sorry this happened. Well, we double our efforts. So everybody was trying and no real success. And at that point, we decided that we really needed to change our strategy. We need more of a public health strategy. And I wound up hiring someone who had done global public health And she was in the interview, you know, I asked, What do you think of our strategy so far, and she said, you know, no offense, but your entire model is you're going to convince people in the most exhausting 24 hours or 48 hours of their lives, do something, you know. And you're not thinking about how we really build a community coalition and engagement in order to change this. And she built the more bright healthy babies, which is a coalition of over 100 organizations in the city. And they started by focusing on safe sleep, but they did it very differently. They worked with parents who lost kids, and unsafe sleep in Baltimore, and they were telling their stories, they were a lot of community members, they got all kinds of interesting information out. And then they progressed to more structural issues, including the ability of women to get jobs to support their families, particularly. And as well as training for other family members, they have a whole dad's initiative, the University of Maryland School of Social Work, absolute heroes, they got a big grant in West Baltimore, and they developed a very collaborative program there that actually drove the infant mortality rate in that area below the city average. And that was a very comprehensive effort.

So collective impact projects are, where it's not like the academic institution showing up and saying, like, great news, we're here to solve this problem for you, you know, it's more like, Okay, we need someone who really can design a great video to help and here are the people who you know, are going to work on it. And we need leadership in the social work school to help bring in resources, but then to partner with different communities. And there, there are criteria for how you do a collective impact kind of project. And these are great things for universities to pick to participate in, and be really a partner, and it can be extremely effective for the organization, communities can feel great about it. And the public sector can feel great about it. I know I'm covering a lot here, but let me give you the last part part of this year. So we covered insufficient connection to communities a little bit, that there's a lot of work to be done a lot of work for health departments. And it's pretty exciting. What's happening today, at the CDC meeting, there's a whole new round of grants that's going out intended to help help departments collaborate with community organizations. So a lot of this work is happening. Let me just go to this last point, which is inadequate public engagement. And now you're kind of just getting you're getting my my view on this, which is, I think that it's very exciting and emergency to take over, you know, and to issue orders. And sometimes you have to do that in public health. It is, however, not a great thing to keep doing because then if people don't like it, they get very angry. And so it's really important for public health, if it's absolutely necessary to make it a decision like that really has to be done under time pressure and explained after that. But for the most part, people don't love hearing about your decision, and why you did it, after they're already dealing with the consequences. And so, I think that it's important whenever you have time, to try as a public health agency, to put out proposals, to listen to people to think through with people what those difficult trade offs are. I think the best practice is to make the case first, explain the challenges that you're facing. Sometimes ask the public for help when there is conflicting information. Be transparent, provide opportunities for engagement, and then respond to criticism. Don't just get the comments and then bulldoze your way through. But listen to the comments. respond to them, if necessary, alter your approach a little bit. It can go a long way people. And you know, I have an intuition about this because, you know, as a health official, people would call me and be very upset. And if they had heard about it ahead of time, and they knew where I was coming from and they knew I given them a chance. They were much more willing to accept something, even if they didn't fully agree with it.

Thanks so much for listening to today's episode. I hope you learned as much as I did about the ways that research, advocacy and public engagement can play in advancing health outcomes for the communities in which we live and work. Until next time, keep questioning.

Retrieving the Social Sciences is a production of the UMBC Center for Social Science Scholarship. Our director is Dr. Christine Mallinson, our associate director is Dr. Felipe Filomeno, and our undergraduate production assistant is Jean Kim. Our theme music was composed and recorded by D'Juan Moreland. Find out more about CS3 at socialscience@umbc.edu. And make sure to follow us on Twitter, Facebook, Instagram, and YouTube, where you can find full video recordings of recent CS3 sponsored events. Until next time, keep questioning.