NURS 6050: Policy and Advocacy for Improving Population Health

population has access to great recreation facilities, excellent housing. There’s been one lead poisoned kid in the entire county of 300,000 people in the last couple of years, total. The percent of folks who are uninsured in that county is about 7% to 8%, 9%. Compared to 30% of the adults in this neighborhood in Baltimore.

The school system is ranked the best in the state. Probably one of the top 10 in the country. And there are innumerable living wage jobs. And, not surprisingly, the healthiest county in the state of Maryland is Howard county. And the poorest, the least healthy county in the city/county in the state of Maryland is Baltimore.

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DR. PETER BEILENSON: So the paradigm that the Institute of Medicine put out- – probably now it’s 15, 18 years ago. But it’s looking at health problems and health policy with a three step process. And epidemiology is particularly important in the first and third steps.

First step is doing a needs assessment of whatever population you’re serving. You assess the needs of the population that you’re serving. And that’s where epidemiology comes in. Statistics, data, et cetera. Depending on what issue you want to deal with. And when we picked priority areas when I was in Baltimore City, the Baltimore City Health Commissioner. We looked at areas that had large numbers of years of productive lives lost. Basically means if the average life expectancy is, let’s say 75 in the community, and something tends to kill people in their 30s, like AIDS did several years ago, that’s 40 something years of productive life lost. And so that’s an important thing to focus on.

Similarly, infant mortality. That’s 75 years of productive life lost. So the paradigm needs assessment can be done in looking at years of productive life lost. It can also be in a specific policy area like immunization. The needs assessment might be what part of your population is particularly un-immunized. And then go after that.

And then the second phase of this paradigm is policy development. So you assess the needs of your population. And to deal with them, you come up with policy. It could be legislation to address the issue that you’ve found. It can be a program that you start up. It can be advocating for change in a certain area to get that need addressed.

And the third component is assurance. Which is basically evaluation. We almost always in my work– whatever initiative that we launch– we always build in an evaluation tool at the end. So you can see if what you did, the policy you developed, met the need that you assessed.

© 2012 Laureate Education, Inc. 2

There are three classic examples that I’ve worked on in the last 15 years or so that highlight the use of this paradigm that The Institute of Medicine uses in terms of looking at ways to look at public health problems. Of needs assessment, policy development, and assurance.

And the first is the immunization issue. In the mid to late 1990s– 1996 ’97 to be exact– we had worked with the Agency for International Development. At that time Vice President Al Gore wanted to choose an American city to show that the lessons that were learned outside our borders by the AID could be brought to bear on third world parts of the United States. And we were chosen first, here in Baltimore.

So the vice president came, along with the mayor and myself. And we went around a lot of vulnerable areas. And he was talking about some of the success stories that AID had had internationally.

And one of them was that the immunization rate in several impoverished developing countries, including Kenya, were significantly better than the immunization rates we had in our schools here in Baltimore. Even though there is a law that requires kids to be fully immunized before they go to school. It just wasn’t being enforced. Only 62% of kids in the school system were fully immunized or have records there of.

So the policy that we developed was multi-pronged. One of which was to do a lot of public relations communication to parents saying, hey we’re going to be dealing with this. We’re going to start holding you responsible. We had huge clinics in the school system buildings prior to school starting in the ’96- 97 school year. Where we had thousands and thousands of kids coming in to get immunized. And by the way, at the same time, not just school aged kids but their little siblings. So we hoped it would make a difference for kids coming up.

So we instituted these two policies. Again, this is something we could do ourselves. It was both communications based as well as offering services. And we went from 62% of kids at the beginning of that school year to 99.8% immunized within three months. And because we enforced this– so we went from something like 40,000 of the 100,000 kids unimmunized at the beginning to about 200. And as far as we could tell, from a lot of heavy work, most of those 200 actually moved out– they just were incorrect information that school system had about them. They actually weren’t even in the school system anymore.

So we basically went from one of the worst immunized cities in the country to one of the very best. And it stayed that way for the last 12, 14 years because the enforcement tools have been kept in place.

So needs assessment– in this case pret ty simple. You just look at the data from the school system that show we were very under-immunized. Policy

© 2012 Laureate Education, Inc. 3 development, communications, legal ramifications. And offering clinics to immunize kids.

And assurance, following up to make sure that the law was enforced. That the rules were enforced at the schools system level. And keeping track of the kids going forward that were immunized. So a good public health success story. And a little bit unusual in that most public health problems, from AIDS to chronic disease, take decades to develop. And usually take a while to fix. In this case it took a decade to develop, but it took three months to fix.

Early 1998 the CDC– the Center for Disease Control and Prevention– comes out with their national rankings on syphilis. And Baltimore not only ranks first in the country, but we have one of every 20 cases in the entire United States in Baltimore City. You’ve got to assess what’s the epidemiology behind this outbreak. And it was very interesting. We actually, by the way, had hit the trifecta of being number one the country not only in syphilis but gonorrhea and chlamydia, too. Obviously, you would think somewhat related, but in reality not.

And that was because gonorrhea and chlamydia we’re tending to hit 13 to 25- year-olds if you looked at the data. Serially monogamous, which many nurses know, especially if you’ve taken care of teens. Serially monogamous means basically– you’re talking to the teenager, how many partners you have? One. How many partners in the last seven weeks? Five. Well you’ve been serially monogamous. But they tend to know their partner. And so it’s easy enough to do contact tracing. And to get the partners notified and medicated so that you can deal with the gonorrhea chlamydia outbreak. And so that was being done a lot through the school system and through our family planning clinics for teens.

Syphilis, when you looked at the data, was very, very different. It was 25 or older. More like 30 to 50-year-olds. Who were involved in drugs for sex, particularly crack. And were in crack houses and barely knew the person’s first name, if that. And so it was much harder to track and much harder to deal with. And looking at the epidemiology of it actually looked like it was sort of dispersed around the city. Which was surprising. But if you followed Baltimore’s history you knew that the year before a lot of the high rises that were disastrous, that concentrating a lot of impoverished drug-using population were torn down. And so they sort of shredded the populous and placed them all over the place. And so that was actually, we think, part of the reason for the spread. Because it wasn’t concentrated in one, or two, or three, or four places. But was all over the place. And so your chances of coming in contact with someone with syphilis was greater.

And once enough of the population, particularly the drug using population, of that age were infected then you’ve reached a tipping point whereby which you’re more likely to come in contact with someone who’s infected and therefore get infected yourself.

© 2012 Laureate Education, Inc. 4 So the policy we develop was a multi-pronged again. Partly was communication. So we wanted patients, or individual citizens, as well as providers, doctors and nurses, to know the signs and symptoms of syphilis. Because it was actually relatively rare before. And so we were seeing a lot of patients coming in from emergency rooms who had been treated for fungus. When actually they didn’t have a fungal infection, they clearly had syphilis. But the doctor or nurse practitioner had not seen a syphilis patient ever. And so they were misdiagnosing.