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EP35 Urban Health and Governance with Dr. Jo Ivey Boufford
Alexandra Arriaga: Hello and welcome to I AM GPH, this is Alexandra Arriaga and today we're very excited because we have Dr. Jo Ivey Boufford with us who is an expert in urban health, healthy aging, disease prevention, health promotion, as well as health disparities. Since college, Dr. Boufford has integrated activism and social justice in her education and practice by advocating for patient driven care and more engagement with the community and the underserved. In 1985, she became the first woman to be elected president of the New York City Health and Hospitals Corporation, the largest municipal system in the United States. She then entered federal government serving as Principal Deputy Assistant Secretary for Health in the US Department of Health and Human Services. While she was there, she was a US representative on the executive board of the World Health Organization. To some of us though, she is our Foundations of Global Health professor, and today she's going to talk to us about urban health. Stay tuned. Hi Dr. Boufford.
Dr. Boufford: Good morning. How are you doing?
Alexandra Arriaga: Good morning. We're very happy to have you here. Could you please tell us about your background and what made you want to come back to academia?
Dr. Boufford: Well, I'm a pediatrician by training and my early experience was in the South Bronx, back in the 70s and 80s and so it was very clear to me that medical care was just one component of what it took to create healthy communities and make people healthy. And I, sort of, kept that theme through my career. I've been attracted into management early, and policy, and have worked at federal government and city government, and with state government, and most recently worked with the president of the New York Academy of Medicine, which is an NGO, really, trying to advocate for improved population health. At this stage of my life and career, it seemed like a good time to really re-enter academia and re-engage with students and find out what really matters from their perspective and, kind of, hone skills, get, take some time to read, take some time to, sort of, revisit topics and how they've developed over time. I'm really enjoying it. It's also nice, you know, to be in the teaching ranks and not necessarily, you know, having to manage like I was the Dean of the Wagner school for five years and so it's, you know, this is very good to, really, just work directly with students.
Alexandra Arriaga: No, yeah, we're very glad to have you as faculty. So what would you say are the mega trends that are currently influencing urban health?
Dr. Boufford: Well, in answering that question, I think they're influencing urban health, but to me, they're also the major challenges for public health in this century and perhaps beyond. I mean, first is the sort of epidemiologic transition from, really, a primary focus on acute infectious diseases and maternal-child health to chronic disease. Hopefully, preventable cardiovascular disease, tobacco or exercise, diet, cardiovascular disease with cancers, diabetes and others, and we're not really prepared for that. Our history in international development has been really focused on the infectious diseases. So there's unfinished business, but this new, almost epidemic, is global. It's not just a problem of the North or high income countries. It's a problem worldwide. Secondly, is the demographic transition, which is, sort of, the good news of people aging, having longer life expectancy and having a lot longer life expectancy. It's really a victory of public health that we have been able to accomplish that along with colleagues. And so we need to deal with the issue of aging and aging populations. Climate change is another, third one, that I think is really important. It's important in general, but it's also important for cities because most major cities are on bodies of water still rising in sea level and concentration of heat are issues that have been written about and we know about. And then urbanization, I think, joins those four public health challenges. And the issue really is getting people used to the fact that the majority of people in the world live in cities, that that number is only going to increase over the next 20 to 30 years. And that we really haven't thought a lot about how to manage the urbanization process and how to have health, sort of, at the basis of the actions of elected officials and of public health professionals working in the urban environment.
Alexandra Arriaga: And on that trend, for those who may not know, what is health governance and what is the role of healthy urban governance?
Dr. Boufford: Well, the idea of governance is that, you have stakeholders in a problem. Anyone who has to be involved in solving that problem or who's affected by that problem should be involved in a process of discussion and, hopefully, aligning their interest towards a shared goal. So, governance means that group coming together and working towards some kind of consensus for action. Government is usually, who should hopefully be a player and maybe a catalyst or facilitator of that process, but government has, sort of, special responsibilities and accountabilities to the public for its actions in the way that private sector organizations may not. One of the exciting things about urban governance is that when you are an elected official or a city manager or an agency head running a department in cities, you know what's happening in communities, you can talk to communities directly. They will, you will hear from communities directly in a way that you won't if you're at state and federal level. So it's a very exciting level of governance and an exciting opportunity for health.
Alexandra Arriaga: And what would you say is unique about cities when it comes to health?
Dr. Boufford: I think the conceptual framework that many people have been using for a while, to think about cities, is their density, they're dense, in terms of population density. They're much more diverse, in many ways, than rural areas. More complex, if you think about the transportation systems and the infrastructure that makes cities work or not work. And then people, working on issues in urban environments are very aware of the issue of health disparities. If you look at averaged city data, you could miss disparities in vulnerable populations within the city. So, this idea of how do you tailor services, how do you get information to people? How do you create healthful environments when you're dealing with this density and diversity and complexity and disparities is, kind of, the guiding force of thinking about promoting urban health.
Alexandra Arriaga: And how important is collaboration across sectors to address health and health equity?
Dr. Boufford: I think it's fundamental. I don't think any agency or any entity can solve problems these days. They're just too complicated. So we, I think kid ourselves thinking that, by thinking in silos or sticking to a particular discipline, we can really come to solutions that are going to be sustainable. Part of urban governance is engaging agencies beyond the usual health agencies, like transportation and housing and environment, in discussions about how decisions made in their agencies can be positive or negative for health, and then learning how to collaborate on, again, this governance focus, how to bring people together to develop consensus on how to take action. But there are different vocabularies, people have different vested interests. They have different experiences and, obviously, when it comes to resources you really have to begin to trust other individuals and organizations that you may not have worked with in the past and try to really learn about them and develop enough of a relationship to come to compromises that can move the agenda ahead.
Alexandra Arriaga: Can you think of a country that, maybe, is doing really well in terms of all sectors collaborating in order to address health equity?
Dr. Boufford: Well, there are countries, and parts of countries, that historically have produced very high levels of health with very low expenditure and investment. Costa Rica is the, sort of, classic example. Kerala, one of the states in India as well. Cuba, actually, given limited resources, has had enormous success in dealing with promoting good health indices, health care access and education. So I think, again, it's, sort of, the, we often think that investing large amounts of money in personal health care services, which is sort of the US model, specialty care and personal health care is going to solve the health problems. And we now know and have learned more over the last 20 years or so, there's an evidence base that says, really, it's these other determinants of health that create communities where people have healthy choices. It's all well and good to say you need to lose weight or you need to get more exercise, but if you don't have safe places to exercise and the kids can't go out in parks and the moms feel comfortable that their kid's going to be okay or you don't have access to fresh fruits and vegetables that are affordable, the person can't really be expected to take those kinds of actions that you're encouraging.
So we've got to do both at the same time.
Alexandra Arriaga: And is the US doing enough in order to address these factors?
Dr. Boufford: It's a difficult question. I mean, I think, again, a lot of the way these issues are being addressed are local. At a national level, most federal policy is focused on the personal healthcare delivery system. There isn't, really, a lot of leverage on public health. Public health has always been a state function. So I think looking at individual states and what they're trying to do, California has always been ahead on looking at the health impacts of activities across agencies and government, looking at environment more seriously, dealing with issues of air pollution ahead of everybody else. New York is doing very well. I mean we have something now, called the prevention agenda, which has been going on for about a decade and it really involves coalitions at county level across the state of New York. Multiple stakeholders, again, multiple groups working together with government to identify local health priorities and then develop action steps to tackle them. And New York state has moved up in the rankings nationally, since this program began, so our goal is to get it to number one.
Alexandra Arriaga: Hopefully we'll get it. And can you tell us a little bit more about the importance of social determinants of health?
Dr. Boufford: Yeah, you know, this is something that's developed more recently, in, I would say, the last 10 or 20 years and research done primarily in Europe, but also in the United States and the more, most visible articulation, probably, was, Sir Michael Marmot's commission on social determinants of health. It was done for WHO about five to six years ago. It coalesced a lot of research and a lot of evidence and made recommendations of how communities and governments could act to improve health. And it really wasn't so much about investing in health care. It was really looking at the conditions in communities that create these opportunities for health, as I talked about. So I think, in the current conversation, there are two definitions of social determinants being used. The clinical community and the healthcare financing community are talking about the social determinants for the individual with a particular illness. So if the person is diabetic, you want to make sure they have access when they're discharged from the hospital or when they're in their communities to fresh fruits and vegetables and social supports and you know, exercise opportunities and they're all planned around that person and they may not be planned to change that community for everybody. And then the other conversation about social determinants is more the conversation with public health professionals, which is to say, let's look at these social determinants at the community level. So it's great to create a, if you will, a prescription for health and social care for an individual, but wouldn't it be even better if those conditions already existed in the community where that person could easily find the healthy solutions that, if they say, the sort of healthy solution was a default choice, not that you had to go out and look for it.
Alexandra Arriaga: Absolutely. And taking it back to public health schools, what approaches do you think schools of public health could take in order to engage more in global health?
Dr. Boufford: I think there's a movement in schools of public health to get students to have field experiences, more field experiences, more, if you will, action learning. So losing, using case studies going into the field, hearing from practitioners, hearing from community members about what they're doing, and I think that's really important. I think, what we have to be very careful that students also have a context to understand how the project they're working on fits in the big picture of that country or health policy or global health, and that's harder because you can go in and do a good piece of work with an NGO that needs your help on a project that they would not otherwise be able to do, but you also need to be aware of the sustainability of that project. What's, how strong is the health system, if it's in the health system. How strong is government support for civil society if it's a non-profit organization and how, while you are doing the project, can you think about building the capacity that gets left behind so that individuals in that country can really take it over and be self sufficient and direct the work, and I think that's a challenge we're all still struggling with, but it's really two pieces of work when you're in global health. One is the project you're working on. The other is, what's the capacity that you're leaving behind with your partners, especially in low and middle income countries.
Alexandra Arriaga: That is great advice. And here at the College of Public Health, we say that we are reinventing the public health paradigm. What does that mean to you?
Dr. Boufford: Well, I'm relatively new here, but I mean, I think the message is certainly one of engagement, one of advocacy and one of, you know, evidence-based problem solving. So, I think there's a big emphasis on skills and evidence, but also an expectation of moving it into action, and that action can include programs at the local level but also policies and changing policy that can be acting against health. So, I think that's a message and it's a really good message and I think the school has made a lot of progress, certainly before I've come and I'm looking forward to working with colleagues to keep moving it forward even more.
Alexandra Arriaga: That's great. And as a faculty member, what would you say are the most important messages that you would like your students to know?
Dr. Boufford: I think, the biggest message for students is, kind of, disconnect the content that you're being given in class and from what's on the exam. I mean, really trying to think about, and I know this is hard to do, but try to think about the learning opportunities in class and how it fits in a plan for your own career and that the goal is to have a grounding in facts, but to be able to use the facts to solve problems that you don't even know what they're going to be. They're going to come up and you're going to be called on to engage actively with others to solve those problems. So, I think the more you can read that your teachers give you, ideas, the more you can discuss the issues and where we as faculty can provide opportunities in class for students to discuss and problem solve together. I think the clarity of why this course is being taken, how it fits with the skills sets and the knowledge and the attitudes that you have to develop will become clearer. But it needs to be an... I know it's difficult for students, but I think ideally it would be an exploration of knowledge, a gaining of new knowledge and then thinking about how you can put it together to advance your own career.
Alexandra Arriaga: That's a very interesting perspective. I mean, I definitely relate. I think that sometimes we're so worried, Oh, it's going to be the grade, or how can I make the A, that we forget that we're really just learning skills because we will be professionals in a field that requires us to think.
Dr. Boufford: Yeah and then the field you'll be going into, two, five, ten years from now is going to be so different. So, sort of, learning ritual facts is not as important as knowing where to go back to get the updated facts on that topic. It's really going to be your reality I think going forward.
Alexandra Arriaga: Yeah, absolutely. And finally, a more personal question, where does the motivation to do this work come from for you?
Dr. Boufford: For me it's very simple. It's always been values. I mean, it's always been a values orientation towards addressing inequities and inequalities and, you know, I was exposed to it early on in my life. I grew up in the South and had different experiences from a lot of people in other parts of the country. Both positive and negative, and, sort of, my medical education experience led me into government, into policy and management because it seemed to me it had a greater impact. But that concern for social justice has always been, kind of, fundamental. Even though my route has been a little crooked from time to time, it always ends up in the same place. So it sustains one's motivation, I think, is sort of having that value space and kind of agenda to do what you can do while you're active to advance the ball as they say. No, you know, sort of, net forward motion on your watch, I think we tell ourselves in public sector because it's a little bit harder there to sustain changes.
Alexandra Arriaga: Absolutely. Well thank you so much for teaching us today and for, just, sharing with us. We hope to have you back again, maybe to talk about another topic and yeah, we've really enjoyed having you here.
Dr. Boufford: Thank you. Great questions and a great interviewer. So thank you very much. Thank you.