Profile

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What do the potential outcomes of Yes on 3 look like for coalition members who are invested in the campaign? PHP sat down with (left to right in photo) Alexis Krohn (she/her pronouns), Trainer and Coach with Yes on 3 Coalition; Eurah Ko (she/her pronouns), Volunteer and Coach with Yes on 3 Coalition; and Linda Fingerson (she/her, they/them pronouns), Volunteer and Leader with Yes on 3 Coalition.

Alexis Krohn: Trainer and Coach
Pronouns: She/Hers
Why is Yes on 3 important to you?
The biggest thing is that we are assuring the inherent dignity and respect of all transgender people within the Commonwealth. It is not just about having access to public accommodations, but the message that sends to transgender people: that they are a valued part of our society. And that also goes not just for me, because I am transgender, but also for folks who are even more vulnerable than I am. Especially for children, like my former students, where having that affirmation of value from the state is a huge piece of assuring their dignity. And the Yes on 3 campaign has an opportunity not just to assure the dignity of everyone in the Commonwealth, but also to send a message to the rest of the country about how we value our citizens in Massachusetts.
What would a No on 3 outcome mean to you?
It would be distressing, mostly because of the message it sends. Ultimately this bill is about whether or not trans people are allowed, basically, in public life. A no vote would prevent my students, who are more vulnerable, from moving through the world as well and as easily, while also sending a message to them that they are not valued members of our community. And the toll that takes on the psyche, as I know myself from being a transgender teen who was in the closet... I don’t want any of my students to have to go through that themselves. A No would indicate that a large slew of Massachusetts do not consider transgender people an important segment of the community.
Eurah Ko: Volunteer and Coach
Pronouns: She/Hers
What does Yes on 3 mean to you?
It has been really heartening and electrifying to see this many passionate volunteers. And from talking with voters, I have found a lot of people that I don’t expect to be supportive. Like retired Navy veterans, laughing at the bathroom concern, who say: “Oh I definitely support this, why wouldn’t you?” I know there are people out there who don’t want this, but to know that there are people who actually exist outside of whatever queer-bubble I’m living in is amazing. To know that there’s this base level of support around the state really matters to me as someone who lives here.
What would a No on 3 outcome mean to you?
It would signal that even the so-called ‘liberal haven’ of Massachusetts truly isn’t safe for queer people, trans people, etc. It would mean that all the trans people I know would be walking about Massachusetts, paranoid and worried about where they’ll get rejected next. Whether it’s a job, or a bathroom, or a hospital. Discrimination still happens, even with this law in place. And without that base level protection of the law, it’s only going to get worse.
Linda Fingerson: Volunteer and Leader
Pronouns: She/Hers and They/Them
Why is Yes on 3 important to you?
Well, for a number of reasons; I’m a queer person, I’ve identified as bisexual my entire life, ever since the fifth grade. I have a parent who is gay and it’s influenced my life in certain ways. They are in the teaching profession, and I really feel like a lot of the choices they made throughout their life were to keep the profession safe. Being gay in the 70s and trying to teach was a difficult thing to do. My very strong feeling is that the messaging from the opposition that has come down from those times continues as a sort of bad apple that spoils the barrel. And since it’s affected my particular family’s fortunes, I feel like I want this messaging gone. I feel like I want it out, just out of the public discourse, and I want people to grow up around the whole bathroom thing.
What would a No on 3 outcome mean to you?
Of course, I would be upset. One of my personal goals was to create a safe space in my particular area of the suburbs for queer folks. But I don’t feel it’s all that safe now. The closest queer community effort that I’m aware of is in Framingham. For the non-binary and trans folks, it seems the impulse [has always been] to get out of Dodge; that suggestion has been made to me by people who care about me from time to time. And my answer to them is that I would rather create something here if I am able to. A loss [on 3] would set that back for me, personally, but it wouldn’t stop me.

These conversations were lightly edited for length and clarity.

Photos of Alexis Krohn and Linda Fingerson by Erin Polka. 
                    [post_title] => Three Voices on 3
                    [post_excerpt] => What do the potential outcomes of today's vote on MA Question 3 look like for Yes on 3 coalition members Alexis Krohn, Eurah Ko, and Linda Fingerson? 
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                    [post_content] => Public Health Post: What do you think is the greatest threat to Native American health, under the current federal administration? What do you foresee happening as a result of that potential threat?

Michael Bird: I think there is, in fact, a very conscious effort to disenfranchise the citizens of this country, and going back to a historical context, it is not the first time. It really is a replay of what has gone on since the beginning of this nation. What is interesting is that now everyone else is having an indigenous experience. The economic inequities and policies that are benefitting the few to the detriment of the many, the redistribution of wealth, and the lack of support for public education and public housing is a threat to a host of programs that benefit us all. I think compassion is hard to come by with some people in this country today.

There’s a metaphor for the transfer of property and wealth in the Indian experience: when Christians came here, they had the book and we had land; now we have the book and they have the land. There’s been a real shift and that started with Native people in this country, and, it’s predicated on avarice and greed, with no concerns for the wellbeing of all people.

PHP: Is there a piece of legislation regarding Native American health either unwritten or in the process of being written that you would like to see passed or get voted down?
If you look at the Indian Health Service, it has only been funded at 50% of the level of need, and that continues to this day.

 
MB: The Department of Health and Human Services recently proposed that Indian tribes not be acknowledged, and was seeking to categorize Indians as another ethnic population. This diminishes the US government’s unique commitment to tribal nations, which is the basis of federal Indian policy and Indian law, established over 250 years ago when the first treaties were made. If you look at the Indian Health Service, it has only been funded at 50% of the level of need, and that continues to this day. So, we know there are issues and a big piece of it has to do with a lack of adequate resources, and recognition by federal officials and people in this nation that, historically, we continue to suffer and have some of the worst economic, social and health conditions of anyone in this country today. And, while this nation is committed to treaties with other countries across the globe, we are still waiting to see that this nation fulfills its commitment to tribal nations here. Part of it has to do with the commitment of resources, and engaging the private sector as well.
Public health is one slice of the big pie, and the other pieces fall under self-government and self-determination.

 
PHP: How would you advise young health professionals or grassroots organizations interested in Native American health to navigate this administration’s policies, and work towards effectively bringing about positive change?

MB: There’s the National American Indian Housing Council, for example, a nonprofit organization that works to promote housing for reservations and for Indian communities. And you know there are for-profit entities, some of them Indian and some of them non-Indian who have been incentivized to engage and work with the Native community by building housing and looking at tax credits. Public health is one slice of the big pie, and the other pieces fall under self-government and self-determination. Some tribes have been able to leverage their resources, both human and economic capital, and have done a better job than some of the federal agencies. I think it is about looking at those models of success and seeing if they can be replicated. And it’s not easy. If you’ve met one Indian, you’ve met one Indian; if you’ve been to one reservation, you’ve been to one reservation. It’s not a one size fits all, though; very community has a different experience.

PHP: Any final thoughts?

MB: By and large, the knowledge of Indian history among most non-native people in this country is next to nil. For those building programs or making policy, it’s really important to listen. I would say the major challenge is that, to the American public, Indian people are invisible. They don’t see us, they don’t think about us, and they don’t know about the history.

Feature image: Michael Bird, pictured with his mother at the University of California, Berkeley School of Public Health 75th Anniversary celebrations. Photo: Hewitt Photography. 
                    [post_title] => Michael Bird
                    [post_excerpt] => PHP sat down with Michael Bird, former president of the American Public Health Association, the first American Indian to hold that position. Mr. Bird works to call greater attention to the American Indian experience.
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                    [post_content] => In April of 2018, writing fellow Erin Polka and PHP executive editor Michael Stein sat down to speak with Mr. Roy on his ideas of health care reform.

Public Health Post: Could you talk about how to decrease health care spending? 

Avik Roy: We pay for health care by saying: “Not only is a third party insurance company going to pay for most of your health care, but a third party is going to buy the health insurance plan on your behalf.” So you really have a 9th party payment because there’s a multiplicative effect of a third party buying a third party form of health care payment for you.

The vast majority of Americans have no sense of what drives their health care cost up or down. They just know when they go to the doctor they’re expected to be covered. And that psychology is not natural to economics. It’s something that we’ve decided to do because of the way we’ve designed our health care system. It doesn’t have to be that way. I think the more we put those choices back in the consumer’s hands the better, and I think the ACA exchanges can help in that regard by helping people who shop for coverage. Creating a competitive setup where you know you have six different plans competing on price would help.

What about technologies that make it an option for consumers or beneficiaries not to have to come into a medical office—can we reduce costs that way? 

AR: The conventional health policy person will say: “Well, one of the biggest drivers of increased costs in the health care system is technology.” People really don’t stop to think often enough, I think, of why that’s not true in the rest of the economy where technology helps reduce cost and improve quality.

Telemedicine is a very important part of the new technology—we should have been doing this a long time ago. I think one of the areas where you’re going to see the most opportunity for innovation and delivery of care is the use of machine-learning and particularly computers that have digested the medical literature to assist, if not replace physicians in differential diagnosis. But I think it’s important to appreciate that while those kinds of technologies can reduce costs, they’re not the reason, today, why our health care system is so expensive.

Could you discuss why Medicaid has some of the poorest health outcomes of any health insurance system, and what you would like to see change? 

AR: It’s the peculiar way in which Medicaid is designed that has led us to this point. Particularly the fact that it’s jointly run by the states and the federal government, which means it’s not really run by anybody directly.

States have three choices when it comes to Medicaid: they can accept Medicaid spending and increase and raise taxes, they can cut spending on education, and police and fire departments, and other public priorities, or they can basically gradually reduce what you pay hospitals and doctors to see Medicaid patients. And, many states have used all three of those policy options. But, the third, reducing what you pay doctors and hospitals, every state has done that. And it gradually has a big effect; there’s now massive disparities in what Medicaid pays versus what private insurers pay.

Because of these disparities, you create a situation where access to providers is much poorer, particularly for primary care and the everyday maintenance of chronic medical conditions that low-income people have disproportionately. So, what I’ve advocated is that people who are low-income and need health insurance should be put on the exchanges, where they have access to a competitive market of private insurers to help them afford health insurance. There’s no fundamental reason why people below the poverty line should be in a different system than people above the line.

So what do you think the path for universal coverage looks like? 

AR: I think both parties, in terms of the partisan stuff, have to fail in a sense to get to the right place. Republicans had to fail on repeal and replace, at least the type of repeal and replace that they were offering, in order to maybe come to a more pragmatic approach to health reform, where the goal of covering more people is part of the equation. And I think on the left, on the Democratic side, the goal of single payer has to fail again.

I think both sides, in a sense, are going to have to fail in their more partisan options before you can come to the table with bipartisan approaches. I hope that’s not the case! I certainly will continue to try to work with the people in both parties who are looking for a more bipartisan approach. And that’s my hope: to find ways again, where both progressives and conservatives can win at the same time.
This conversation was lightly edited for length and clarity.
Photo courtesy of Avik Roy. 

 
                    [post_title] => Avik Roy: One Republican’s Advice on Health Care
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                    [post_content] => By the end of almost every one of her shifts at the University of Colorado Hospital, emergency room physician Emmy Betz treats at least one patient who is struggling with thoughts of suicide.

Yet for the nearly 44,965 people who die by suicide in the United States every year, most don’t live long enough to make it to the ER, and more than half of these individuals kill themselves using guns. Despite these statistics, suicide is often left out of broader discussions on firearm violence.

“Every death clearly is very important,” Betz says. “But when you look at the magnitude of things like mass shootings or accidental childhood shootings compared to suicides, the numbers aren’t even close. That felt frustrating to me, because it feels like that it is somehow implying that those suicide deaths didn’t matter as much and they really do.”

Outside of the ER, Betz devotes her time to public health research and advocacy. She and her colleagues have noted several gaps in hospital and community services: many patients who visit the ER with thoughts of suicide don’t receive information on reducing access to dangerous items around the house, such as guns, medications, or rope. In another study, her group found that gun retailers appear willing to offer temporary storage if a gun owner or family member is experiencing suicidal thoughts, but more research needs to look at how to engage these groups in public health efforts and address potential barriers.
“You don’t want to have outsiders marching into any kind of community and saying, ‘This is what we’re going to do,’” Betz notes. “You need to have that grassroots buy-in.”

 
To improve communication between different groups, Betz co-founded the Colorado Firearm Safety Coalition in late 2015. The coalition brings together public health researchers and owners of gun shops and shooting ranges to discuss suicide prevention—a topic particularly relevant in Mountain West states, which have high rates of gun ownership and almost double the rate of suicide deaths compared to other states. The coalition is modeled after the work of Harvard researcher Catherine Barber of the Means Matter Campaign and the New Hampshire Firearm Safety Coalition. These programs emphasize the importance of choosing a trusted messenger to convey gun-relevant suicide prevention information.

“You don’t want to have outsiders marching into any kind of community and saying, ‘This is what we’re going to do,’” Betz notes. “You need to have that grassroots buy-in.”

During events, members discuss safe storage or locking devices. Although research supports these safety options to prevent unintentional shootings and suicides, a recent report published in the Journal of Urban Health found that 4.6 million U.S. children are living in homes with at least one firearm stored loaded and unlocked—more than twice the number reported in 2002. Betz argues that public health researchers, physicians, and gun shops can do more together to educate families on gun safety.

At “Ladies Nights,” women receive training to recognize signs if a partner or teen is at risk of suicide and dispel misconceptions about suicide. Betz notes that suicide attempts are often impulsive and, of those who survive, most don’t attempt suicide again. With guns, “there’s no second chance.”

Coalition members don’t agree on solutions all the time, but Betz believes that working with the group has challenged her to better understand diverse viewpoints.

“This has been really a great way for us to learn from them, and for them to learn from us, to realize people in public health aren’t all…interested in baby-proofing the whole world and taking away everything dangerous and so forth,” she says. “And on the flipside, of course, people who own and sell guns don’t want family members to die. The reason many people own guns is to protect their family, so the messages around safety and protecting your community really resonate.”

 

Feature image: courtesy of Emmy Betz
                    [post_title] => Emmy Betz: Preventing Firearm Suicides
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                    [post_content] => At Cityblock, Iyah Romm is evolving new ways to offer Medicaid and lower-income Medicare beneficiaries access to high-value, convenient and personalized health services. As the first in a new series of conversations with public health innovators, Michael Stein, MD, executive editor of Public Health Post and co-author of The Public's Health, spoke with Romm.

Michael Stein: What problem is your company trying to solve?

Iyah Romm: There is a fundamental mismatch between where venture capital is investing in innovative services and technology and where health care dollars are actually spent in an out of control way in this country. The health of low-income urban populations is being profoundly left behind by venture capital and Silicon Valley. With technology in the passenger seat, not the driver seat, I thought we could tackle a really hard and really economically and socially important problem.

MDS: Why, in the new digital technology world, have we not seen real successes in health care delivery yet?

IR: We’ve focused on the wrong problems. I do not think we need another FitBit for a healthy 55-year-old who is running marathons and wants to be able to count his steps. We need tools that allow low-income Medicaid moms with three kids and two elderly parents at home to communicate with her caregivers in a seamless way and to be able to access services after 5 pm to match their lifestyles. We need models built around low-income communities with multilingual access points and cultural competency that are available all day, every day.
The health of low-income urban populations is being profoundly left behind by venture capital and Silicon Valley.

 
MDS: And those models are not built around physicians, correct?

IR: We start with the perspective of: how do we help people arrange the services they need that will be most effective for them? So a person’s primary point of connectivity is a community health partner, a workforce that we at Cityblock are developing that’s informed by the community health worker movement, health coaches, and navigators. We believe we can build a workforce of people who are enabled to engage effectively as facilitators.

MDS: So a new kind of workforce is part of your business model? Can you tell us more? How do you get members to join up?

IR: We are a provider, not a health insurance product. We contract with managed care plans that already have captive members, and we act as a capitated provider. We offer members clinical services they don’t receive in a traditional health care environment. We will provide after-hours, in-home, wraparound services to help facilitate their medical and behavioral health and their social needs. In some instances these services come in an opt-in basis and in other instances in an opt-out basis. We build, manage, and curate a network of community-based organizations who are delivering social determinant services.

MDS: So it sounds like a new kind of business, bridging medical care and public health.

IR: I am an accidental capitalist. I met investors who were looking to make a big bet in a very hard-to-move area. There was a real energy and excitement there for doing very hard things, and a belief that application of technology capabilities in operationally-oriented ways was a powerful way to think about health care.

MDS: As someone interested in efficiencies and improving health for all, are you a single-payer person?

IR: I believe health care is a human right. But I don’t think you can really effectively have single-payer without a single provider and getting from here to a nationalized health system is not going to happen in my lifetime. You’ll find me in my personal time saying that single-payer is likely a very efficient and effective model in a perfect world, but also I'm not out there as a single-payer advocate because I don’t think it’s the most practical way of engaging in healthcare reform in this country right now. So to me it’s a question of how do we meaningfully simplify all of these different programs and services to make it not so bloody complicated for our patients and providers.
This conversation was lightly edited for length and clarity.
Photo courtesy of Iyah Romm. 
                    [post_title] => Iyah Romm
                    [post_excerpt] => As the first in a new series of conversations with public health innovators, Michael Stein spoke with Iyah Romm, cofounder and CEO of Cityblock, a start-up focused on improving the health of underserved urban populations.
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                    [post_content] => Today marks the second anniversary of the Pulse nightclub shooting in Orlando, Florida. We spoke with Josh McGill about surviving the shooting, his nursing career, and his thoughts on gun violence prevention policies.  In April 2018, Josh spoke at CAMTech’s Gun Violence Prevention Challenge Summit at the Edward M. Kennedy Institute and mentored innovators during CAMTech's Gun Violence Prevention Hack-a-thon at Massachusetts General Hospital. On Friday, June 15, 2018 all teams from the Gun Violence Prevention Hack-a-thon will pitch solutions that aim to curb the gun violence epidemic and improve the lives of survivors.

Public Health Post: In light of the Challenge Summit and Hack-a-thon, recent unfortunate events, as well as walkouts and marches supporting gun violence prevention, how involved are you in causes for social reform?

Josh McGill: In Orlando we have something called Impulse Orlando. It encourages the LGBT community to get tested for HIV, and if they come back with positive results, counseling is offered. I do all kinds of walks: I was in the Pride parade, I walked for breast cancer, I walked for heart cancer. And all the money that we spend to do these things go to a charitable cause. On top of that, I’m also in school for nursing, and I work full time as a medical assistant at a doctor’s office. I stay pretty busy, but I try to put myself out there, and voice what I can, when I can.

PHP: As a medical assistant and a student pursuing nursing, how do you think gun violence impacts health care?

McGill: My friend mentioned before that, at a walk-in clinic, one of his friends had a patient come and kill her. And that scares me because sometimes I’m in the doctor’s office, by myself. We have cameras, but in the building itself we have no metal detectors, no security. I know hospitals have security and security cards. I think private practices need to have something of the sort.

I am not against guns, but I personally would not carry, because I don’t like them. I do think that there need to be more restrictions. There needs to be a background check, an age restriction, and I think that people need to go to either see a therapist or a psychiatrist, and get medically cleared to bear arms. We need to make it a little harder to get guns.
I grew up with guns, I’ve lost three family members to gun violence. I lost four friends at Pulse.

 
PHP: Do you have any ideas that you might share with the Hack-a-thon participants about messaging gun violence prevention?

McGill: As a Mentor, this weekend, I will talk about psychological evaluations, and to not ignore any signs. I think if people want to carry a gun, they need to make sure they are ready because it’s a big responsibility to have in a house. Gun storage needs to be a big angle to focus on this weekend. I grew up with guns, I’ve lost three family members to gun violence. I lost four friends at Pulse. One of my friends had rifles just hanging on the wall in their house, above the mantle. And they had a whole cabinet full of rifles and shotguns—they were hunters—but there was no lock and key. I could have easily opened the cabinet, reached in and grabbed a gun and, you know, an accident could have happened.

PHP: What do you think policymakers should do to work towards preventing gun violence?

McGill: As I mentioned before, the psychological aspect of gun violence is something that needs to be considered. There needs to be clear ammunition policy, the background check needs to be reassigned, and the age limit has to be raised. I think it needs to be raised to 25.

PHP: What is your advice to fellow survivors of gun violence events on coping and dealing with triggering situations?

McGill: Family and friends have helped me so much. The Pulse shooting happened June of 2016. Fireworks for the following Fourth of July were triggering for me, and my friends were there to help. As the years have gone by, the triggers stopped, but the PTSD and the nightmares are always there. The Parkland incident triggered me: I was at work that day, and by just seeing another mass shooting, and the high schoolers, I started hyperventilating. I called my mom, and she talked me down. Sometimes, I just need to go into a quiet room and turn the lights off and do breathing exercises.

I had panic attacks before Pulse but, after Pulse happened, they got worse. I finally sought counseling and got on a good level of medication to help me cope.

PHP: How did you decide to pursue health care as a career? Were you interested before your experience with the Pulse shooting?

McGill: My grandma got sick and after trying a nursing home (she hated it, and so did we), we had a nurse come check on her twice a week at our home. Later, I took it upon myself, because I was the oldest, to drop out of college and take care of her. My parents worked, all my aunts and uncles worked and all the kids were still in high school or younger. I learned from the home nurse how to check my grandma’s blood sugar, and give her insulin shots. She did pass away a couple years ago, but on her death bed, she made me promise that I will pursue something in the medical field. I like nursing because it involves more patient care.
This conversation was lightly edited for length and clarity.
Photo: Alejandra Spruill
                    [post_title] => Josh McGill
                    [post_excerpt] => Today marks the second anniversary of the Pulse nightclub shooting in Orlando. We spoke with Josh McGill about surviving the shooting, his nursing career, and his thoughts on gun violence prevention policies.
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                    [post_content] => Fast fashion is everywhere; trend-churning retailers like Zara, Primark, H&M, Forever21 make the latest designs accessible to the public, but at a sometimes deadly cost. When Bangladesh garment factory Rana Plaza collapsed five years ago, killing 1,134 employees, big shots of the fast fashion world fell under extremely sharp, and much needed, scrutiny. This disaster shed light on how outsourced mass clothing production is plagued by complex public health challenges including workplace regulations, wage discrepancies, pollution, and the physical health of garment makers.

In an effort to shift consumer practices, Barenblat is trying to refocus fashion as a “force for good.” She and her Remake team share stories of Humans of Fashion, the folks in developing countries who work long hours for low pay to produce the clothes we consume at bargain prices. Remake also partners with filmmakers and young designers to visually engage consumers in “learning journeys,” transporting them to the origins of clothes, and encouraging them to rethink purchase culture. Remake’s mission is to “build a conscious consumer movement,” and the company aims to achieve this goal by working with creators to discuss the harms of fast fashion and the dangerous appeal of purchasing more at a low cost.
Water contamination from synthetic dyes, climate change impacts from carbon emissions, and the consequent health implications for consumers and laborers alike act as different entry points in that lifecycle.

 
An example of such a collaborative effort is Remake’s learning journey, the film Made in Sri Lanka. The documentary features striking scenes of the inner workings of Sri Lankan garment factories and testimonials of their employees. Discussing the shocking imagery, Barenblat stated, “our stories and first-hand documentary footage are very photo rich, and tend to connect you to issues across the lifecycle of the fashion industry supply chain.” Water contamination from synthetic dyes, climate change impacts from carbon emissions, and the consequent health implications for consumers and laborers alike act as different entry points in that lifecycle. Garment factory workers can faint from exposure to harmful chemicals used to treat clothes and breathe in the fabric dust generated by cutting and sewing clothes en masse. The run-off from the synthetic dyes and chemicals pollute the water in areas near garment factories, further impacting workers’ health. Those who buy these chemically treated pieces risk having the toxins leach into their skin and bloodstream.

“Fast fashion comes from places where labor laws are weak, and enforcement is much weaker,” says Barenblat. She explains that the fight against these huge corporations is often missing one integral component: the consumer. Understanding that “wallets are powerful,” Barenblat and her colleagues at Remake push for the public to engage in a “buycott” rather than a boycott. While it is important to hold fashion brands accountable for the ethics behind their production models, Barenblat believes that talking at the public and demanding they refrain from purchasing fast fashion will not change much. She stresses that calling for action must also include supporting alternative, more conscious brands, and sharing how people can easily incorporate sustainability into their daily lives.
Barenblat stresses that calling for action must also include supporting alternative, more conscious brands, and sharing how people can easily incorporate sustainability into their daily lives.

 
Divesting from fast fashion often means losing out on massive discounts and spending more money for smaller quantities. Barenblat recognizes that people may approach the sustainable fashion movement with different budgets. She recommends that people buy secondhand, and consider giving clothes second lives by holding swap parties or revisiting pieces they already own. Barenblat notes that this will help alleviate carbon emissions, since just one kilogram of discarded clothing in landfills accounts for 3.6 kilograms of carbon dioxide emissions. She also suggests using conscious laundry techniques such as cold washing to avoid the leaching of microplastics from fabric into waste water, and line-drying clothes when possible.

Barenblat started her career in strategy consulting and completed a graduate degree in public policy at University of California, Berkeley, where her professors introduced her to the world of sustainability. With a new understanding of the intersection of sustainable practices and social justice, Barenblat interned with Levi's®, and later began working for non-profit sustainability organization BSR, advising businesses on how best to “embed human rights into the corporate space.”

Barenblat is dedicated to the idea of collaboration between the private sector, policy, non-profit organizations, and consumers in order to drive positive change. And as for Remake, Barenblat says, “we are over two-and-a-half years into this journey, and it has been really fun. We involve a lot of women of color, and we can see ourselves in her narrative,” with “her” referring to the young women who create the clothes for fast fashion retailers.

Photo courtesy of Ayesha Barenblat
                    [post_title] => Ayesha Barenblat
                    [post_excerpt] => Ayesha Barenblat is the founder of Remake, a platform dedicated to changing consumer perspectives on fashion and style by increasing awareness about the public health impact of the fashion industry supply chain. 
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                    [post_content] => In July 2014, the Lancet, one of the world’s best known medical journals, devoted a special issue to sex work and HIV. The publication was timed to coincide with the 20th International AIDS Conference in Melbourne, Australia. One of the articles, led by researcher Kate Shannon of the University of British Columbia, caught Senior Abt Associate Michael Shively’s eye.

The article, which Shively refers to as “the Shannon study,” used forecast modeling to test HIV prevention scenarios and estimate their impact on transmission rates among female sex workers and their clients in three very different cities: Vancouver, Canada; Mombasa, Kenya; and Bellary, India. The authors plugged independent variables like “safer work environment” and “elimination of inconsistent condom use due to any client violence” into their model and estimated their effect on averting HIV infections over ten years. They found that the decriminalization of sex work and its resulting benefits would have the potential to avert 33-46% of infections over a decade.

This finding made international headlines. “Decriminalization of sex work could reduce HIV infections,” declared the Washington Post. “The evidence is in: Decriminalizing sex work is critical to public health,” affirmed the Center for HIV Law & Policy. The authors circulated their findings to influence Amnesty International’s policy on the decriminalization of consensual sex work, which the organization released in May 2016.

“This is a very consequential study,” says Shively. “This is presented as the state-of-the-art, capstone event of decades of research and it was received that way and it was presented that way by the authors. They’re basically saying, the evidence is in. We’re done here. We figured this out.”

A self-proclaimed “certified nerd” and long-time criminal justice policy researcher working with Abt and the U.S. Department of Justice, Shively says he was excited that a policy measure like decriminalization could have such a positive impact on the health of sex workers. So he decided to “look under the hood” to see how Shannon and colleagues got to their influential conclusion. What he found, however, was significantly less conclusive than the study seemed to suggest and, perhaps more importantly, than reporters and activists made it out to be.

Shively scrutinized the (more than 300) citations used in the study and its adjoining appendices, and recruited statisticians at Abt to validate the modeling. Based on their critical analyses, Shively says there are several ways in which the study lacks credibility.

A major limitation he cites is the “assumption used to simulate [the] impact of decriminalization on HIV.” For one, the model assumes that decriminalization of sex work will immediately result in several overly optimistic outcomes, for instance, 0% violence toward sex workers, 0% police harassment, 100% access to prevention and treatment services, and maximum condom usage. It also assumes that decriminalization will result in all  all of these changes overnight, regardless of context or details of the legislation.

Shively presented his findings and concerns at a Commercial Sex Symposium in November 2017, arguing, “there is no evidence that fully decriminalizing prostitution produces any of the outcomes assumed by Shannon.”

Of course, this type of modeling can be useful, but only if a variety of reasonable assumptions are used to determine a realistic range of outcomes following decriminalization. “What Shannon really found,” according to Shively, “was that HIV transmission would be reduced if violence, harassment, inconsistent condom use, and barriers to healthcare were eliminated.”

The authors do not qualify their findings, and, instead, present their work as unequivocal. Shively says he is not necessarily arguing that the study is wrong, but that the data is not sound enough to base international policy decisions on. When Shively attempted to confront the co-authors of the study, he was not well-received.

“When you say that you've got hard science that proves something, it needs to be challenged [and] scrutinized, and when it doesn't hold up, they should be welcoming scrutiny,” Shively says. “I don't expect people to just accept what I've said, I want—I should get challenged on it.”

Shively doesn’t know what will happen next. He has plans to publish his critique of the Shannon study and says, “I don’t think this is going to end well for me.” Point in fact, a reporter who attended the November symposium castigated him during the question and answer session and was more or less given the last word. Shively hasn’t heard from her since, but said he would have been glad to address her concerns.

For anyone writing about research, as we do every day at Public Health Post, Shively’s quest to “advance knowledge, build science, [and] get closer to the truth” is an important reminder. It is easy to gloss over the nuanced methods and results of academic papers and focus on the data that support our positions. Shively set out to understand the Shannon study and replicate it—a standard scientific practice. By asking unpopular questions and challenging overly optimistic conclusions, researchers can be sure they are producing the most thorough, transparent, and accurate evidence possible.

Feature image: Michael Shively, speaking at the Boston University School of Public Health Dean's Symposia "Understanding Commercial Sex Policy: A Global and US Perspective"
                    [post_title] => Michael Shively on Science & Sex Work Policy
                    [post_excerpt] => PHP spoke with Michael Shively about a prominent study in the Lancet that suggested decriminalization of sex work could reduce HIV infections. Shively maintains the findings were significantly less conclusive than reporters and activists made them out to be.
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                    [post_content] => In 2016, Brandi Harless was elected mayor of the city of Paducah, Kentucky. Paducah lies along the Ohio River and has a population of over 25,000 people. She has been in office for just over a year. Before Harless, who earned her master’s degree in public health in 2009 from Boston University, was elected, she worked in Sierra Leone, in Washington D.C. for the international firm Management Sciences for Health, and in Haiti. She recently sat down for an interview with Public Health Post to talk about how her global health work influenced the initiatives she is now working on in Paducah.

While at Boston University, Harless studied global health, taking a wide variety of courses that covered everything from human rights law to program implementation. She stresses the importance her education had on her current work, saying, “Working in rural America is very similar to all the things I learned about in global health studies.”

After moving back to Paducah, Harless began running a free health clinic in the city. Once it became apparent that Medicaid was going to expand, she knew she had to help lead the organization through some big changes. “We did a pretty big project to transition that free clinic into a foundation, so that it could continue to fund the unexpected consequences of the Affordable Care Act. Then, we recruited a federally-qualified health center network to take over our clinic, and it expanded access to care tremendously.”
Harless originally did not think she was interested in politics, and personally prefers to be called a “public servant” rather than a “politician.”

 
Currently, Harless is working on getting a comprehensive smoking ban in workplaces, parks, restaurants, and hotels passed. She emphasized that this change is a goal shared by many. “It’s not just me wanting to do this. It’s a statewide coalition. It’s the Chamber of Commerce, who knows this is important for our state economics.” She also said, “There is significant evidence behind this piece of legislation locally that these comprehensive smoking policies are helping to reduce smoking rates.” At 27%, Kentucky has the second largest proportion of smokers after its neighbor, West Virginia (28%). (The national average is 18%.)

Stories of women running for office have dominated the media throughout the last year, despite well-known challenges ranging from gender bias to difficulty fundraising. When asked what motivated her to run, Harless explained, “It was a combination of being encouraged to but also realizing that if I wanted to make some pretty big changes to the way things were being done, then it was the position that I needed to have to do that.” She originally did not think she was interested in politics, and personally prefers to be called a “public servant” rather than a “politician.”
"I’m still a public health professional. That’s still me, and I think that’s a really key thing because we need public health professionals to be in elected office."
—Brandi Harless

 
When asked how difficult it was to transition into politics, Harless said, “I don’t think I ‘transitioned’ into politics. That assumes that you went from something to something. I’m still a public health professional. That’s still me, and I think that’s a really key thing because we need public health professionals to be in elected office. It’s not one or the other. Politics is such an important way that we make change in our country. For me, it hasn’t been that dichotomous. It has been very natural.”

She also believes that her education gives her an advantage in her current role because she analyzes challenges from a population perspective. “Elected leaders at my level need to be able to think about population. It’s not individual. We’re not making decisions for individuals; we’re making decisions for a population. The skillset of getting outside of the individual mentality and thinking more about the population is a learned skill. It has been crucial for making decisions for an entire group of people.”

Photo courtesy of Brandi Harless. 
                    [post_title] => Brandi Harless
                    [post_excerpt] => Brandi Harless, Mayor of Paducah, Kentucky, talked with Public Health Post about how her background in global health informed the initiatives she's working on now, and the intersection of public health and public service.
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                    [post_content] => In February of 2015, a press release from the Indiana State Department of Health reported that new cases of HIV had increased exponentially in Scott County. When Shari Rudavsky, a health and medicine reporter for the Indianapolis Star, arrived in the southern Indiana county, she saw “an ingrown community of substance users. Grandparents would share with their kids who would share with their grandchildren,” she told Public Health Post.

There was an attitude that you could share needles, that HIV/AIDS isn’t something that happens in Indiana. When sharing needles with people you’ve known your whole life, what could go wrong?

In March of that same year, then Governor Mike Pence declared a public health emergency; HIV infections continued to spread. According to Rudavsky, Pence had made no secret of his disapproval for needle exchange programs, but reversed his stance, approving a 30-day needle exchange program for Scott County. Social service agency workers, state health officials and CDC monitors arrived close behind the needle exchange program.

To report on the outbreak, Rudavsky drove down to Scott County regularly from Indianapolis. On her way there she would pass a collection of small towns with shuttered store fronts, an impoverished community with just one physician serving the area. That physician told her that he had 18 year olds coming to his office, asking him to sign disability forms. As Rudavsky said, “it was a culture of substance use.”
“But with public health, even people who you think might be ossified in their beliefs can be persuaded by the experts to do what those in public health say is the right thing.”

 
When measuring public health outcomes, “Indiana counties do not fare particularly well,” said Rudavsky. “But with public health,” she said, “even people who you think might be ossified in their beliefs can be persuaded by the experts to do what those in public health say is the right thing.”

For Indiana, the right thing was a needle exchange program. The HIV outbreak triggered a campaign promoting the importance of clean needles and the dangers of sharing them. Two months after the approval of the 30-day needle exchange for Scott County, a bill passed allowing counties to ask the State House to declare a public health emergency in their counties and request needle exchange programs. Now, this program has evolved so that counties can run needle exchange programs on their own, without going through the State House.

Even with this progress, needle exchange programs are still controversial in the state, for moral reasons. According to the Chicago Tribune, two out of nine counties with needle exchange services recently ended their programs, citing an inability to reconcile the public health benefits with the moral questions surrounding distributing drug paraphernalia.

In a state where public health spending often falls low on the priority list of legislators, health and medicine reporters like Rudavsky struggle to keep the public’s eye on the urgencies of the latest health issues. Reporting on public health and addiction, presents “a kind of human challenge,” said Rudavsky, “taking that [health] information and finding ways to apply it to readers in their own lives.” But that’s a role that journalists can help fill. “That’s why I’m a health journalist,” said Rudavsky.

One way public health reporters can gauge their success is through increased engagement with their audience, listening to the public. Through her own writing, Rudavsky receives feedback from both ends of the political spectrum, reflecting “that it’s a sign that maybe we’re doing something right if we can anger both sides.”

Photo courtesy of Shari Rudavsky. 
                    [post_title] => Shari Rudavsky
                    [post_excerpt] => PHP sat down with Shari Rudavsky, health and medicine reporter for the Indianapolis Star, where she has reported on Indiana’s important public health issues, including the recent HIV outbreak and the opioid crisis.

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