INTRO

JESSICA

Public health informatics is the science and the art of taking raw data and turning them into useful information for health policies and programs. It takes all those data out there and turns them into knowledge of how people can live healthier lives. But how does this process work? My name is Jessica Hill, and I work at the Public Health Informatics Institute in Atlanta, Georgia. This podcast is my quest to learn about informatics and how it’s made people’s lives better, how has it made my life better, and really why does it matter. So I’m ready. Inform Me, Informatics.

Hi, I’m Jessica Hill. Welcome to the latest episode of Inform Me, Informatics. A few weeks ago, we asked you, our listeners, to submit questions about public health informatics and public health, more generally, for a very special episode, with Dr. David Ross, the president and CEO of the Task Force for Global Health. I sat down with Dave a few weeks ago, and we’re very excited to share that discussion with you.

JESSICA

Dave, welcome back to the podcast.

DAVE

Hey, it’s great to be here.

JESSICA

So some things have changed in your life since the last time that we spoke. You got a new job. How’s it going?

DAVE

That’s right, I did. I’m now the chief executive officer and president here at the Task Force for Global Health. How’s it going? It’s busy. I’m very busy. I’m going lots of places.

JESSICA

Right early on in the podcast development and lifecycle, you talked about kind of this idea of having a call-in show because of Car Talk and Click And Clack. And so we couldn’t really do a live call-in show, but what we did do is we asked people to submit questions ahead of time.

DAVE

I think that’s great. You know, informatics itself is the kind of discipline that excludes many people, but yet, what we do actually could be of interest to a lot of people. So I think this format maybe gives us an opportunity to talk to many people at a health department, for example. Imagine a local health department, like over here at DeKalb County Board of Health. You know, they’ve got environmentalists, they’ve got nurses, they’ve got people doing various different programs who might wanna take 5 or 10 minutes and learn a little something, or be amused about something that is going on, or they may have been saying, “Why on earth are those people trying to automate this or that? Or why are we using this system?” Maybe we can start to get at some of that and help them be more informed and more aware, and that’ll be great.

JESSICA

This is incredible, because I swear, listeners, we did not share these questions with Dave ahead of time. But our first question from Matthew Roberts, who’s an informatics project manager for the city of Chicago, the very first question is, how can public health informatics programs improve their visibility and best deliver on value?

DAVE

Let’s start with the people, Matthew. So I think one of the things, one of the real big challenges for people who work in informatics, is to start with the image of who are the people we actually are seeking to benefit. Take a big city like Chicago, you’ve got its amazing health department there. It’s a big one, and they do some important things and actually have done some really leading visionary work there. But who are the people that are supposed to be benefiting from that? When we do a good job of aggregating data in public health, we kind of obfuscate the people. We munch them together. We start looking at distributions and norms and talk about means, and medians, and standard deviations, and things that characterize the variation that is seen within a population. But sometimes, in doing that, we fail to point out who are the people. And so I think, number one is, can you imagine a way to say, “Who are the people that are benefiting because of my work?” That’s not easy to do. I can tell you, we struggle with that here at the Informatics Institute, but yeah, that’s a really, really important exercise. So that would be one thing.

JESSICA

Well, I wanted to follow up on that. When you said think about the faces and the people, that really resonated with me. What if you feel like you have a really good sense of who you’re serving, the population that you…you’re working with their data, you wanna help inform programs, but you feel like the other programs don’t really see you or don’t see the value of what you’re contributing to the overall mission?

DAVE

Well, that would bring me to the second principle, and that is build relationships. A few years ago, we were working on an information exchange initiative, and one of our partner health agencies out in California was trying to work on reducing childhood overweight. And they had done all the good data analysis, and in fact, they’d even done a really good job of working with the local health information exchange that was emerging at the time to get data on the extent of the problem as seen from the lens of the health care providers, the pediatricians who were seeing these kids. But they realized that, actually, to tackle the problem, they had to work with the schools, with the parks and recreation, with the political authorities, with the fast food industries. There were a number of players in the community that were not a part of the direct purview of the health department but people they had to go work with. So we worked with them to bring those parties together and all get in the room and start to uncover the problem. And with that joint discovery came enormous awareness that we each could serve and help the other, that each partner had certain information, certain data that the other could use, that it wasn’t just a one-way street, that it was this complex web of interaction, but it all began with the people meeting one another. And that was a new thing for this health department to actually do that. Those relationships that started that day was what propelled going forward to actually build information exchange. So that’s just a minor example. So I would really stress build relationships, particularly for those of us who are introverts, who wanna sit and look at our data, and that’s probably why we’re in this business anyways, is we’re really good at focusing on something fixed like that. So let’s go out and expand our portfolio of tricks.

JESSICA

And what do you think the value of the informatics role is? When people are coming together and having those dialogues, what is it that informatics brings to the table?

DAVE

So many things. So many things. Informatics can help people be clear about the problem they’re solving. If you’re gonna apply some form of automation to help, well, you’re helping solve some problem. What is that problem? We’re really good at helping ask those questions to the program people. And sometimes that’s an irritating question to ask, is like, “Well, explain the work to me better. Who’s doing what?” So it’s that uncovering who are those stakeholders.

JESSICA

So I just wanna say, so informatics folks out there, we acknowledge sometimes people get really annoyed when you ask those questions, but that’s our job. That’s our role. So my heart is going out to you right now, because I have been in those meetings, and I’ve asked those questions. And it doesn’t feel good when people are, like, “I don’t wanna get specific. I just wanna tell you this great idea.”

DAVE

Yeah, right, right.

JESSICA

It’s really frustrating for everybody.

DAVE

It is. But that frustration, often, just as a reflection, that people haven’t thought through things that clearly. But that is the first value add that you really bring. You’re saying, “Well, heck, how am I gonna automate this if you’re not sure what you’re doing, right?” That’s a really fundamentally important principle, but to do it effectively means you have to be doing it in a way that builds a personal bridge with the people you’re working with so that they want to go through that collective pain and answer the question, because the easiest thing to do is, if they don’t know you very well and you haven’t done a very good job of building that relationship, the easy thing for them to do is push you out of the room and say, “Well, you’re obviously not gonna help me, so why don’t you just go away?”

JESSICA

Harsh but true. Okay. Now seems like a good time to go to our next question. It’s a voice memo from Mark.

MARK

Hey, this is Mark. First time, long time. I just wanted to ask you what you think are the most emerging global public health issues that we aren’t addressing or paying enough attention to and what do you think we need to do in the next few years to address them.

DAVE

Global public health problems that we are not paying attention to. Well, there’s a lot of attention being paid to lots of issues. So part of what I’m gonna say isn’t intended to say there’s no attention being put to this, but I would argue not nearly enough or the right kind of attention. That first starts with climate change. It’s an undeniable reality that climate is changing. It’s warming. And what we know, scientifically we know, water levels rise. Water levels rise. You will create forced migrations. Forced migrations create conflict. They create spread of disease. Climate change changes things even like the microbiota, so the things like breeding grounds of mosquitos change. Mosquito-borne vector problems are likely to increase. Desertification is increasing, again, pushing people out, reducing food supply. Climate change is also associated now with changing acidity levels within the ocean, which is changing the food chain within the ocean, and we’re going to affect then the world’s food supply. So a lot of things are changing because of that. And climate change as a major public health problem is something we all have to be thinking about and trying to do something about. What do we do about it? It’s, you know, a mega problem and not easily grappled with.

Back to Mark’s question, one of the meta problems that I see in global public health is public health people learning how to work across sectors. So in a typical ministry of health of a developing country, water is in one ministry, sanitation may well be in a different one, and health is yet in another one, and finance is in another one. How do you bring them all together? Understanding how to be the ambassadors to bring multiple parties together, to convene them, to focus on an understanding of the problem, to be tolerant of other people’s lack of understanding of the problem, to help educate, if you will, and make people aware. I think there is this new emerging skillset for global health diplomacy, as well as another set that has to do with the ethics associated with global health work, driven by, what, by compassion, or driven by business, or both.

JESSICA

Do you think that there’s sort of a pendulum in public health that goes back and forth between, you know, maybe previously it was horizontal versus vertical services, and now, you know, then it was very focused on primary care, and focusing there, and building those systems, and then it kinda swung towards, in the ’80s and ’90s, being really specific about the business case and having to show return on investment? I mean, is this just sort of, just throughout history, pendulums just swing back and forth?

DAVE

Jessica, you’re right. There has been this swing and sway, this challenge of having narrowly targeted vertical programs where you can at least say, “In this one domain, we’re going to go solve this one problem,” that we can’t solve the entirety of a society’s problems when we treat it through a systems lens. So instead, we’ll just forget about all this other stuff, and we’ll narrowly focus on one thing.

JESSICA

And we’ll do that thing to the max.

DAVE

We’ll do that one thing. On one side, we have disease elimination programs, like our river blindness program, that because of the disease, onchocerciasis or river blindness, lends itself to a narrow targeted approach. With that kind of a program, all you need is enough support from the government to allow it to happen, enough support from the people to want it to happen, and through a network of partners, being able to deliver the drug, administer the drug, and work with the people that are receiving the drug. So that’s kind of a really good example of a vertical program that will soon bring its final purpose to close. It will have eliminated the disease. But then other things we see, I gave you the example of intestinal worms. We can’t win that battle with drugs alone. We’re gonna win it by building public health systems, the clean water, clean sanitation. How do you do that? Well, you’ve got to involve lots of people, including anthropologists who know the populations and know how to get them, the people, to adopt new practices. You’ve got to work with the business sector and build business rationale to keep sanitation and water systems functioning, right?

It’s a systems problem. There’s no way around it. The solution, ultimately, is through a systems approach. So I think where we’ve come in global health is a recognition that, at times, vertical programs work, and more and more as we move past the severe threat of infectious diseases and eliminate many of them, and we start to expose, then, populations having longer lifespans to chronic illness, the more we’re gonna have to adopt strategies that we’ve done well here in the U.S., either primary prevention strategies that involve multiple players, like tobacco cessation, you could call that a vertical program, but it involves lots of different players to make it work, or other kinds of chronic illness programs that involve an infrastructure of health care delivery and other sectors if you’re gonna actually prevent and/or treat those conditions, right? So I think it’s both. I’d like to think that the pendulum has stopped when we see that it can point to both directions.

JESSICA

Well, I feel like we could talk about this for hours, but let’s go ahead and move on to our next question. It’s a voice memo from Katie.

KATIE

Hi, Jessica and Dr. Ross. If a guiding principle of your work is to engage all stakeholders, how can informatics professionals engage community members to define goals and use informatics in a way that would be meaningful to their own lives? Please inform me.

DAVE

Jeez.

JESSICA

We got smart listeners.

DAVE

We have smart listeners. I love it. Thank you for that question. Let’s start with an example and see if we can work to a couple of general principles. Of course, engaging all stakeholders, yes. We preach that, and we have preached that for a long, long time. And we preach it because, in fact, we know that until all the people who own some part of the problem or solution understand their role in the problem or solution that it’s very hard to make real progress, particularly real sustained progress, right? Yeah, you can invent an information system, but if the people who are supposed to use it don’t wanna use it, it’s a waste of time, or if the information it produces doesn’t actually inform the people who need to be informed or they aren’t aware that they need to be informed and choose to want to be informed, then again it fails. We all know that there are social and behavioral factors that play a very big role in people’s health, and health at both an individual level and when viewed as the aggregate of populations, when you measure health that way, it is highly dependent on multiple determinants, not just whether or not you saw a doctor.

JESSICA

We have seen in the news just a lot of coverage recently around your ZIP code predicting your health and your life expectancy.

DAVE

That’s right. And so that’s the easy way to say it, is that your ZIP code predicts your lifespan. Well, that’s a shocking fact to a lot of people. So what can we do about it? How do you engage people? So one of the things that we’re doing, I’ll give you this as an example, it’s actually happening here at the Task Force for Global Health, here in the DeKalb County, Georgia, home of the Task Force for Global Health, but guess what, also home of the Centers for Disease Control and Prevention, home of Emory University, home of the Council of State and Territorial Epidemiologists, home of the National Association of Chronic Disease Directors. Here, we live in a county that you would think, after I recited all these expert organizations in health, both nationally and globally, that health indicator of Georgia would just be splendiferous. Guess what, it’s not. Why is it not? It is not because we know it is split between rich and poor. It is split racially. But how?

Well, when you talk to the local government officials, the answer is we don’t know. We don’t have a picture below, at best, the county aggregate levels. So one of the things we’re doing is reaching out to all elected leaders in this county and several other of the counties in metro Atlanta, to build a coalition to begin to look at the sub-county facts, in effect, to use the data, and so this is where informatics comes in. We’re the artist. We’re the ones who paint the picture of the county, but we’re gonna paint it in enough details so people actually see the picture. RWJ has a new initiative called Data Across Sectors for Health that is built on this proposition of helping community groups begin to engage their stakeholders, all of the people who own a part of the problem together, to focus on sub problems.

JESSICA

Can we go back to your painting example? And I wanna explore that a little more because I think there’s a step that I think was implied, but I just kinda wanna unpack it a little bit, which is that we, with our data, can paint, but what that picture is or what it means is actually co-constructed with the people who are in those neighborhoods. I think there’s a really sensitive spot between the data and then what the data mean and what we’re going to do about them that has to be a dialogue, to return to Katie’s question.

DAVE

Right.

JESSICA

It has to be a dialogue, but it also has to be, like, well, what do you want us to track?

DAVE

There are a number of initiatives going on, and one happens to be with the national community of bio and health statistics that is preparing to make a recommendation to secretary of HHS to adopt a consistent framework based on the social determinants, so the major domains like health, and transportation, and housing, so forth, and subdomains that get more specific about access to medical care, and so forth. So each of those domains breaks into a handful but a very limited number of subdomains, and those subdomains then have evidence-based metrics that actually can be used to measure, so for, like, access to care, right? There are agreed-upon statistics that would measure that.

JESSICA

What you track in order to be able to say something about access to care, yeah.

DAVE

Yeah. And so this framework built around the social determinants would…our view is that it becomes kind of the guide for community groups to put their arms around and say, “Evidence says these things, these various factors, actually play a direct role in our community’s health.” Now, what we have to do is get our community’s data on every one of these measures and then look at it together so that we can understand, Jess, what you were saying. Is, so what? Do we have in this part of DeKalb County parks? But guess what, they’re not safe. So that’s not gonna help us very much with getting exercise, because nobody is gonna risk their life to go to the park, right?

JESSICA

Right, right, right.

DAVE

Or possibly quite the opposite. We have the park. We have no sidewalks to allow the kids to ride their bikes to get there, you know. And so they’re not going to be used. So what we’re really advocating now is a standard framework that is usable to engage your community stakeholders. That’s part of our job as far as I’m concerned as informatics people, is to not leave it at just populating the framework with data and then lobbing that over the wall and hoping somebody picks it up. I think part of our job is to go and get people engaged, get them looking at it, and help forge the community coalition. Once that’s forged, then it is our job to help them support their questions. Because as you give data to people, they’ll have a lot of aha moments, and then they’ll say, “But what about this?” And then it becomes a search for some more facts, right? So we’re helping supply the facts, but we have to start to mobilize the coalition so that it powers towards getting to some action and solutions.

JESSICA

A very special thank you to everyone who submitted questions for this episode. Piper and I really enjoyed reading your questions and listening to your voice memos, and you gave Dave a lot to reflect on. This episode literally wouldn’t have been possible without you. So thank you. Another thank you goes to Dr. David Ross for sitting down with us again and answering all those questions.

Inform Me, Informatics is a project of the Public Health Informatics Institute and the Informatics Academy. You can find out more on phii.org. Our theme music is called “Carnivale Intrigue” and was composed by Kevin MacLeod. We’re really excited to say that we just passed 1,000 listens. Thank you all for listening and for encouraging others to listen too. We’d like to ask you to consider rating us on iTunes. Those ratings help other people find out about us and, more importantly, find out about informatics.

Finally, many thanks to our production team, especially Piper Hale and Christopher Hall, who made magic with this week’s audio. You made it feel like a real call-in show, and we really, really appreciate all of your creativity and skills.

I’m Jessica Hill, and you’ve been informed.

BUTTON

DAVE

Diplomatic skillset.

[PHONE RING TONE BEGINS QUACKING]

JESSICA

Waters are rising.

DAVE

Chase those ducks out of here. The water is already coming in. I’m so sorry. I forgot to turn off my cellphone.