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Overcoming Health Disparities: Global Experiences from Partnerships Between Communities, Health Services and Health Professional Schools

October 6-10, 2004 in Atlanta, GA USA

Co-sponsored by Community-Campus Partnerships for Health and
The Network: Towards Unity for Health

Report from Day 1
Report from Day 2
Report from Day 3
Report from Day 4
Report from Day 5
Conference Materials

Report from Day 1

Greetings from Atlanta, Georgia USA, home to the international conference on "Overcoming Health Disparities: Global Experiences from Partnerships Between Communities, Health Services and Health Professional Schools" being co-sponsored by Community-Campus Partnerships for Health and The Network: Towards Unity for Health. Over 500 people from over 40 countries are in attendance.

Knowing not all CCPH members are able to attend the annual conference, we will be posting daily reports to the listserv to keep everyone in the loop! You can check out descriptions of most conference sessions and keynote speakers online.

While the CCPH Board of Directors held its board meeting on Wednesday, October 6, conference participants took part in one of four half-day intensive skill-building workshops: service-learning as a strategy for eliminating health disparities, essentials of community-based participatory research, getting an article published or effective communication for health.

On Wednesday evening, participants boarded buses to the National Center for Primary Care (NCPC) at the Morehouse School of Medicine, which hosted the conference opening reception and session. The mission of the NCPC is to promote excellence in community oriented primary health care and optimal health outcomes for all Americans, with a special focus on underserved populations and on the elimination of health disparities. After a delightful cocktail hour, participants took their seats in the auditorium to hear an inspiring presentation by David Satcher, the 16th US Surgeon General and now director of the NCPC. His presentation, "What Will it Take to Eliminate Health Disparities Globally?" began with reflections on his significant leadership roles in this country, from President of Morehouse School of Medicine to director of the Centers for Disease Control and Prevention to Surgeon General and Assistant Secretary for Health. As Surgeon General, he was able to draw attention to issues that are often overlooked and had never been subjects of previous Surgeon General reports: mental health, suicide, and oral health, to name a few.

Satcher went on to highlight the Healthy People 2010 objectives and their focus on eliminating health disparities. To eliminate disparities, he warned, we will need to address the barriers posed by people who are uninsured, underinsured, underserved, underrepresented, uninspired, untrusting and uninformed. He outlined a strategy for the future that will depend on community partnerships, advocacy, undoing individual and institutional bias, and cultural competency.

Turning his attention to health disparities on a global level, he shared the success story of immunizations. Due to the concerted effort of the World Health Organization and its many partners, nearly 3 million deaths a year in developing countries are prevented through the effective use of immunizations. He also noted accomplishments in tuberculosis control, especially directly observed therapy and its success in both developing and developed countries. He spoke passionately about the leading preventable cause of death in the world: tobacco.

In May 2004, the World Health Assembly adopted a resolution on tobacco that would significantly decrease the use of tobacco through such means as restrictions in marketing and changes in health warning labels. The bad news, he warned, is that the resolution still needs to be ratified by 40 countries, including the United States. Considering the tobacco industry's stranglehold on the U.S. Senate, this action is unlikely at this time. Still, he highlighted the tobacco resolution as a rare example of the global community coming together to address a major global health issue.

What will it take to eliminate health disparities globally? He asked. First, we have to care enough as people and as a country to act. We need a global community invested in global leadership of such organizations as the World Health Organization. We need global sharing of resources and intervention strategies. We need global agreement on policies to protect and improve global health (the tobacco resolution being a recent example). We need global investment in research to develop new technologies and new interventions. Perhaps most importantly, we need a global attack on poverty. Without attacking poverty, we will not eliminate health disparities.

He ended his speech with a quote from John Gardner, a former U.S. Secretary of Health, Education and Welfare, "Life is filled with golden opportunities, carefully disguised as irresolvable problems."

After his prepared remarks, Satcher fielded questions from the audience on such topics as the movement of health professions from developing countries to developed countries, the current Surgeon General's commitment to oral health, the cost of prescription drugs and the role of health professionals in eliminating poverty. In addressing the latter topic, he stressed that health professionals need to be active members of their communities and active in the political process (for example, serving on the school board, volunteering in free clinics and of course voting). He called upon health professionals to provide leadership for the public's health - indeed, they have a responsibility to provide such leadership.

Report from Day 2

Keynote presentations on the 2nd day of the international conference on "Overcoming Health Disparities: Global Experiences from Partnerships Between Communities, Health Services and Health Professional Schools" offered views of health disparities from the "trenches" and from "30,000 feet."

In her talk entitled "Health Disparities and Migrant Farmworkers: CBOs in the Trenches," Andrea Cruz, director of the Southeast Georgia Communities Project highlighted her experiences and insights about how a community-based organization struggles to improve health and quality of life for a marginalized community.

Although immigrant farmworkers are a resource to the economy and culture, too often they are seen as a burden to society. In Southeast Georgia, as in other parts of the country, migrant farmworkers are targeted for hate crimes and discrimination. Day-to-day needs are also an issue. Although health care and English-language training are priority needs, other concerns are often more immediate. Enrolling children in school and securing stable housing, for example.

Andrea Cruz was one of ten children born into a poor migrant family. As a farmworker, Cruz witnessed and experienced firsthand the poor treatment that migrants often receive. For nearly a decade, Cruz and the Southeast Georgia Communities Project (SGCP) she founded have been building bridges among migrant farmworkers, farmers, local citizens, service providers, academic institutions and legal advocates. Her exemplary leadership was recognized by the Ford Foundation with a prestigious Leadership for a Changing World award in 2003.

In addition to identifying the acute problems Latino migrant farmworkers face, Cruz and her CBO have developed an impressive list of responses. They've created a network of interpreters for medical visits; recruited AmeriCorps members to conduct cultural sensitivity workshops for local health department and hospital staff; established a prenatal education program with follow-up home visits for new migrant farmworker mothers; helped create an HIV education and prevention program; developed a legal assistance program through the Georgia Legal Services Project; established an annual farmworker health fair attended by over 1,500 farmworkers every year; and produced a radio program on health and education issues targeted to migrant workers. Academic institutions, including faculty and students in nursing, medicine and social work, have been valued partners and supporters.

In his presentation on "Catalyzing Systems Problem-Solving in Global Health: A Role for Health Professionals," Tim Evans, Assistant Secretary-General of the World Health Organization, discussed the daunting systems challenges we face in improving global health. He began by highlighting significant set-backs around the world. For example, 16 countries in Africa have experienced decreases in child survival rates over the last decade, not all explained by the AIDS pandemic. The complex health development landscape and major systems constraints, he argued, are getting in the way of bringing proven interventions to scale. The billions of dollars being poured into global health initiatives is of concern, he noted, because there are often too many players in a given country or on a given issue, and sustaining such an enormous investment is nearly impossible. What we need, he said, is one plan, one strategy and one monitoring and evaluation system.

Why can't systems perform effectively? Evans pointed to 5 system-wide constraints:

1. Maldistribution of resources: Conventional wisdom among funders and policymakers has been that in many developing countries, "one size fits all" for a given health promotion or disease prevention intervention. In other words, it was assumed that the country was too poor to have significant stratification of economic and other resources among the population. What we are finding now, however, is that this is simply not true. Even very poor countries have economic stratification and will need multiple tailored strategies and interventions to improve health. He emphasized the determinants of health with an acronym, PROGRESS: place of residence, religion, occupation, gender, race/ethnicity, education, social networks/capital and socioeconomic status (including income).

2. Information systems" There is no coordinated system for gathering or reporting information about health across the globe. At the same time that key constituencies are not able to systematically communicate their needs, poor quality information abounds from multiple independent sources. Evans pointed out an information paradox: paradoxically, countries with some of the highest birth and death rates do not have vital statistics registries in place to reliably and accurately count births and deaths. To make people count, we first need to count people, he observed.

3. Financing: The majority of consumers, especially the poor, are paying out of pocket for health services. Tens of millions of households are impoverished annually by "accessing" care. Despite what many economists say about how we are spending too much money on health care, Evans argued that we are under investing in pre-payment systems such as social insurance.

4. The "drug systems": Evans discussed three issues: market failures in research and development for developing new drugs and vaccines for diseases of the poor, systematic bias in reporting of clinical trials, and ineffective drug distribution systems that lead to inequities in access to drugs.

5. The workforce: According to Evans, the health workforce is the most neglected part of the health system, yet it accounts for 50-75% of the budgets of most nations' health systems. The health workforce is not seen as an asset or an intervention for improving health. There is a paucity of attention to the working conditions that allow health workers to be most productive for problem-solving and leadership. There is now a global labor market in health care, and a serious "brain drain" of trained health professionals from developing to developed countries. The risk of contracting HIV/AIDS is also a major issue for health workers in many countries. Worker density also varies enormously across countries. There is a 10-fold difference between the density of health workers in industrial countries and developing countries. Evans mentioned books like Where Women Have No Influence and Where There is No Doctor, that demonstrate how low-income communities can manage their health without a doctor or other trained health professional. But at the same time, Evans noted, "when you are a pregnant woman hemorrhaging during labor" having access to skilled medical personnel is essential. The Global Health Trust is attempting to address many these issues. Its purpose is to advance global health equity through strengthening the production, deployment, and empowerment of human resources for health in low-income countries. The work has been launched through a Joint Learning Initiative, a multi-stakeholder participatory learning process, to better understand the role of workers in health systems and to identify new strategies to strengthen their performance.

Evans concluded his presentation by mentioning a few World Health Organization initiatives underway designed to help solve these systems-level challenges:

1. The WHO's Ministerial Summit on Health Research, November 16-20, 2004 in Mexico City will convene health ministers from every country to help create stronger linkages between the research, policy and practice communities.

2. The WHO Health Leadership Service is recruiting young health professionals to a two-year work and training programme, specifically aimed at strengthening the knowledge and skills essential for leadership roles in public health at national, regional and international levels.

3. WHO has issued a public call for nominations for Commissioners for the new Commission on Social Determinants of Health. Launching early in 2005, the Commission will be a high-level global body that will gather evidence and advocate for political action to narrow health gaps by addressing the social processes that affect health. Nominations are being sought for 12 to 18 Commissioners and are due on November 15.

Report on Day 3

Community site visits and PEARL sessions were highlights of the 3rd day of the
international conference on "Overcoming Health Disparities: Global Experiences from Partnerships Between Communities, Health Services and Health Professional Schools."

Seventeen community-based programs graciously opened their doors and hearts to
welcome conference participants on 3 hour educational site visits. With over 500 people from more than 40 countries attending the conference, the morning began with an orientation to the U.S. health care system.

Lawrence Sanders, associate dean for clinical affairs at the Morehouse School of Medicine ]link to], presented a concise and thoughtful overview of the system and its many challenges. Trained in internal medicine and having held past positions with the Centers for Disease Control and Prevention, the Philadelphia City Health Department, the DeKalb County (GA) Health Department and Atlanta area hospital systems, Sanders conveyed the perspectives of consumer, clinician, administrator and policymaker.

His points included:

1. 15 cents of every dollar in this country is spent on health care, and is expected to double in the next 10 years. Why then don't we have the best health outcomes in the world?

2. Public health has contributed the most to health outcomes through clean water, clean air and control of infectious diseases.

3. In America, we have a system that provides the best care to some and little to no care to others. Our challenges are controlling costs and assuring access to high quality care to everyone who lives in this country.

After defining managed care, as "managed utilization," Sanders made a joke to illustrate his point: There were three people at the gates of heaven. The first person said to God, My contribution to the world was to invent penicillin to cure disease. God said Come on in. The second person said, I reformed medical education and increased the quality of health professionals and the care they provide. God said Come on in. The third person said I invented managed care to save costs in the health care system. God said, Come on in. But you can only stay three days.

After Sanders' overview, conference participants were assembled into groups and taken by bus to their community site visit. The complete list of sites can be viewed online.

Upon their return to the hotel, participants gathered for lunch and table discussions centered around a set of reflection questions designed to prompt connections between their observations on the community site visit, their experiences at the rest of the conference, and their partnership work awaiting them back home.

In the afternoon, PEARL sessions offered participants the opportunity to discuss topics of critical concern. What are PEARL sessions, you ask? The acronym stands for PErsonally ARranged Learning Sessions (P.L. Schwartz & C.J. Heath (British Medical Journal 1985, 290, 453-4). Basically, on day 1 and 2 of the conference, participants were invited to suggest topics they would like to facilitate a discussion around. The five topics that attracted the most people were added to the conference program and assigned a meeting room. The topics were:

1. How to sustain a grant funded project or program
2. Re-orienting education towards public health, primary care and the community
3. Shaping the future of multi-professional education
4. The concept of anthropological medicine
5. The development of family medicine and primary care in Latin America and Europe

The day ended with a lively dinner and dance at the Freight Room, a converted railway station in the heart of downtown Atlanta. It was evident from the activity on the dance floor that conference participants had renewed friendships and made new friends over the course of the conference's first three days!

Report on Day 4

Day 4 of the international conference on "Overcoming Health Disparities: Global Experiences from Partnerships Between Communities, Health Services and Health Professional Schools" began with a panel presentation by representatives of agencies that provide resources for eliminating health disparities, alleviating poverty and promoting social justice. All were asked to share brief remarks on their lessons learned and thoughts about the future, with a particular emphasis on partnerships as a strategy for change.

Jacquelynne Borden-Conyers, Communications Manager for the health programming
area at the WK Kellogg Foundation, began by highlighting the roles of the Foundation in disseminating knowledge, making connections and leveraging funding. She identified the Foundation's three major priority areas over the next five years: a diverse leadership, a strong safety net, and improved quality of health care services, especially for the most vulnerable populations.

In the area of leadership, she explained that the Foundation is interested in both positional and non-positional leaders. Non-positional leaders, for example, would include community members who don't necessarily have titles or degrees. She singled out diverse leadership in academic institutions as a special emphasis. Giving community a voice in the decisions that affect their lives, including about health care and the delivery of services, is an area of emphasis for the Foundation. Efforts to improve the quality of health care, she said, must include a focus on consumers and patients.

The Foundation's mission is to help people help themselves. Promoting social justice and addressing the social determinants of health are central to this mission. In using the term "diversity" she was quick to point out that while racial and ethnic diversity is critical, we must also embrace diversity in terms of culture and economic status. In using the term "community" she acknowledged that while we all have different definitions of community, we must strive to have everyone come to the table.

She concluded her remarks with reflections on what the Foundation has learned
about engaging academic institutions with communities: Collaborate with communities in the design of programs. People tend to go to the "usual suspects" as partners, but we must dig deeper into the community, learn their language and culture, and gain their respect. Engage in reciprocal learning. Academic institutions and communities both teach and learn through the partnership. Commit to diversity. Regularly assess progress. Commit to knowledge, to talking with people, to learning their stories. Invest in leaders. Leverage resources, including building capacity for the community to manage funding. Pursue shared leadership and governance. This needs to be taught and continually worked on. Just because we say we're now going to work together doesn't mean it will happen.

Peter Levesque, Deputy Director of the Knowledge Products and Mobilization Division of the Social Sciences and Humanities Research Council of Canada began by explaining the mission of his agency: to fund research and research-related activities in social sciences and the humanities, and to advise the Minister of Canada. The agency helps to understand and interpret the social, economic and cultural nature of the country, within a global framework. The agency funds to answer the questions of "what, so what, and now what."

Levesque was quick to point out that the agency does a good job of answering the "what" (data and information), a pretty good job of answering the "so what" (meaning and interpretation of that data and information), and a lousy job of answering the now what" actions, decisions and impact). The same could be said of much of the research that is funded in general. Levesque cited these telling statistics: There are over 24,000 peer-reviewed journals in the world, publishing over 2.5 million articles a year. Of these articles, less than 35% are cited by other articles more than 5 times, with 85% cited less than 10 times. The main audience for peer-reviewed articles is other researchers, limiting the value of research to practitioners and policymakers.

Although the social sciences and humanities represent 55% of the faculty in Canada, it accounts for less than 12% of the research budget. As a result, there is often a sense of powerlessness in these fields. In response, the agency pursues and promotes strategic partnerships. The agency's Community-University Research Alliance program was designed to support partnerships between communities and universities to get at the "now what." [Author's note: Letters of intent for the next round of CURA grants are due December 6, 2004]. Fellowships for master's and doctoral level students are designed to build their skills and competencies in interdisciplinary collaboration and societally-based projects in the hopes of affecting their long-term career trajectories and outcomes.

The final panelist, Edwina Yen, is technical advisor for the Human Resources Development Unit in the Strategic Health Development Area of the Pan-American Health Organization. PAHO is the regional office of the World Health Organization for the Americas. Yen framed her remarks around the Millenium Development Goals, which focus on health and equity and form a platform for PAHO's work. The MDGs are an integrated approach to national health development - health promotion, public health, primary health care, social protection, inter-sectoral collaboration and community participation.

She outlined a series of challenges to public health in the new millennium: Complex and changing relationships between public health and personal health determinants and models of intervention. Combining efforts of the State, the community, health professionals and health institutions through interventions based on local capacity. Being open to change and coming up with strategies that cut across sectors and disciplines. Renewed focus on fostering synergistic partnerships and development of common agendas.

Partnerships have been instrumental to public health's achievements in such areas as reducing morbidity from tuberculosis, strengthening and expanding vaccination programs and eradication of foot-and-mouth disease. But we have an unfinished agenda that includes: the fight against extreme poverty and hunger, reduction of mortality in children under five, improvement of maternal health, the fight against HIV/AIDS, improving access to essential drugs, health of indigenous peoples, and targeting neglected diseases in neglected populations.

In the area of human resources, Yen pointed out a number of lessons learned from primary care in the Americas over the past 25 years: health care models must emphasize health promotion, prevention and education; they must stimulate social participation in health and the incorporation of community workers into health teams; they must include local multiprofessional teams and interdisciplinary cooperation; and they must integrate primary health care content into the curriculum of professional schools.

Yen emphasized that our ultimate goal is to bolster the capacity of countries to meet national, sub regional, regional and global public health targets, especially the MDGs. Fostering a diversity of strategic alliances - with professional schools and associations, civil society and "on the ground organizations", religious institutions, non-governmental organization and the like will be key to achieving this goal, as will advocacy through dialogues, partnerships and intersectoral action and enhancing decision-making power for communities, civil society and vulnerable populations. The "glue" is in the collaboration.


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