The Third Leg of the Stool: Health Care, Public Health, and Structural Social Work

I am a sociologist and macro social worker. I came of age professionally around the time the US was dismantling its safety net through a major overhaul of the welfare system in 1996. By the time I finished my MSW degree, I was a single parent with a ton of student loan debt and not receiving a penny in child support. After a few years of working in the field, doing child policy, research, and advocacy work at the Children’s Defense Fund in Washington, DC, then a small non-profit in Flint, Michigan (and still not receiving a penny in child support), my career began to shift to the health care space. I am just now beginning to understand why that was not a coincidence.

About 25 years later, I find myself wondering why health care and public health aren’t leveraging the knowledge available in the fields of sociology and macro social work, specifically structural social work, to address what public health calls the “social determinants of health.” I struggled to understand why or how entire disciplines, or fields of work, would or could be crammed into a single phrase. I finally found a big part of the answer to that question in a 2015 article I stumbled across on LinkedIn called Why language matters: insights and challenges in applying a social determination of health approach in a North-South collaborative research program.

As it turns out, approaches to understanding and addressing public health issues are significantly different between countries in the global North and global South. Approaches in the North tend to be very quantitative and top down in nature, while approaches in the South rely more heavily on mixed methods and the knowledge and experience of the people directly affected by inequality on a global scale. Using sociological terms, the North places emphasis on ‘objective’ truth, assuming independence from any kind of ideology.

In reality, the North values the white male (colonizer) viewpoint over female and non-white perspectives. This is reflected in scientific approaches that value quantitative over qualitative or mixed methods approaches and valuing fields that use these approaches (health care, public health, traditional economics) over other fields (sociology, social work, anthropology).

Approaches in the South are more consistent with the far less-valued fields of sociology, social work, and anthropology in the North. Southern approaches to health care and public health use a more holistic approach, combining quantitative and qualitative methods, including taking into account the lived experiences of those affected by the global and societal dynamics that directly impact quality of life, particularly for low- and moderate-income people.

It is past time for health care and public health to invite other disciplines to the table. Health care and public health in the US benefit greatly from white male (and arguably colonizer) viewpoints. As illustrated in the recent JAMA debacle (structural racism does not exist), the white male perspective is baked into existing systems and perspectives. 

The white male (colonizer) viewpoint is simply incapable of understanding the lived experiences of oppressed people. In fact, it, and the fields of health care and public health, benefit from their relatively privileged standpoints. If the fields do not take into account knowledge from other disciplines, they will very likely continue to participate in the structural perpetuation of racism.

Back to my original point. I had a huge debt-to-income ratio, so I relied on my quantitative data skills to make a living, which led me to working in health care for the past 17 years. Now I see that literally, social service funding has been diverted into health care in the US. No wonder my need for financial survival led me here. The US spends more on health care and disproportionately more on health care than social services than other countries (The American Health Care Parardox: Why Spending More is Getting Us Less), which is wildly inefficient from an economic standpoint. The US diverts funds from the people who need it (and pay a disproportionate amount of taxes relative to more privileged people) into health care. 

I see public health folks trying to get a piece of the pie (I will talk about the problems with the ‘wrong pocket problem’ in a separate post), but people not realizing the funds should be invested in the actual people who need help via social services (cash assistance), the earned income tax credit, and similar means. After all, wouldn’t some kind of assurance of basic income provide the funds needed to support grocery stores, pharmacies, and other services in low-income communities? 

Addressing social needs using taxpayer money through a largely profitable health care system, or even a struggling public health system, will not address the underlying structural systems that thrive because of oppression and the relative privilege gained (for some) as a direct result of existing systems. There is a real risk of perpetuating structural inequality if other sources of knowledge and experience continue to be sidelined as money is invested in addressing these issues through the limited perspective of "social determinants of health."

Consumer Engagement & Meaningful Use

Below is the comment I posted on the Creating a Vision for Engaging Patients and Families Through the Meaningful Use of Health IT post on the Federal Advisory Committee Blog (as of this post, comment still in moderation).

Thanks to the HIT Policy Committee Implementation Workgroup for hosting an interesting, informative, and lively hearing on consumer engagement today!

It seems there is a fair amount of consensus and support for the current suggested meaningful use criteria for the coming few years. These requirements should serve as a floor – not a ceiling – for progress towards achieving a stronger technology-based health care system. Assuming I am understanding Dr. Tang’s carrot vs. leash analogy, we have a carrot-based framework outlined for encouraging providers to move in the right direction between now and 2015.

However, a possible unintended consequence of having relatively simple and broadly achievable meaningful use requirements is that the articulated criteria may have the effect of stifling innovation among the next generation of health care solutions providers. I suggest we consider creating a second ‘track’ for meaningful use.

Just as a gifted child will likely become bored and disengaged with remedial classroom instruction, current meaningful use criteria will do little to inspire forward thinking health care providers and ‘health 2.0’ innovators. I wonder if it is possible to create an experimental advanced track for the more nimble and tech-savvy crowd of solution providers. This would be equivalent to ‘severing the leash’ for the more advanced folks. Whatever innovation, promising solutions, and lessons learned come out of a ‘meaningful use sandbox’ could be shared regionally and nationally…and inform future policy.

If you have any policy-related comments, please share them on the Creating a Vision for Engaging Patients and Families Through the Meaningful Use of Health IT post.

Interrupt Me Not

I take pride in being a pretty nice person. I am generally very accomodating and I am always an excellent listener. I turned mean, though, on a recent evening. I was talking to a couple of men I know and was sharing an observation about social influences in culture when - mid-sentence - one of the men interrupted me to tell me that my shirt was pretty. If I wasn't so into peace and non-violence, I think I would have enjoyed slapping him right about then. Instead, I gave him a really, really mean look.

He immediately went on the defensive (or more like offensive) and tried to make me out to be an ice queen who couldn't take a compliment.

His friend - let's call him Switzerland - tried to keep the peace. I told Switzerland that this wasn't about this particular incident; it was about a pattern of behavior. Mr. Pretty Shirt oscillates between teasing me and chiding me for being so quiet. That's why it makes zero sense that when I finally start talking, he makes a habit of interrupting me.

Mr. Pretty Shirt is a good person at heart, but is unaware of his tendency to dominate conversations. I think no one has really called him out on it because he's a man. I guess he has enough redeeming qualities where people are willing to put up with this behavior (myself included, thus far). I've seen people deal with him by being loud and boisterous and interrupting back, but that just isn't my style.

Why do we (usually women) put up with this behavior (usually from men)? Well, look at Mr. Pretty Shirt's reaction: instead of acknowledging that he offended me, he acted like I did something wrong. Whether men realize it or not, the deck is stacked in their favor when it comes to defining social situations. There is plenty (I'd estimate a boat load) of research to document this. It has to do with a lot of things ranging from hormones to social upbringing to linguistics.

Why am I writing about this? First, I love writing about taboo subjects that few people want to touch. Second, I think men could use some honest feedback (and it's probably easier to digest the information through a story about someone else's misstep).

P.S. Obviously not all men are like this. In fact, most of the men with whom I interact are quite the opposite. Also, I have a couple of close female friends (you know who you are) who are infamous interruptors. What I am talking about is a pattern and how it plays out when men and women interact.

P.P.S. I've been watching how these dynamics play out in social media for more than a year now. Really interesting stuff. There are definite gender dynamics that play out explicitly and implicitly, both online and offline.

The Data is Shit

After many months of working frenetically to get the data in front of the client, that was their response.

“The data is shit”. – (unhappy) (I mean, *really unhappy*) client

Or so the story goes. Fortunately, I was not invited to that particular client meeting. I don’t know if the client actually used those words, but I wouldn’t be surprised if they did because it was a pretty concise description of the data we had been working with for months.


We had politely been referring to the herculean effort as one of (unprecedented) data “harmonization,” so forgive me if I chuckle every time I hear the term “data harmonization”. Seeing as how I played a leading role in this data harmonization effort, you might be surprised that a) I find the client response amusing and b) I would publicly fess up to coordinating this effort.

The Client

I was recruited to work on this project because of my expertise in data management *and* I had experience working with a (successful) data archiving effort for this particular client. I hope I don’t get in trouble for this, but in the age of “government 2.0” and transparency in government, here goes. The client was SAMHSA, the Substance Abuse and Mental Health Services Administration at the US Department of Health and Human Services.

I had previously been working at the official SAMHSA data archive (SAMHDA) at the University of Michigan’s Institute for Social Research (ICPSR), so I was quickly snatched up by an HIT (health information technology) ‘beltway bandit’ company at the end of 2006 when they realized they were in over their heads on a 5-year $25M project for SAMHSA. The project involved standardizing data from disparate sources for their Data Coordination and Consolidation Center (DCCC).

The Data

There was nothing inherently wrong with the data. Really, it was a matter of expectations. Not many people understand data and what it can and cannot do for you. We were given the challenge of consolidating data from significantly different data streams. This is not impossible, but is a delicate effort. Arguably, the more you work with data in this way, the less it will do for you. Even ‘good data’ has its limits.

It’s All about Context

Part of the reason I didn’t take this whole abysmal failure thing too seriously is because I could see it coming for months ahead of time and it was kind of a relief to get it over with. Beyond the ordinary challenges of working with data and managing client expectations of said data is the larger context of the project. It was one of those huge government contracts that didn’t, um, how should I say this? It didn’t really make sense.

The original contract called for this whole data harmonization effort as well as the creation of a data analysis tool to view and analyze the data. Sounds simple enough, right? Simple, yes, but also expensive and unnecessary given that such tools already exist. Apparently the contract was set up in such a way that incentivized creating a whole new data analysis system from scratch. And so the HIT company did exactly that. It spent two years and a few million bucks reinventing the wheel. While this expensive and unnecessary toy was being developed, I worked with a team of SAS programmers to harmonize the data to put into the shiny new object.

Should anyone have been surprised when the client, at least $7M later, looked at the data and said it was shit? They took the luxury car (that they had asked for in the original contract) for a test drive and when it only drove 3 MPH, they were livid. Was the problem that the engine maxed out at 3 MPH or that they accidentally ordered a luxury car when a lawn mower would have been more appropriate?

How to Choose a PCP

I am an expert in PCP (primary care provider) selection. Why, you may ask? Because I have a lot of experience selecting PCPs.


I am a member of the generation of workers that changes jobs at least every two years or so. This means I get a new health insurer every two years or so. And I have yet to find a new health insurer who will cover expenses if I stay with my current PCP.

At this point, I don't even bother trying to remember my doctors' names or build much of a relationship with them. I don't go through the effort of transferring my health data either. Whatever energy I put into that relationship gets flushed down the toilet every two years or so.

Anyway, back to the point of this post: to share my personal wisdom on how to select a PCP. Here are the basic options:

a) Let the health insurer automatically (and presumably, randomly) assign you a PCP.

b) Choose a name randomly from the list they provide (which, by the way, may be out of date and require you making endless phone calls to find a PCP that *actually* accepts that insurance *and* is accepting new patients).

c) Choose someone who has a name that sounds appealing to you. If you are 'white bread' and proud of it, choose a PCP with a last name like Smith or Jones. If you are Latino/Latina, choose a PCP with a common Latin name. You get the picture, right?

d) Choose a PCP with a last name in the second half of the alphabet. If you are into fighting alphabet discrimination, this is a nice route to take. Those PCPs with last names that start with A, B, or C? They get way too much attention based on their arguably unfair placement in directories.

I've learned to take a slightly different route. Warning: this may not work for you.

I examine the entire directory. I assess the available information. This typically includes name and sex. You can guess at information about physician ethnicity from here. Sometimes directories include languages spoken. Again, this gives you a clue as to the ethnic background of the physician, if that makes a difference to you. Whether you are afraid of ethnic differences or embrace them, you can make decisions based on this limited information.

Oh, yeah, and if they list medical school? Bingo! That rounds out all the available information I've ever seen and brings me to sharing three of my most recent experiences in selecting a PCP.

A few years ago, I selected a PCP for my then pre-adolescent son based on one of these simple directories. I scanned through with ease and expertise (given I have plenty of experience analyzing such lists). And voila, I found my son's PCP! He fit my only preference (being that he was male!). I thought my son might like a male PCP. This doctor had an Indian-sounding last name, went to Howard University medical school (a predominantly African-American school in case you live under a rock or in the suburbs), and spoke several languages, including Spanish!

I hit the physician jackpot! I don't speak Spanish, but I thought it was cool that he did, especially considering he was likely Indian (really, how many people of Indian descent speak Spanish?) and he went to Howard?! This dude had to be an interesting person. (And turns out, he was a great doctor. But guess what? I changed jobs and ended up with a new health insurer that considered him 'out of network'.)

The next PCP I picked for my son was within the Kaiser Permanente (KP) system. I had a fairly short list to work with (trust me, this is *not* a complaint) since I wanted to go the facility closest to home. I ended up picking a female PCP based on her last name; it looked like an Arabic name. I figured she probably gets discriminated against by white people who grew up in the suburbs and watch too much network news. And sure enough, she was a lovely PCP for my son...until I lost my job. (Turns out I wasn't eligible for COBRA, so keeping KP was not an option.)

I picked my own PCP at KP based on where he went to medical school. Normally, I prefer female PCPs, but this guy went to medical school at the University of Michigan. I went to school at the University of Michigan (both undergraduate and graduate program) and relied on the University of Michigan Medical System for health care for many years. After having had countless negative experiences with the health care system in and near Flint, Michigan, I was happy with my care through the University of Michigan (ok, maybe there was one or two docs I didn't particularly care for, but that can be chalked up to personality issues).

Seeing as how neither my son nor I currently have health insurance, I have been spared the chore - for now - of selecting new PCPs for either of us. Hopefully I will have health insurance soon. Then, I will go through this process *yet again*.

Entertaining Sanity

I publicly proclaimed (via twitter) the following 2010 New Year's Resolution:

"I will no longer entertain people's delusions,
even if they are willing to pay me to do it."

It's only the last day of January and I've lost business over this resolution this year. Some people might consider this a failure (losing business), but I consider it a success.

Psychology in the Workplace

I had a great phone conversation with a friend in Washington state yesterday. We talked about a lot of things, including this. I almost jumped out of my skin when she referred to "family of origin" issues in the work place. Someone else knows what I'm talking about! (I guess it's not just us social work types that notice these patterns.)

Consulting is One Way to Find the Exit Sign

Forgive me for putting a big picture of myself right here, but there's something I love about this picture (hint: it's a word in the background).

People bring an incredible amount of psychological baggage with them to work every day. If you can avoid the worst offenders, great. But what if your boss is one of these people? As I like to say, "lawd ha' mercy."

Consulting is not an easy answer. I still need to negotiate endless unwritten (and often unreasonable) expectations (more about that in future posts). However, if you're willing to give up health insurance (yes, that is a big 'ask') and the delusion of 'job security' (um, if you haven't figured this out by now, it simply doesn't exist), you are in a position to regain a level of self-respect you may not realize you've somehow lost through your experiences in the traditional 'workplace.'

Retired

I am thirty-something, a few years shy of being 40 years old. I decided to go ahead and officially retire. Now. Actually, I retired a few months ago.

I never really wanted to have a job. I never wanted to get married. I couldn't see myself having children. From my vantage point in the suburbs of Flint, Michigan, I saw absolutely nothing I wanted to replicate.

My parents struggled to send me to college. With a good education, I could get a good job. I, on the other hand, was incredibly relieved to find that college wasn't anywhere near as brain-numbing as high school.

I briefly considered getting a degree in computer science. In high school, I programmed better and faster than my peers. On an Algebra final exam, I proved I could solve algebraic equations better and faster than any of my peers at the University of Michigan-Flint. But, alas, I found my true love: sociology. Introduction to Sociology, Social Stratification, Urban Sociology, Race and Ethnicity...

I was in heaven.

My parents were mortified. (What can you DO with a degree in sociology?! )

I responded by saying, "I can get a PhD and be a college professor". I'll never forget the response I got to that statement. I felt like I was 5 years old and had just announced I was going to be a fireman when I grew up. (Neither of my parents ever completed a BA or BS degree. Apparently me attending graduate school seemed about as realistic a possibility as a trip to Pluto. Now might be a good time to mention that I have always been the "black sheep" of the family, breaking all of the rules.)

With all the talk of web 2.0 and health 2.0, I'm surprised we don't hear more about "work 2.0." What is work 2.0, anyway? I'm not completely sure, but I do know that it's probably similar to "unwork" (think "unconference") in the sense that hierarchy is considered an antiquated concept. Think cooperation. Mutual respect. Not what can you do for me, but what can we do together?

On that note, I am pleased to announce my retirement from "work 1.0."