Take a damn risk already.

The time has come to try to get in trouble.  Just a little bit.  By all means, go on collecting your data and hitting your targets, but stop keeping your head down all the time.  Be a badass and try something new.  Use whatever leeway you’ve got to do small things that are different and bold and a little risky.  Build some credibility with your little wins.  Then go a bit bigger with it.  Why?  Tired, mediocre junk bullshit doesn’t change anything.  You do want to change things, don’t you?  Otherwise you’d probably be reading a paper newsletter called Status Quo Public Health, written in Microsoft Works.

Of course, the system isn’t set up as a friend of innovation.  Federal, state, and local governments are set up to favor existing providers and previously funded programs.  Public grants come with hefty reporting requirements, and tend to go toward evidence-based interventions – even if they’re based on small studies from twenty years ago.  Foundation grants come with their own restrictions and motivations.  This means that we all wind up spending a lot of time just trying to function within some pretty inflexible parameters.  But my point stands:  You have to find a way to do some things differently from your peers.  You have to be willing to be risky.  It’s the only thing that will keep you competitive as the funding continues to melt away.

Right now, you might be thinking about how you don’t have time or resources to waste on things that might not work.  I hear you.  But listen:  there is waste, and then there is risk.  Somewhere along the line, we started to mix them up, but they’re not the same thing at all.  Waste is often dressed up as “but that’s the way we’ve always done it.”  Waste is neutral colors, safe language, and talking about the weather.  Risk, on the other hand, is loud and boisterous.  Risk is probably wearing a big, crazy hat and cracking sex jokes.  You might love it or you might hate it, but it definitely makes an impression.  Waste fades into the background.  Risk stands up and gets noticed.  Waste is safe.  Risk isn’t.  Waste gets you nowhere.  Risk might get you somewhere.

We happen to be pretty comfortable with waste in public programs.  We are way less comfortable with risk.  This a problem for most humans, but it’s a problem that public health can no longer afford to have.  It’s impacting our ability to do our jobs well in an environment where we’re increasingly competing for attention.  What are you so afraid of, anyway?  That your little program will get called out on a national level like those Obamacare keg stand ads from Colorado?  You should be so lucky.*

Target Audience

No it’s not. Knock it off.

Here’s the thing.  I can promise you that someone will always think that you are wasting money.  It’s a natural consequence of almost everyone having to pay taxes, whether they like it or not.  If you are trying to please everyone, then you are serving no one.  This is an idea that is accepted by smart businesspeople, but foreign to the public sector.  Trust me – if no one is complaining about your program, then no one knows you’re there.  (If you don’t believe me, go to a public meeting on something.  Anything.)  We can’t serve every person with every dollar that we spend.  So stop trying.  

Instead, try to serve a smaller number of people really well.  You can do that by thinking about the people you’ve had a positive impact on already, and figure out what they need.  (Here’s a hint: it might not be what they think it is.  They might say they need a meal, but what they might really need is both a meal and to know that someone cares enough about them to give them a meal.)  What could you do that they wouldn’t be able to shut up about?  How can you do something just crazy enough to get noticed, but not so nuts that you lose your funding?  Figure those things out, and then do them.  Build something different.  If it works, the funding will follow.  Oh, and you might really help some people along the way.

TL;DR:  Take a damn risk already.

And then do it again.

*For the record, I’m not a huge fan of those ads.  That being said, I’m not their target audience so my opinion doesn’t mean jack.  Plus, I appreciate the ballsy approach.  Props to the Colorado Consumer Health Initiative and ProgressNow Colorado for getting people talking nationwide with practically no budget.

Where the people are

Recently I watched the Frontline documentary on AIDS in Black America and I had a moment of insight (Aha!) that I thought I would share.

In the documentary,  a social worker who runs a needle exchange program in Atlanta talks about why he thinks people respond positively to his HIV testing and harm reduction program. He says what we have all heard a million times (and I’m paraphrasing), “we meet them where they are”. Now he didn’t mean that he uses some slang and sex-positive jargon. No, he meant that he goes to the neighborhoods where people are using, coping and surviving. His program gives out food, clean syringes, rapid HIV tests, support and links to other resources. But it’s a bare bones operation. A minivan with a notebook paper sign taped to the window reading  “HIV testing”. It’s hotdogs and water bottles. It’s actually on the street, not a storefront. He doesn’t try to get people to stop using drugs, he just helps them be safer about it.

I’m getting to my point, please be patient.

And before we go there, let’s go back to my former post about connection, a.k.a. “be a human”. If you will recall (or just take five minutes and read it, I’ll wait here for you) the main point of that post was to remember that we all are human beings just trying to make it through the day. The key to making connection with the people we work with (and for) is to be ourselves. And you know what? That’s the Aha! I was talking about.

If we are going to “meet people where they are” we have to be willing to go where they are. I don’t just mean to the corner, I mean be present with people, listen to them, see them. We put a lot of stock in geography (and venues) and forget humanity. Go to where the people are and be human(e).  Care for them. Listen to their concerns and their fears. Figure out how to get them a little closer to the end goal: wellness. Don’t focus on the means to the end: treatment, testing, adherence, etc. Focus on the person in front of you and what they need. Sometimes it starts with a sandwich and leads to an HIV test which leads to talking about substance abuse treatment which leads to sobriety which leads to….

But sometimes it is just about the sandwich. And you have to be ok with that. Or else you are in the wrong line of work.

Because no matter what you want or think is best, people gonna do what people gonna do. Just like you do.  I do at least two things that I know for a fact are risky and unhealthy, but I do them anyway. And I KNOW BETTER. Knowing ain’t doing. Thinking ain’t doing. Doing is doing.

In order to make any behavior changes or even think about those changes, we need to have some basic things in our lives. Remember those needs Maslow was so concerned about? If someone is hungry or scared or cold or jonesing….they aren’t going to give two damns about an HIV test or a flu shot, but they might take that sandwich or a kind word. And it’s our job to work from there.

Even after we build some trust and share information, there will be people who will keep doing whatever it is they gonna do. That doesn’t make our work a failure. The failure is never showing up, or checking off the boxes without ever really considering the PUBLIC whose health we are supposed to be protecting and improving.

We don’t work for health departments or research institutions or non-profit organizations. We work for the public, our fellow humans. Don’t you ever forget it.

Now get out there and be human.

On belief, part 2

In my last post we explored how belief dictates behavior and how we can influence and even change beliefs by talking about values. So now, as promised, I’m going to share some wisdom I gained from the badass Dr. Paul Offit on how sometimes we just have to ignore the beliefs and stick to the facts. I know, this contradicts everything I said last time. Stick with me here.

Dr. Offit is an expert on vaccines (he even invented a rotavirus vaccine, RotaTeq). He has written books on the history and science of vaccines and why Americans have such irrational fears of them. Lucky for me, Dr. Offit is a Philly local so I got the chance to talk with him at Public Health Book Club back in October about his new book, “Do You Believe in Magic?“.  The conversation naturally turned to how public health pros can address people’s fears about vaccines and do good public health work. So here is the synthesized wisdom from that discussion in one sentence:

Don’t accept their premise.

When confronted with an anti-vaccinations argument, just stick to the facts. Don’t start down the road of engaging with them about their fears and beliefs, because it’s not a good place to be: telling people what they believe is false (or stupid). People don’t like being told they are wrong or their beliefs are stupid (even if they are). Talk about how vaccines save lives (103 million American lives).  Talk about what life was like before we had vaccines for deadly and debilitating diseases like polio, measles, hepatitis, and influenza.  Talk about how outbreaks of polio pop up in countries that haven’t seen a case in decades. Talk about the outbreaks of pertussis in the last few years that have killed American children.

Go for the saddest stuff out there, take advantage of their emotional response to make the connection that vaccines are necessary, that these diseases still exist and still kill. The emotional response is your key to their hearts and minds. It works the same way as using values to frame other health issues and behaviors. I mean, that’s the goal anyway. Some people will never change their minds no matter the evidence or heart-rending pleas. Just let them go. You have more important work to do. Do not engage with them about mercury or overloading a child’s immune system or whatever other bunk people believe now.

You have science and history on your side. They have beliefs and fear and myths. As Dr. Offit told us at book club, “Ignorance is never an advantage.”

Go get ’em, tiger!

So we were talking about vaccines here, but this same approach can be applied to any issue or health topic. Just follow the advice: don’t accept their premise.

An 1802 illustration depicts Edward Jenner vaccinating a young woman. Several former patients demonstrate the effects of the vaccine—miniature cows erupt from their bodies. (Courtesy of the National Library of Medicine)

And in case you want to geek out about vaccines or bone up for your next Facebook debate, here are my favorite vaccine resources:

The Panic Virus by Seth Mnookin. This book is extensively researched and is engrossing. You can learn all about why Americans are crazy about vaccines and what we dangers lie in the myths that pervade American culture.

A History of Vaccines – a project of the College of Physicians of Philadelphia that shares the science and history of vaccines. It’s really a great website.

Pox: An American History by Michael Willrich.  A book about the smallpox outbreak at the turn of the last century which lead to widespread panic, questionable public health practices and ethical dilemmas about public health versus individual rights. It’s a bit dry at points but worth the effort.


Public Health Happy Hour on November 26!

Has the internet failed to sate your thirst for extensive public health discussion?  Join some of Philly’s finest public health professionals, students, and aficionados for real-life, in-person happy hour.  Both of the badasses behind this blog will be there, and so will an assortment of very interesting people.  Come for the beer, and stay for the epidemiology jokes.

Here are the details:
Public Health Happy Hour
Perch Pub, 1345 Locust Street (Broad & Locust), Philadelphia
Tuesday, November 26 at 5:30 p.m.

Be there or be chi-square!

Healthcare for Geeks: A Discussion from BarCamp Philly

On Saturday, I attended a fantastic annual event known as BarCamp Philly.  If you’re not familiar, it’s an “unconference” – a conference with a user-generated schedule packed with a wide variety of user-generated content. BarCamp tends to be more techy/web-oriented, but the topics extend to all areas of life, from transportation to food to raising geeky kids.  If you weren’t there this year, I’d keep an eye out for info on next year’s.  The unconference is a pretty brilliant format.  Setting the schedule the morning of the event breeds excitement and community and even brand-new ideas for talks.  (If you’re thinking we could use that kind of energy in public health, I’m with you.  More on that in a future post.)

After a midweek shower epiphany, I decided to use a small part of my BarCamp time to host a discussion on the Affordable Care Act’s impact on the tech community.  My session was sleepily and unsexily titled “Healthcare for Geeks,” and would focus on  insurance for freelancers, start-ups, and entrepreneurs.  I came with a small stack of paper handouts (quaint, I know), but mostly I came with questions.

We started the session off with a review of some figures.  We talked briefly about the subsidies and cost-sharing that are available to people without employer-provided coverage making between 100% and 400% of the federal poverty level ($11,490 – $45,960 for individuals, $23,550 – $94,200 for a family of four).  We also talked about the premiums on the health insurance marketplace (which range from $147-$357/month for a 27 year old in southeastern PA).  At the time, I had an Excel spreadsheet with the rates; since Saturday afternoon, I’ve learned about a fantastic marketplace premium aggregator site that covers 34 states.  (Note: the aggregator site recommends contacting the insurance companies directly to sign up for a plan, but subsidies are only available when signing up through the Marketplace.)   Given that information, our group was able to get into the meat of the discussion.

Americans have long been accustomed to the idea that a good job is worth having for the health insurance alone.  I personally know dozens of people that have successful part-time businesses, but have never been able to quit their day jobs because they needed insurance.  At the same time, widely-available insurance doesn’t mean free healthcare.  My main question for Philly’s tech community was this:  In a field that skews toward relatively young, healthy, well-resourced men – a demographic that doesn’t tend to access preventative care, and might have been more comfortable living without insurance than other groups – will the Affordable Care Act help or stifle innovation?  And will the new healthcare options reduce barriers to entry to the field for women, parents, people with pre-existing conditions, and other groups that would have been more averse to walking away from insurance?

I wish I could say that we came up with all the answers in that Wharton classroom.  We didn’t.  But our twenty-five(ish) participants seemed hopeful… in the long run.  People are excited about the idea of freelancing full-time or starting new businesses while still having access to health insurance.  But in the here and now?  Almost everyone is confused at best, and many people are scared.

Frankly, I was disappointed.  Not in the conversation (honestly I was excited that anyone showed up and thrilled that they wanted to talk), but by the lack of information.  Here were a group of smart people who are incredibly good at The Internet, and even they hadn’t been able to find the information they needed about their health insurance options.  (An aside: props to us all for not lapsing into a 45-minute healthcare.gov vent session.)  If these very capable people don’t know that health insurance companies have to spend 80% of premiums on actual healthcare, then who does?  And how will we ever get this information out to anyone but health policy wonks?

This adventure in bringing public health discussions to BarCamp Philly is something that the CDC might call “non-traditional methods of stakeholder engagement.”  But to steal another CDC term, it’s hardly a scalable approach (meaning that it’s not the type of thing that can be done on a big enough scale to reach a good number of people).  We will never have enough public health workers willing to spend their days off having conversations about the ACA with seemingly random groups of people, at least not enough to make a large-scale difference.  Yet we know from our discussion that the new availability of insurance could create some serious opportunity for creativity and innovation – something that we could surely use.

So, I’m going to turn to you, creative and intelligent reader.  Clearly what we’re doing isn’t working.  (See: our very first post on Badass Public Health.)  What tools do we need to reach people that don’t talk about health policy for fun?  How do we separate fact from fiction?  Where do we go from here?  And where do we start?

On vulnerability

I promise you that this is not some kind of bait-and-switch.  We brought you to a blog about being badass, and now I’m going to start talking about feelings.

Fun fact:  Badasses have feelings too.

Before we get started, you should watch Brene Brown’s TEDx talk on vulnerability.  Maybe watch it again if you’ve already seen it.  I’ve watched it at least half a dozen times.  It’s worth the 20-minute investment.

Now on to what on earth vulnerability has to do with public health.  As public health professionals, we know that this is hard, and often thankless, work.  There’s the prevention side, where we do everything we can to make sure that some thing (disease, violence, behavior) doesn’t happen, but we can’t see the thing that never occurs.  There’s the administrative side, where we wallow in paperwork that doesn’t seem to actually help anyone.  There’s the client side, where we still can’t figure out if we’re doing any good.  And there’s the bullshit side.  That’s the one where someone has some kind of meltdown, you find out your program will probably get cut (either by a FT position or entirely), and then your supervisor calls you in because you forgot the cover sheet on your TPS reports, and really, who even cares anymore.  So, as Brene Brown would say, you have a couple of beers and a banana nut muffin.  And you numb, because that’s the only way you can wake up and do it again tomorrow.

I’m not about to tell you that you should never check out and have a drink or binge-watch Scandal or whatever does it for you.  We have to numb at least some of the time, because we have to cope.  But in constant numbing, we lose our connection to other people.  If we lose the connection, we lose the purpose.

In a previous post, Nicole talked about the importance of being a real person.  This isn’t just important because it helps us to reach our target audiences.  It’s important because it allows us to be ourselves and live in alignment with our values.  It’s important because it makes us happy.  And it requires a hell of a lot of courage.  That’s pretty badass.

But this whole vulnerability thing goes further than that.  It’s not just about us.  We can’t get better at what we do if we don’t talk about our shortcomings and our programs’ shortcomings instead of putting everything on those social determinants of health we get so excited about.  We have got to stop being so defensive, and think critically about our work.  We need to have conversations that go beyond ascribing every frustration to “burnout.”  Honestly, how often do you hear public health professionals talking about how they can do their jobs better?  And how does that compare to the amount of time spent worrying about things completely out of our control?

Listen, I’m not saying that you don’t have a right to be stressed.  I am saying that we could all do a little bit better by acknowledging that things suck sometimes and letting the frustrations wash over us.  It’s the only way we can come out swinging on the other side.

In future posts, we’ll talk about what exactly vulnerability looks like in the public health workplace.  In the meantime, let’s find out what happens when people stop being polite afraid, and start getting real.

On belief

We are in the belief-changing business.

Think about it for a couple of minutes. We tell people to wear seatbelts, get a flu shot, wash their hands, wear a condom, drink water….because we have evidence that these things promote health and wellness. But people choose to follow our evidence-based advice because it fits in with their beliefs about life, health, science, God, risks, etc. If people only made health and behavior choices based on facts and rational thinking, many of us would be out of a job.  Anyone familiar with humans knows this is a ridiculous idea. So, let’s take a moment to think about belief’s role in public health. We might get a bit philosophical for a moment or two.

In order to know something we have to believe it. And in order to act on something, we have to know and believe it.

We can tell people to get a flu shot a million times, but if they don’t believe that flu shots are safe or necessary, they aren’t going to get one, even if it’s free. So how do we help them believe that flu shots are important, safe, and necessary? By appealing to their values and beliefs. We point out that by getting a flu shot they not only help themselves, but all the people they live, work and play with. There are people for whom the flu is deadly and dangerous: little kids, older people, and people with compromised immune systems. We can appeal to the values of community, fairness, and protecting the most vulnerable.

Another example is condom use. Condoms work very well to prevent the transmission of STIs and pregnancy- when used correctly and consistently. We often forget to mention that last part when we tell people to practice safer sex (but that’s a topic for another day). We also tend to ignore the fact that most people don’t like condoms and will  find reasons not to use them (and that’s not hard to do). So what’s the value-based solution? Respect: for self and your partner. Respecting your partner (and yourself) enough to protect him/her and honor their health and well-being. For long-term (committed) couples, you could use love as a value too: loving yourself and your partner enough to be honest, responsible and protective. For women, the values of self-sufficiency and independence can be quite effective. An empowered woman carries condoms and can talk to her partner about using them.

Just talking about the positive effects of a particular behavior can change the beliefs about it. So often we focus on the negative: if you don’t do X, then that horrible thing Y is going to happen to you. We should frame messages in the benefits of healthy lifestyles and preventative measures. Values help us do that.

Values + positive effects = behavior/belief change

In my next post, I’ll share some things I have learned about how to confront those pernicious myths and beliefs that impede our progress to public health utopia. Dr. Paul Offit (one of my heroes) gets the lion’s share of credit for my beliefs about belief (how meta!). More on that badass public health hero next time.

Badass public health, now in your ears

A couple of weeks ago, I sat down with Teagan Keating for the first episode of her new public health podcast, Action Phase.  It was a fun interview, if I do say so myself.  Teagan provided me with a lovely cup of tea from faraway lands (Nepal, maybe?) before we settled in to talk about community planning, sex, coding, why condoms won’t stop the HIV epidemic, and my opinions on how to fix pretty much everything.  Spoiler alert: I also reference an upcoming post I’m (still) writing on vulnerability.  It’s going to be a whole series now.  Buckle your seatbelts.

Visit the Action Phase website to listen to the podcast, and leave her a nice comment while you’re over there.  And maybe follow her on Twitter, too.

Ceci n’est pas another post about the shutdown.

We started this blog right before domestic public health was brought to its knees.   As of this post, it’s been ten days since the federal government shut down.  Biomedical research is being destroyed, WIC programs are running out of money, and the CDC isn’t tracking the flu.  Oh, and there’s already been a salmonella outbreak.

It’s bad out there.

But you knew that already.

We started this blog in hopes of creating a public health community that’s all about growth, expansion, and breaking some rules.  We don’t need another place to lament about what’s broken, and you won’t find that here.  That’s what your local watering hole is for.

I read a post recently about keeping your mouth shut when you have nothing to say, and I’m (mostly) taking Jim’s advice.  You can follow the latest on the shutdown from the news outlet of your choice, and we’ll keep writing the kinds of posts that we were already working on.  Public health will still be kicking long after this shutdown is a distant memory.  Let’s make sure it kicks some ass.

On connection

The first rule of connecting with other people, no matter who or where: Be a person.

So often in public health we get hung up on labels and demographics. We focus on the differences between people, and often lose sight of our shared humanity. For instance, we are often looking for the right person to lead a program or communicate a message,  based on demographics or look. Having a person that the intended audience can relate to is important, but that relatablility is not only dependent on demographics or skin color. Even if you find the perfect peer to lead your program, if that peer isn’t also a friendly, reliable, honest person…well, you’re screwed. Your program is likely to fail, or at least not be as effective as possible, and you are going to lose some of your street cred. And when you’re dealing with hard to reach populations your street cred is everything.

In my day-to-day life as a public health practitioner, I spend a lot of time interacting with folks who look nothing like me, didn’t come from the same socio-economic background, and are my senior by at least a decade or two. Even though there are many good reasons why we shouldn’t connect, we do (most of the time). Why? Because I’ve earned their trust by being real with them, sharing my values (their values) , protecting the safe space we share, and being reliable.

When I say “being real”, I don’t mean it as anything more or less than being authentic. If I’m having a crappy day or am tired of someone’s disruptive behavior, I tell them. I also talk about my family with them, ask about theirs. We share laughs and tease. I praise their accomplishments and mourn their losses. You know,  treat them as I would like to be treated. This takes time and trust, it’s not something that happens easily or quickly. But over time, people see that I am the person I show them; I am really this silly, geeky lady who cares about inequalities and our city. This isn’t a show. But equally important are the boundaries I have established about what I am willing to do for them, how we talk to each other, and what is appropriate behavior in our shared space.

You can’t earn trust by being the smartest person in the room. I have learned this the hard way. So many times I tried to sound like the authority or drown them in facts and data. People don’t want to hear all that. They want to know why they should care, why you care, and what we can do about it. Save the data and wonky business for your wonky nerdy friends (or me, I like that stuff). How do I share my values? I say it out loud. I also ask them what they value. We discuss big things like inequality, racism, HIV stigma, sexuality, addiction, our histories, you name it. Some people will shy away from those big -isms, but I don’t know how you can address the big public health problems without acknowledging the contexts in which they occur. Especially not in a city like Philadelphia.

We can have these honest conversations (sometimes very silly and TMI conversations) because there is a defined safe space, a circle of trust. I protect that space by modeling non-judgement, sex-positivity, and stigma-free language.  We protect each other’s confidentiality, and follow a set of ground rules. It’s not easy to foster trust when you combine 20-30 people with a variety of experiences and backgrounds, but it is a must for long-term participation and community buy-in. Sometimes it is very hard to keep my straight face or bite my tongue, but I do it (except for that one time).

And that last bit is the easy part: reliability. Do what you say you are going to do. Show up. Just by showing up, you win.

I have to end by saying, by no means am I perfect or always comfortable with every interaction. Oh no. I’m nowhere near perfect. I believe the group forgives my shortcomings because I do my best to embrace them for who they are, to really see them.

It’s either that or the free Snapples. I’m not sure.