Friday, June 12, 2015

Be healthy, be happy; U.S. needs to get wise


According to the World Health Organization, someone born in the United States will not, on average, live as long as someone born in England, Sweden, Spain, Norway, Malta, Netherlands, France, Finland, and other countries, even though we spend more than they do on health care.

In fact, we spend more than any other country on health care, but rank at the very bottom among the wealthiest countries on the quality of our health care system. (The United Kingdom, ranked in first place, spends only about 40% of what the United States spends, yet achieves such better health for its population.)

We’re not the happiest country, either – with a rank of 17 in a 2013 United Nations report. Interestingly, the countries where people live the longest also tend to have the highest levels of happiness.

How can our bodies and our spirits get into better shape?

In thinking about health, we often jump immediately to health care. However, effective health care probably only accounts for about 20 percent of the reasons why we are healthy (or not). Our health depends on much more. The condition of our bodies, the illnesses that afflict us, and even how long we live depend largely on the social determinants of health. These social determinants include our housing, our income, our education, the availability of nutritious food, air quality, the level of crime in our neighborhood, facilities to promote physical activity, and other aspects of our environment. In short, many of the factors that lead to illness, or promote good health, lie outside of the health care system.

The President of the Robert Wood Johnson Foundation recently invited me to attend a meeting, to discuss how we can transform thinking and action in this country to promote health. The Foundation has worked intensively on a major initiative to “build a culture of health” in the United States They have traveled the country, delivering lectures and participating in meetings, including three, annual Healthy Communities conferences in Minnesota, organized by Wilder Research and the Federal Reserve Bank of Minneapolis.

The movement to build a culture of health predicates itself on the premise that promotion of health, in the words of the Robert Wood Johnson Foundation, “must place well-being at the center of every aspect of American life.” The movement focuses on “the key influences of factors found in communities, business and corporate practices, schools, and the many other spheres of everyday life.”

Think about it. The sick leave policies of our nation’s businesses directly enable us to achieve better health by offering the opportunity to rest and to fight an illness that strikes us. Indirectly, those policies keep us healthier by enabling sick people to stay home and recover rather than feeling compelled to work and coincidentally to infect us. Government decisions to create or protect space for physical activity enable us to maintain a healthier lifestyle. Sick leave policies and greenspace policies strongly influence our health, yet neither falls into “health care policy” in the traditional sense.

So, we will likely see the culture of health movement take action in four areas.

For one, we’ll see increased emphasis on making health “a shared value.”
That means developing a public mindset about health as a fundamental building block of our communities. Developing such a mindset will require education, attitude shifts, and social interaction to motivate our population to want to improve health on their own and with others.

We will see increased emphasis on fostering cross-sector collaboration to improve health.
That means that members of the traditional health care system – doctors, hospitals, health plans, etc. – will collaborate more with people and organizations outside of health care. Health departments might work with banks who want to finance preschool education facilities and community health clinics. Units of state government such as transportation, housing, and natural resources will take action jointly with the state health department to shape policies and programs which promote health. Ed Ehlinger, Minnesota’s Commissioner of Health stands out as a national leader in terms of promoting collaboration and infusing “health into all policies.”

We will see increased energy and resources devoted to changing our environments.
Even the best motivated, most well-intended individuals cannot ensure optimal health on their own. Without access to healthy food, people cannot provide suitable nutrition to themselves and their families; without affordable housing, some families cannot achieve stability and ensure good education for their young members; without feeling safe on the street, individuals cannot engage in health promoting activities, plus they have greater likelihood of suffering injury or death.

Finally, in the movement to promote a culture of health, we will see efforts to strengthen and integrate the system of health care services on which we rely.
We will see action taken to improve the access of people to health care, to improve patients’ experience, to contain costs without compromising quality, to improve outcomes for all, and to focus on prevention.


Can we achieve the levels of health and happiness of other major nations? Can we eliminate the disparities in health which now exist among groups in the United States? Focusing attention on building a culture of health, including work in the above four action areas of interest to the Robert Wood Johnson Foundation, can hopefully move us in that direction.

Wednesday, May 06, 2015

Effectiveness, and the Case of Dr. Oz

Dr. Oz became famous on Oprah, then developed his own TV show. Millions of people who seek health and medical information hang on his every word. But can we believe him?

A group of doctors publicly called for Columbia University to fire Dr. Oz. Their accusations?
“Dr. Oz has repeatedly shown disdain for science and for evidence-based medicine … he has manifested an egregious lack of integrity by promoting quack treatments and cures in the interest of personal financial gain.”

The controversy focuses attention on evidence-based practices. So, what do we mean by evidence? What constitutes credible information that a treatment works or that a specific behavior promotes good health?

In human services, the meaning of the term, evidence-based practice, has achieved some consensus, at least in a general sense. Most people would agree that, to meet the standard of evidence-based, a treatment, service, or policy must have multiple rigorous studies which support it. Rigorous usually means either some form of experimental design or at least a very strong comparative effectiveness study. Comparative means that information exists to show that people who received a service achieved an outcome to a higher degree than people who did not receive that service. The Substance Abuse and Mental Health Services Administration, for example, has established criteria, as have some other organizations.

Oftentimes, the fact that a practice has appeared in a scientific journal becomes accepted as proof of adequate strength to demonstrate effectiveness. However, in the field of medicine, many practices with early promise of effectiveness, as reported in credible medical journals, actually turn out not to work during later years of testing.

We can’t let a similar-sounding term, best practice, confuse us. It sees a variety of uses, one of which unfortunately constitutes a bad use: as a synonym for evidence-based practice, but without any evidence! Sometimes, a so-called best practice is a new service approach that seemed to produce positive outcomes in one situation, perhaps only for a limited period of time, and now it attracts other providers to incorporate it into their operations. However, no sound research has demonstrated the effectiveness of that new approach. If an approach appears promising, evaluation researchers can work in unison with practitioners to determine its effectiveness by creating a sound base of evidence.

So, what should we do?

·         We should move forward with a combination of hope and humility, using the best information available to make informed choices about what services to deliver. Strong evidence of effectiveness means that a specific service, delivered as intended, will produce positive outcomes for many or most of those who receive it. Keep in mind, though, that nothing’s perfect. If we go with the evidence, we maximize the chances of taking the best possible action using our current state of knowledge, even though we will not produce our desired outcomes 100 percent of the time.

·         Let’s remember that science is just science. It never reaches the final “truth”; it always searches to discover more. New evidence inexorably supplants current evidence, sometimes changing the way we think and act. In addition, our environment changes; our communities change. Science strives to keep up and provide the best answers at any given point in time, acknowledging for example, that actions by individuals and government that worked effectively to produce strong communities in 1915 might not work in 2015.

·         The fact that science has imperfections and we may never achieve absolute certainty should not compel us to ignore the best evidence and put all of our trust in self-proclaimed experts and authorities. From blood-letting during the Middle Ages to quack remedies of today, many “experts” have had no basis for the approaches they use to treat the illnesses of individuals and the social problems of communities.

Effective service delivery requires blending the latest evidence, the wisdom of practitioners, and the preferences (cultural, personal, etc.) of an individual or group who receives a service. Over time, we continually refine our knowledge and competence so that human service practitioners, policy makers and others can shape services, programs, and policies optimally to meet the needs of our ever changing communities.

What does this all mean for Dr. Oz? Dr. Oz speaks as one, fallible physician; hopefully, he uses research evidence wisely. The conflict of interest that his accusers charge might, or might not, exist. But I’m willing to let others fuss over the fate of him and other celebrities, while we work on improving the future of our communities!

Thursday, March 26, 2015

From Selma to the Present -- Some Progress

Commemorative events in Selma during this past month brought to mind events of the 1960s. I vividly remember hearing the junior high principal announce the assassination of President Kennedy. I remember TV coverage of the Selma march to Montgomery and newspaper coverage by the New York City papers of the rationale for the Civil Rights Act of 1965.

Have we made progress during the past 50 years? In advocating for the passage of civil rights legislation, President Kennedy asserted that a number of inequities existed in the United States:

The Negro baby born in America today, regardless of the section of the State in which he is born, has about one-half as much chance of completing a high school as a white baby born in the same place on the same day, one-third as much chance of completing college, one-third as much chance of becoming a professional man, twice as much chance of becoming unemployed, about one-seventh as much chance of earning $10,000 a year, a life expectancy which is 7 years shorter, and the prospects of earning only half as much.

Where do we stand today?

Drawing valid comparisons, for our nation as a whole, across the span of a half century presents challenges, but evidence definitely points to elements of progress related to most, but not all, of Kennedy’s concerns. We have not met Kennedy’s goals, but we have moved in a positive direction.


  • A black young person today is 80% as likely as a white young person to complete high school – up 30 percentage points from the “half as much chance” cited by Kennedy. 
  • A black young person has about two-thirds of the likelihood of a white young person to complete college – so double the probability from Kennedy’s era. 
  • Regarding the “one-third as much chance of becoming a professional man” which Kennedy noted, contemporary statistics show about 30% of black workers classified as employed in “management, professional, and related occupations,” compared with 39% of white workers. That significantly boosts the likelihood from Kennedy’s “one-third as much chance” to a current “75% as much chance.”
  • A 1965 income of $10,000 equates to about $75,000 today. Among black households, 20 percent have income above that mark, compared with 37% of white households. So, we see movement from Kennedy’s “one-seventh” to the current “one-half.”
  • The lifespan gap has improved, from 7 years difference between blacks and whites to about 4.
  • The unemployment rate for blacks remains about twice the rate for whites; so no change from when Kennedy did his assessment.


Moving forward, we must ask ourselves how we can reduce even more the social and economic differences which Kennedy identified. We know that some of these differences result from social and environmental conditions outside of the control of any single individual. So, no matter how well you eat and exercise, aspects of your surroundings partially influence how long you will live. However, individual choice also makes a difference; what you eat and drink, what lifestyle you lead – those things add and subtract years from your life.

We need to determine what we can meaningfully achieve through our formal government and community institutions and what we must encourage individuals to do on their own to improve their lives.

As Dr. Martin Luther King, Jr. stated (in one of his many quotes which I love): “In a real sense, all life is inter-related. All men are caught in an inescapable network of mutuality, tied in a single garment of destiny. Whatever affects one directly, affects all indirectly.” Those words provide a rationale for action – that the inability of any one person in our society to achieve good health and prosperity detracts from the health and well-being of all. The words also bring us to recognize that progress on social issues requires changes in the habits, customs, systems, and activities of all of us, with the ultimate consequence of a better life for everyone.

(By the way, if you have additional interests regarding social disparities, consult Minnesota Compass.)

Wednesday, February 25, 2015

Je Suis Charlie


Democracy, whatever its imperfections, provides a relatively hospitable environment for research.

The events at the beginning of this year in France bring me to recommit to research which benefits all human beings – all races, age groups, genders, ethnicities, nationalities, and religions. Extremists in their many forms – Muslim radical jihadists, Christian radical fundamentalists, hyper-politically correct liberals, and obdurately reactionary conservatives, for example – frequently dislike, even condemn, research. Totalitarian regimes suppress free-thinkers, journalists, artists, researchers and anyone else who seeks to promote transparency, see through diverse lenses, or challenge the status quo.

No single person or entity owns the “truth.” The truth emerges and evolves through the collective efforts of people with disparate vantage points – we strive to discover it, we approach it, we never fully know it. The best researchers never cease the search. They continually challenge the beliefs which they themselves and others hold, in order to increase understanding of social issues, human biology and health, the environment, or whatever their focus of study. We move forward with determination – hoping that we know more now than we did previously, and recognizing that we know less now than we will know in the future.

The murderers in France represent visible threats to the advancement of knowledge and understanding. As researchers, we frequently confront less visible, but perhaps even more pernicious and insidious, threats. Vested interests sometimes promote biased research, or suppress or vilify valid research. Certain nonprofit programs and professionals committed to one variety of treatment or service resist study of their activity to prevent discovery that such activity does not work; some political activists and advocates consider research a potential threat to their ideologies and/or their power over their constituencies.

At Wilder Research, we collaborate actively with many individuals and organizations who seek to gain knowledge and understanding with the goal of greater positive impact on society. The majority of you fall into this camp. You constitute the "reasonable middle", not an extreme fringe; you hold varied points of view, and may disagree with one another and with us regarding what research findings mean, but you have a willingness to respect different viewpoints and to find common ground. You take risks; you learn by trial and error; you have no hesitation to try something new, fail, and then try something else. You promote the use of research, the transparency of information, and the discussion of facts as we know them. Partnership with you enables us to collectively improve the lives of individuals, families, and communities, locally and throughout the world.

We do our work objectively, creatively, beholden to no vested interest, political group or ideology, save our commitment and passion for improving human well-being.

So, how can you expect Wilder Research to push the envelope, promote transparency, create new understanding, and collaborate with you in diverse communities, nonprofit programs, government agencies, and foundations in 2015?

We plan to continue to promote health – a human right – within our communities. We hope that our efforts – research on the effectiveness of systems of care, evaluation studies, health impact assessments, convening and engaging public officials and community members – can transform that right into reality for everyone. For example, one ambitious analysis this year will include input from all 87 counties in the state, as well as interested tribes, community partners, and consumers, to examine gaps in services for older adults, persons with disabilities, adults and children living with mental health challenges, and persons affected by a traumatic brain injury.

Young people always comprise a special focus for Wilder Research – their physical and mental health, their systems of support, their educational achievement. Our well-being depends upon the existence of educated community members, with technical and social skills suitable for the 21st century, as well as with the wisdom to participate in an equitable, democratic society. So, we will continue to promote the education of young people. For example, our efforts in 2015 include collaboration with Generation Next, Northside Achievement Zone, and The Saint Paul Promise Neighborhood, improving the educational achievement of youth affected by parental incarceration in Minnesota, and promoting the quality, availability, and effectiveness of out-of-school time learning. Some of our work specifically intends to disrupt and prevent the exploitation of young people through sex trafficking.

From our initial housing and health studies in 1917 to our current statewide homeless surveys and Homeless Management Information System, Wilder Research has devoted energy to promoting the human right of adequate shelter for all. We hope this year to promote the “coordinated assessment” of people who find themselves homeless, by increasing the capacity of Minnesota’s Homeless Management Information System, an on-line database used by 250 service providers, to assist those providers to deliver services more efficiently and effectively.

We will continue to support communities to strengthen themselves. Good research enables people to act to improve their lives. Efforts in 2015 include providing more information to neighborhoods in our larger cities, as well as to small towns, so that residents can monitor their quality of life and take action to improve it. We will work with ethnic communities who collaborated with us to shape the Speaking for Ourselves project, which gathered information directly from residents regarding their quality of life, living conditions, and needs.

We value our relationships with you. The activities mentioned above represent just a fraction of the close to 200 projects that our 92 employees will work on during 2015 – a year during which, more than ever, we must continue our quest for knowledge and understanding, as diverse people united in defiance of forces, violent and nonviolent, which promote narrow, partisan ideologies for discovering the truth.

For more details on this year’s projects, visit Wilder Research on the web.

Wednesday, January 21, 2015

Martin Luther King: Continued Inspiration for a Continuous Journey

Dr. King’s words – “Darkness cannot drive out darkness; only light can do that” – speak loudly to researchers. I like to think that we have had the ability to shine at least a little bit of light by means of our research activities at Wilder Research, our engagement with communities and institutions, and our continuous searching for insight regarding the most significant social issues which face our society today.

As a keynote presenter at the 1967 conference of the American Psychological Association, Dr. King advised the social scientists in attendance: “White America needs to understand that it is poisoned to its soul by racism and the understanding needs to be carefully documented and consequently more difficult to reject.” He suggested three areas of study which he felt deserved research and which could promote the cause of civil rights. Although some of his language seems a bit dated, and although research during the past half century has improved our understanding of these topics, his key messages still resonate.

“Social science may be able to search out some answers to the problem of Negro leadership.” He lamented a tendency of upwardly mobile blacks to separate themselves from those in the lower class. “Social science should be able to suggest mechanisms to create a wholesome black unity and a sense of peoplehood while the process of integration proceeds.”

“The second area for scientific examination is political action.” Dr. King went on to say that some political scientists had suggested that “voting is not the key that will unlock the door to racial equality because 'the concrete measurable payoffs from Negro voting in the South will not be revolutionary'….My own instinct is that these views are essentially erroneous, but they must be seriously examined. The need for a penetrating massive scientific study of this subject cannot be overstated.”

“The third area for study concerns psychological and ideological changes in Negroes. It is fashionable now to be pessimistic. Undeniably, the freedom movement has encountered setbacks. Yet I still believe there are significant aspects of progress.” Dr. King explained that social science needed to move forward to expose underlying, taken-for-granted precepts of American society which result in social and economic disparities. We would now use terms such as systemic racism or structural racism to capture the essence of Dr. King’s insight. He pointed out in his address that such racism can have a more significant negative impact than what he called “superficial prejudice.”

In his characteristically penetrating style, with a tinge of satire, he mordantly suggested to the psychologists who comprise the American Psychological Association that, despite their ever present efforts to help people to “adjust” to societal life, they should perhaps create an International Association of Creative Maladjustment. “I am sure that we will recognize that there are some things in our society, some things in our world, to which we should never be adjusted. There are some things concerning which we must always be maladjusted if we are to be people of good will. We must never adjust ourselves to racial discrimination and racial segregation. We must never adjust ourselves to religious bigotry. We must never adjust ourselves to economic conditions that take necessities from the many to give luxuries to the few. We must never adjust ourselves to the madness of militarism, and the self-defeating effects of physical violence… As President Kennedy declared, 'Mankind must put an end to war, or war will put an end to mankind.'”

“For social scientists, the opportunity to serve in a life-giving purpose is a humanist challenge of rare distinction,” Dr. King stated. We at Wilder Research strive, with determination, to take on that challenge more and more every day.