The Boston Indicators Project
Sector Convening Notes
Health Convening
Wednesday, July 12, 2006 

Brief Project Overview
The Boston Indicators Project is a collaborative project of Greater Boston’s civic community. Recognized for its comprehensive framework and selected by the Government Accounting Office (GAO) to help inform the development of national indicators, the project is coordinated by the Boston Foundation in partnership with the City of Boston and the Metropolitan Area Planning Council. Its goals are: to democratize access to high quality data and information; to foster informed public discourse, and; to track progress on shared civic goals. Since 2000, the project has released four biennial reports, the last three as a summary in hard copy and a detailed web-based report on the award-winning www.bostonindicators.org. The Boston Foundation is committed to issuing a biennial report through 2030, Boston’s 400^th anniversary. 

To begin to frame the findings of each report, the project hosts a series of convenings in each of the ten sectors it tracks: Civic Health; Cultural Life and the Arts; Economy; Education; Environment and Energy; Public Health; Public Safety; Housing; Technology; and Transportation. Each convening, chaired by stakeholders from within the field, includes a range of perspectives from academic experts, community-based practitioners, public agency and foundation staff, private sector representatives, and consumers. 

The convenings range in size from about 20 to 100 participants, the latter for large, complex sectors such as education, civic health and housing, which are broken into sub-sectors, each with its own co-chairs. Each convening uses the same structured agenda, eliciting views on key long –term trends, major developments and accomplishments of the previous two years, and key remaining challenges. The notes are then compiled, reviewed by the co-chairs for accuracy and completeness, and used to frame and prioritize the findings of the next Boston Indicators Report.  

What follows are the notes from the Health convening.

In Attendance: 

Co-Chairs: Debbie Klein Walker, Principal Associate, Abt Associates; Elmer Freeman, Executive Director, Center for Community Health Education, Research and Service

Jennifer Bennet, Executive Director, The Family Van Program at Harvard Medical School
Lynne Doblin, Program Officer, Smith Family Foundation
Jean Flatley McGuire, Lorraine Snelling Visiting Professor, Bouve College of Health Sciences, Northeastern University
David Ford, Executive Director, Richard and Susan Smith Family Foundation
Saul Franklin, Director, MassCHIP, Massachusetts Department of Public Health
Henia Handler, Director of Governmental Relations, Fenway Community Health Center
Tom Hubbard, Special Adviser, The New England Healthcare Institute
Debbie Klein Walker, Principal Associate, Abt Associates
Judith Kurland, President, Massachusetts Public Health Association
Bart Laws, Senior Investigator in Social Science and Policy, Latin American Health Institute
Michael Soo Hoo, LGBT Health Manager, Boston Public Health Commission
William Walczak, Executive Director, Codman Square Health Center, Inc.

Welcome and Introductions
The co-chairs welcomed participants to the convening and asked participants to describe the primary indicators that they worked with. 

• Disparities in income as affecting health outcomes (emphasized strongly by nearly every participant)
• Issues and indicators surrounding diabetes, asthma, and aging/Boston’s aging demographic
• HIV/AIDS treatment, which is moving increasingly towards a focus primarily on HIV (1,100 of 11,000 treated)
• Youth-related risk factors
• Culturally-competent health services; also mentioned with reference to the gay/lesbian community
• Redefining ethnicity to break it into more comprehensive categories
• Mental health services, which could include indices for adults as well as children/teens (not reflected in 2004 BIP report)
• Issues surrounding population and demographics, statistics for which are lacking and/or underfunded in the legislature (lots of discussion on this throughout the meeting)
• Strength of primary care network
• Economic indicators; poverty emphasized as a top concern in addressing public health
• Diabetes and diabetes interventions ($5 mil. Over 5 yrs.) which is being evaluated for effectiveness
• Family Van Program; focus largely on disparities and socioeconomic factors and their relation to health outcome.
• Impact of budget cuts on public health, particularly relating to defense/Homeland Security concerns
• Infant mortality rates
• Diversifying leadership, labor force, civic health as a means of improving/alleviating disparities in health outcomes 

Key Long-Term Trends, Developments and Accomplishments, and Remaining Challenges
The co-chairs then asked participants to brainstorm key long-term trends, recent accomplishments and developments, and remaining challenges. 

Key Long-Term Trends

• Demographics for Boston are dynamic and changing.  Immigration inflows are continuing, particularly from “new” locations (Latin America, Africa, etc.).  These changes will affect priorities for public health in coming years.
• The educational system is focusing on MCAS (and behavior) to the detriment of physical education and other health-related activities/learning.
• Lack of health education in public schools is part of a larger problem.  Schools can/should be used as mediating institutions, much like community health centers currently are used (e.g., fruit signs and immunizations in schools).
• Lack of emphasis on prevention.
• Recent decline in health education funding has led to an upswing in youth smoking.
• Rising post-traumatic stress disorder in response to youth violence and fear of violence.
• Public health advocates have decreased their reliance on media as a tool for modifying health-related behaviors.
• Anti-immigration issues are affecting public health, particularly influencing racial/ethnic disparities in health outcomes and Medicaid.
• Mental health diagnostics are changing to reflect our epistemology on health, the invention of “new” diseases, and the availability of new drugs (e.g., doctors diagnosing based on predilections to prescribe certain drugs); doesn’t mean kids are crazier, just change in definitions.  Boston, which is disproportionately served by medical schools that focus on new drugs/research (medical Mecca for prescription drug companies), is particularly prone to this problem.  Research-for-profit may not always be compatible with the most exigent treatments for each individual.
• Shortfall of medical labor is a growing concern (fewer people in the field nationally; problem compounded if one considers that a lot of MDs aren’t direct care providers). 
• Specialization in medical practices is increasing, so Boston increasingly lacks access to the right kind of doctors and nurses
• Declining number of primary care physicians.
• Decline in use of clinical professionals like midwives.
• Class/race/ethnic diversity of the medical profession is not sufficient, and is likely to grow worse if disparities in education cannot be addressed.  The growth of Boston’s “vulnerable populations” will only compound the shortfall of labor in the medical profession.
• Bed availability in hospitals has declined.
• Shift to focusing on informing the individual and allowing him/her to make healthy choices.
• General lack of “health care” (as opposed to “sick care”) information available online or in general.  Individuals are not easily given access to the kind of information that is necessary to intelligently use the responsibility that has been given to them (also concerns about the cultural competency of this data).
• Obesity and diabetes trends are both negative
• Low priority on women’s and maternal health (baby friendly hospitals overturned); Women’s education is one of the single major initiatives that can be taken to improve public health.
• Population losses in Massachusetts will also affect aid, labor shortage, etc.

Accomplishments and Developments, 2005-2006

• Asthma initiative no longer exists. Concerns around meeting standards for a minority-service initiative; pushed accountability to be more community-sponsored and get minority populations more engaged in research (imp., b/c lots of researchers don’t appreciate local factors and are more interested in publishing in prestigious journals).
• Community violence initiative funded…Johns Hopkins, Brown U., Harvard, CHERS
• Harvard’s prevention center has made some good progress in Boston schools.
• Infrastructure expanded for Racial Disparity Project
• Smith Foundation’s diabetes intervention (funding 6 health centers in Dorchester, the sickest community) has made some new efforts to fund community health centers’ outreach efforts for people who have diabetes or are at risk.  The project tailors its interventions to different communities, and may be able to extrapolate from its small scale, short term results the potential impact of a much larger project (e.g., number who will lose their feet or sight in next decade).  The strong foundation community is a boon to projects like these.  This project suggests an alternative approach, changing behaviors with wraparound services, and then addressing public policy (despite the fact that many institutions, such as HMOs, aren’t geared towards long-term investment in health).
• Division of Health Care has helped to refocus funding towards diabetes treatment more effectively, allowing for a broader range of health care; has also allowed the field to agree on broad levels of diabetes (and asthma) guidelines.
• There have been budget and funding gains in many areas, including substance abuse and suicide prevention.  However, these gains are tempered by the fact that they have still not returned to their 2000/01 funding levels (CDCs had one of their biggest cuts ever: 15%).  The federal budget is still bad, cutting even from emergency preparedness.
• The new health care bill has increased funding for public health, creating major change; however, this is still fraught with problems and inadequacies.  Have to look at insufficiencies of funding and concerns that forcing people to buy health insurance may not improve health outcomes if it leaves them unable to afford food.  It also makes it easier for employers not to provide insurance.  (Need to determine how this issue will play out).
• Genomics is rising in importance.  Analysis of genetic risk factors poses several concerns.  Gene mapping and the predictive powers associated with it will transform best practices in the medical profession and create a need for retraining/education programs for the professionals in that field (being investigated primarily in the private sector).  Moreover, it may affect disparities and/or limit access for many as health insurance companies use genomics as a tool to limit risk (will this be beneficial in our current system?).
• NIH requirements that funding go to degree-granting institutions makes Boston, which has only one public school of public health, ineligible for some of this funding (structural problem).
• Want to convert MassCHIP to a fully web-based service.
• Proliferation of new STD vaccines will necessitate a new mode of thinking about sexual health and a new form of discussion about sexual choices with our youth.  This issue also raises possibilities of access to vaccines and the associated disparities.  The potential changes with youth sexual health in the future contrast with current approaches, which deemphasize discussion and access to condoms (abstinence only; driven by moral values, not data).  Also a concern about proper interpretation of the data: fewer teen births doesn’t mean fewer teen pregnancies, nor does it mean that fewer teens are having sex.

Key Remaining Challenges

• Concerns about monitoring health care reform to ensure that it gets to those who really need it.  Vulnerable populations have a lot of risk with little protection.
• Lack of sufficient data measuring real health outcomes across different health care plans.  Questions arise regarding the efficacy of the “high deductible” health plans.  No leadership in the city or state (Delores Mitchell was mentioned as an exception) wants to be responsible for collecting this data, though it would be beneficial to investigate smaller groups than “the whole city.” 
• Possibility of losing the standardization of Medicaid, which places vulnerable populations at increased risk.
• Labor resources for the future of health care are threatened, particularly with the decrease in Massachusetts’ population.
• Exacerbated for newcomers groups for whom services already are not available.
• Capacity expansion creates new challenges for community health provider that they may be unable to address effectively (e.g., Bart’s example about institutions having to become Medicaid providers as they grow, which is a money loser).  Nevertheless, it is important to preserve these community health and mental providers.
• It is important to address gaps in service delivery.  Disparities in outcome are a measure of our inability to close these gaps.
• Lack of conversation across sectors and between Public Health Dept. and hospitals.
• Limitation by the federal government on what actions can be left to state/local government is an issue. (Devolution to the states/federal exception)
• Demographic trends towards an aging population will pose challenges in the coming years.  We currently lack sufficient elder care programs (incl. cultural competency issues) and expertise in mainstream agencies.  Primary care facilities should remain the vehicle behind health aging, which should be geared towards allowing people to age in place.  Additionally, public health doesn’t get funding for elder care at present, and lacks sufficient infrastructure.
• This ought to become a major focus, since behaviors determine 50% of health outcomes.  Having the money to employ media tools is important to affecting individual behaviors, which in turn are pivotal in determining health outcomes.  We’re simply not looking at a lot of things.
• Emergency preparedness is an arena in which Boston is not well prepared, especially its minority population.  Focus needs to shift away from anthrax, for example, and more towards capacity building.  The federal government in particular is withdrawing funding and responsibility for disaster preparedness, and is also spending less time/money gathering data and establishing national standards in this area, but still uses government regulations to support “what they want.”  There are also concerns that the most vulnerable populations would be those most affected in a disaster.  Data gathering on this issue is also important, as Boston can’t afford to compare its circumstances to those faced by other cities.
• Issues surrounding health insurance coverage are a concern.  Simple coverage may not be enough to effect meaningful improvements in health outcomes.  Giving everyone bad insurance (w/high premiums and copays) doesn’t help people make smart choices.  High copays and the like also reflect a shift to individual (financial) responsibility with which people are being saddled (moral hazard issue: New Yorker article about people pulling their own teeth).
• Environmental health issues should be investigated on a smaller scale (e.g., air near the highway, where public housing is, is of significantly poorer quality than the city as a whole).
• Government minimizing intervention and play up individual responsibility for public health with recent reforms, despite what is known about the social determinants of health (redefining the role of these institutions).  Some degree of public intervention will be necessary to positively affect individual health choices.   
• Need to see *real* outcomes.
• A new bill may eliminate illegal immigrants’ access to dental health care, and threats of harsh punishments may limit immigrants’ willingness to seek care at all, negatively affecting public health (Many immigrants are healthier when they arrive).

Suggestions for Indicators to Highlight
The co-chairs then asked participants for suggestions on indicators to highlight in the next report. 

• Infant mortality and rates of low birth weight.  The latter is complicated by the fact that there are a lot of older women on fertility drugs giving birth to many low weight babies.  Additionally, half of Boston (or MA?) births are to women over 35.  Some measure of maternal health is a reasonable indicator to highlight.
• Issues of racial/ethnic disparities in health outcomes are important to retain in the big highlights, though we should work to disaggregate these broad categories.
• The disproportionate representation of women and minorities in prison for drug-related offenses, despite their under representation in other external public drug treatment programs is an issue to highlight.
• The number of preventable deaths and/or premature mortality (grouped by race/ethnicity) is an indicator to highlight.
• Violence (as well as prison health/inactivity) was mentioned as a major issue, though its applicability to this sector was debated.
• Type II Diabetes may be used as a general proxy for health.
• Substance abuse (incl. alcohol, tobacco, and other drugs)is also a major concern to highlight, as Massachusetts is in the top 5 for both alcohol and heroin use.
• STD rates have become a major issue worth emphasizing.  The rates of infection are very high, especially among teens (perhaps even more important than smoking).  They are epidemic to the point that individual cases are often ignored for lack of resources (Saul’s example).
• Gains made in asthma hospitalization rates are a positive trend we may want to emphasize.
• Cancer, obesity, reproductive rights,and theimportance of Boston’s changing demographics and public policies were also issues briefly mentioned.
• “Lack of hope,” especially among kids/teens, may be a valuable indicator, including various mental health indices and kids’ experience of violence (first hand and otherwise).  Strength of this indicator may support assertions made during discussion that we have abandoned our youth in many ways.
• Question: Healthy aging is lacking well-defined indicators (imp. given the impending demographic shift.  Can we integrate this into the project?  Cost implications? 
• Missouri has a system in place that enables them to set priorities in sorting and addressing issues raised by their data, though this is not a whole cloth gold standard.