A Healthy Collaboration (Extended)

This is a web-only extended version of "A Healthy Collaboration," the Conversation published in the Winter 2012 issue of SSA Magazine.

Galloway: Another major initiative of Building Healthier Chicago is FIT City. FIT stands for flavorful, innovative and tasty. We all know that if you put a healthy heart or a star next to a menu item in a menu, very few people buy it. The thought is that when folks go out to eat, they generally think, “I deserve the most flavor I can get, and the last thing I want to do is order and pay good money for something that tastes like cardboard because it’s healthy.” So we’ve been working with folks like Pam Smith, our FIT City chef and nutritionist from Disney’s Food and Wine Festival, along with local chefs like Ryan Hutmacher and our local culinary schools to develop menu items that don’t mention health issues anywhere, but focus on food that is full of flavor, color and full of fruits, vegetables and local products.

We’re also working to integrate into the community to encourage eating healthy new foods at home. We feel very strongly about the necessity to intervene in food deserts. But part of that intervention is teaching people how to incorporate the vegetables and fruits into their regular diet—and that may take some cooking lessons as well.

Grogan: Those are fantastic ideas. When I talk to people in the community, it seems like in some ways, cooking is almost a lost art, that there’s been a loss in the transfer of generational knowledge. It’s really good to hear that that’s part of the initiative, introducing cooking. But one worry I have is the time factor. It seems that one reason fast foods came into fashion is because they were so convenient and so easy. Are you thinking about if we want people to start cooking again, how do we make that work with really busy lives and single parents?

Galloway: You’re exactly right. This effort has to be a multifaceted approach. We’ve talked about the integration of grandmothers and others in the family who used to cook regularly. Perhaps bringing them into the efforts to learn new styles of cooking and integrate this information into the family. It’s going to take many efforts from many individuals, in many different arenas, We cannot allow ourselves to be discouraged because any one way, no matter how passionate we may be about it, won’t be the solution to developing a healthy community. It will be a mixture of all of our efforts in many different ways.

When we look at South LA, for instance, they put a restriction on fast food licensing. We know that fast food density directly relates to the levels of obesity, and if we could decrease the density, then presumably we could decrease some of the obesity. So South LA has passed a law that limits the density of fast food restaurants. That evaluation is currently underway I understand.

Grogan: In New York, I have a colleague who did a study of calorie labels, and he’s found that it did slightly change people’s choices. Of course, as is often the case with research, another study suggested it didn’t make any difference.

Galloway: Right. If you look at New York City’s study, it appears beneficial, and if you look at other evaluations, particularly fast food restaurant studies, it hasn’t made much difference. It’s going to take a little while to settle that out, I think. Another study recent evaluation showed that parents utilized those calorie counts when selecting their children’s menu items, but not their own.

I’d like to mention something else that connects prevention to the Affordable Care Act. In addition to providing broad coverage for prevention and care to millions of uninsured individuals, we know of two major components of the population that do not tend to have insurance: young adults right after they get out of high school and the folks who retire before they are eligible for Medicare. This administration has focused to expand coverage availability in these two areas, among others, including allowing youngsters to remain on their parents’ insurance, and in the older group, to make sure that we give tax credits to businesses to be able to provide coverage for these individuals after retirement until they are eligible for Medicare. So there’s been a lot of activity on that aspect as well.

Grogan: I think young people realize that [the ACA is having an impact] when their parents add them onto their insurance, but the broader public doesn’t realize how much progress we’ve made since the ACA passed in 2010. There’s been a lot of infusion of money in various aspects of the system that I think already has made a difference.

Galloway: I couldn’t agree more. I think that it has had a tremendous influence on funds to maintain the public health community, which is in a serious downsizing mode right now. The folks that makes sure our restaurants are safe to eat and that the water is safe to drink, those who will track a case of TB—that is, the very basic public health workers in the state and in the counties—are under significant budget cuts and in some cases, their offices are being downsized. Funding from the ACA is helping support some of these critical public health positions and infrastructure ...

For instance, just late last week, the CDC rolled out the Community Transformation Grants, $103 million, which are focused on coalitions working together across public health--business, the private sector, academia and community organizations--utilizing evidence-based interventions to improve health. That includes the area that I feel is most important, and that’s in systemic and policy areas, to make that healthy choice the default choice again.

Grogan: The work for health promotion: I can see how the collaborative network can be extremely powerful and necessary—it can’t just be local and state public health workers. But for some of the work around basic infectious disease control and clean water, for some of that you just need public health workers to be out there doing the work. With the idea of downsizing, I think that’s something that people are worried about, another outbreak for example, or emergency response systems. Can any of the money from the ACA public health fund be used to cover [those traditional] public health department costs?

Galloway: The current status for the U.S. Government’s 2012 fiscal year is still under congressional review, to it’s too early to provide a clear analysis where funds will be going over this next year. But the health and safety of Americans will certainly remain a priority. In the past, many of these funds through the CDC and other agencies have been focused on areas related to the largest public health issues facing us right now, which includes obesity. But the idea is that those funds would also allow, along the margins if not more directly, for some stabilization of the public health community in general. For instance, our workforce development efforts: A large amount of public health money from HHS [the U.S. Department of Health and Human Services] and the CDC has gone to make sure that there are public health workers as well as clinicians to care for the expanded number of folks who now have insurance through the ACA.

Grogan: Right. I remember reading about that. I thought it was primarily to develop a primary care workforce, clinicians, which is crucially important.

Galloway: It is primarily, but there are also public health aspects that have been parts of that as well. That’s an incredibly important part of the entire public health initiative as we move forward.

Grogan: I want to switch gears and ask you about your involvement in the Indian Health Service in Arizona. I have a special interest in the Indian Health Service because I did a study in Washington state. One tribe would be so well off in terms of socioeconomic well-being, and other tribes were just incredibly poor and really suffering. Lots of these things we talk about in terms of health promotion and behavior, and creating healthy behaviors, seems to apply in the Indian Health Service as well. Are these same initiatives happening there?

Galloway: That’s a great question. That’s where I developed my passion for public health, first as primary care internist on reservation for years, running a hospital and doing some research that showed that American Indians were having a rapidly increasing rate of cardiovascular disease [CVD]. Despite very high rates of obesity and diabetes, they previously had always had have very low rates of CVD, so when we started seeing an increase, it really prompted us not only to publish that data, but also to work on interventions. I went from invasive cardiology to non-invasive cardiology to preventive cardiology to public health, and that’s when I was asked to come to Chicago. I have recognized the health of the public in general is really the basis of my passions in health.

When I started working at Indian Health Service, there wasn’t as much disparity between tribes. Most of the populations had very poor levels of health compared to other populations in the U.S., and very poor levels of funding. Since that time, there have been some significant improvements. But you’re exactly right. When working with a tribal community—or any community for that matter—the community has to lead. You can go to them with perhaps knowledge they don’t have, but they have to lead and guide you with what they want. Otherwise, it simply just doesn’t work.

One of the things that also made a big impact on me was the Community Health Representative world. Indian Health Service has an entire system of community health representatives, similar to promotores, [someone from the neighborhood who educates, assists and may connect local residents with assistance and health care providers]. They taught me and proved their value beyond question—to have people from the community, from the same culture, with the same language, who can bridge that gap between the health system and the community. That’s brought some real guidance to all of us as we roll out a new vision of prevention and health care across America.