Tag: University of Washington

What is Public Scholarship?

IMG_3174My irreverent answer: work done by nerdy, bookish, abstruse (yes, abstruse), people with way too much formal education who can get over themselves enough to care about the ‘real’ world, what’s going on in it, what they might have to offer it on a more practical level, and what they can learn from that big, scary ‘real world.’

Here is one of the more reverent official answers:

“Publicly engaged academic work is scholarly or creative activity integral to a faculty member’s academic area. It encompasses different forms of making knowledge ‘about, for, and with’ diverse publics and communities. Through a coherent, purposeful sequence of activities, it contributes to the public good and yields artifacts of public and intellectual value.” (From: Ellison, J., and T. K. Eatman. 2008. Scholarship in Public: Knowledge Creation and Tenure Policy in the Engaged University. Syracuse, NY: Imagining America.)

The photo above is of me looking very happy yesterday at the University of Washington Odegaard Library (first floor) in front of my public scholarship multimedia exhibition Soul Stories: Homeless Journeys Told Through Feet.
This is a collection of poetry, prose, photographs, and digital storytelling videos about my work as a nurse providing health care to people marginalized by poverty and homelessness. I understand homelessness at a visceral level, having lived through it myself as a young adult. I also readily acknowledge that just because I ‘made it out of homelessness’ doesn’t mean everyone can, nor that it is an easy thing to do, especially within our society.

The Soul Stories exhibition will be at Odegaard Library (opposite Suzzallo Library on ‘Red Square’) through March 20, 2015. Odegaard Library is open to the public during regular library hours. Many thanks to the wonderful librarians at Odegaard who opened this space for me, and thanks to 4Culture for helping to fund part of this project. I was looking happy in this photograph because this has been the most challenging, fun, and soul-satisfying scholarly project so far in my career.

Public or community-engaged scholarship has never been valued by ‘high brow’ university types, especially not at research-intensive universities. It generally doesn’t ‘count’ as a valid activity for those pursuing graduate degrees. It generally doesn’t get you tenure. But that all seems to be changing, albeit at the achingly slow speed of any change within higher education. The catalyst for this change seems to be less from sudden altruistic enlightenment on the part of the academy, and more from public pressure for universities to show tangible positive impact at the local, national, and international levels. Within medical science scholarship, you can see this outside pressure manifested in the embrace of ‘translational research.’ Research within the realm of public scholarship doesn’t need to be translated.

Within the area of health-related public scholarship, a terrific resource I have used throughout my career is the Community-Campus Partnerships for Health (CCPH).  Check out the free, no membership required resources on their website, especially CES4Health, for peer-reviewed products of community-engaged scholarship.

Got Medicaid (Expansion) Virginia?

DSC00367_2My hometown of Richmond, Virginia is fond of putting large statues of white men on horses in the middle of its streets. Richmond is also the setting for a political and health care drama of Southern Gothic proportions. Virginia is an ACA non-Medicaid expansion state, but the state’s leaders have been debating Medicaid expansion over the past year. Earlier this month Phillip P. Puckett, a Virginia Democratic state senator, suddenly resigned to take a job on the Virginia tobacco commission. Curious circumstances surrounding his resignation have led to an investigation by the U.S. Department of Justice and the FBI, as reported in this recent Richmond Times Dispatch article. His resignation flipped control of the Virginia State Senate to Republicans intent on blocking Medicaid expansion efforts. Today Virginia Governor Terry McAuliffe announced his plan to bypass the recalcitrant Republican General Assembly and expand Medicaid to 400,000 low-income Virginia residents. (see: Modern Healthcare Va. Governor to Bypass Lawmakers, Expand Medicaid, 6-20-14). Governor McAuliffe also plans to block funding a $300 million facelift of the Capitol complex where many of the lawmakers have their offices. The bright and shiny Virginia State Capitol is shown in this photo I took about a year ago.

Medicaid plays vital roles in people’s lives and in our health care system. Medicaid improves access to basic health care services for millions of our children, low-income adults, the elderly (long-term care services), and people with disabilities. Medicaid saves lives. Medicaid funds large portions of our public hospitals, health centers, and nursing homes. Without Medicaid, most of our children’s hospitals would be forced to close.

Several of my struggling small business owner nieces and nephews who live in Virginia would benefit from Virginia’s Medicaid expansion. My elderly father who lives in Richmond would benefit from Medicaid expansion for long-term care services not covered by Medicare. My own son who lives in our Medicaid expansion state of Washington is about to get Apple Health, our version of Medicaid because the University of Washington has ended their student health insurance plan–or at least what was masquerading as a health insurance plan (see my previous post, “My Young Invincible, His Lost and Found Toe, and University Health Insurance that ‘Technically Isn’t'” 4-23-14).

Virginia and other Southern states have high ratios of physicians to the general population, yet have the worst poverty and shortest life spans of any region in the U.S. Virginia has the second highest number of free clinics in the country. North Carolina has the most and Georgia is close to Virginia’s number. Most of the free clinics are faith-based and pride themselves on not accepting any ‘government handouts.’ This generally includes the clinics not accepting Medicaid or Medicare reimbursements. These Southern states are part of the Black Belt of entrenched poverty and severe health inequities. Are free health clinics part of the solution or part of the problem?

The deeply entrenched American notion of charity care as the way to provide safety net services engenders stigma, shame, dependency, and resentment among recipients. Charity care is especially pronounced in the Bible Belt South. People do not want to have to depend on the kindness of strangers. Charity care further fragments an already fragmented, disorganized health care system. Charity care clinics have to compete for donations, grants, staff, and patients. Charity care further fragments and separates us as members of society—sorts us into the haves and the have nots, into worthy and unworthy citizens. Charity care perpetuates poverty. Despite compassionate staff and health care providers, charity care is always leftover care, afterthought care, second-rate care. Charity care gets discouraging, both to give and to receive. I know this first-hand, having been on both the giving and receiving ends of charity health care.

Medicaid and Medicare are both basic entitlements; they are not charity care. So Virginians, come down off your high horses and get Medicaid expansion.

The Intima: A Journal of Narrative Medicine

IMG_0678In case you haven’t run across this journal before, I encourage you to check out The Intima: A Journal of Narrative Medicine. It was created by some of the students in  the Narrative Medicine Master’s Program at Columbia University. They state, “…we seek an ongoing mode of self-expression as a group, to continue outside the classroom that which was created within. With that in mind we call ourselves and our efforts The Intima, resonating on the concept that Narrative Medicine defines itself as the intimate interface between two people, one as healer, one as being healed, yet both yielding and both gaining from the experience. (…) The Intima is an electronic journal dedicated to promoting the theory and practice of Narrative Medicine, an interdisciplinary field aiming to enhance health care through the development of effective communication and understanding between caregivers and their patients. By providing an online venue for the expression of personal experience within the medical arena, The Intima creates space for caregivers, professionals, patients, and families to share their narratives in a format that fosters empathy, reflection, and deeper understanding of the diversity inherent in effective delivery of care.”
In their Spring 2014 edition under Fiction, I have an essay “Steps to Footcare” about my work as a faculty preceptor with the University of Washington’s Teeth and Toes Clinics, where we provide basic foot and dental care to Seattle’s homeless population. This particular essay takes as its form the actual list of instructions we give students to follow when providing care. I fictionalized it by creating a composite female character based on several ‘real’ patients.

Devilsih Dealings in Hospital Mergers

devilish latte
devilish latte (Photo credit: strikeseason)

Hospital mergers between faith-based (mainly Catholic) and secular healthcare systems are picking up speed and setting off more alarm bells across the country. Here in my home state of Washington–one of our nation’s most secular and socially progressive states–we are quickly becoming the state with the largest percentage of Catholic hospitals. If all of the pending hospital mergers go through, more than half of all hospital beds in Washington State will be in Catholic hospitals. How can this be?

In my previous blog post “God and Mary and Jesus are back….and Coming to a Hospital Near You” (February 27, 2012) I wrote about the concerns raised by the merger of Seattle-based secular Swedish Hospital with Seattle-based (Catholic) Providence Health and Services. As part of the merger deal Swedish Hospital dropped its abortion services. Since the merger, employees have reported they are not allowed to talk with or refer patients for pregnancy termination or give patients resources about our state’s Death with Dignity Act. There are also concerns voiced about the merger’s effect on access to and quality of health care for LGBTQ individuals.

My own physician is part of Swedish and I’ve had conversations with her about whether or not my end-of-life wishes/Advance Directives would be honored if I ended up in a Providence/Swedish hospital. I considered switching health care providers, but now most all in the Seattle area are affiliated with Catholic hospital systems. Even the University of Washington Medical Center is merging/affiliating with PeaceHealth, a large Catholic healthcare system. You have to wonder about these names. Who can argue (especially all of us Pacific Northwest hippies) with a name like PeaceHealth?

As I stated in my previous post– I am all for religious freedom. But I also believe that the separation of church and state goes both ways—not only protecting the
church/religion from the bully-power of the state, but also the state
(government and civil society) from the bully-power of the church.

The ACLU of Washington has taken up the issue of hospital mergers and hosted an excellent panel discussion last week on this topic at Town Hall, Seattle. You can hear a full recording of it here. The audience Q&A session was the most interesting part of it for me. Someone asked why no hospital administrators were on the panel. The answer from the organizers was that they wanted an educational forum and not a public debate–and that hospital administrators had ample resources and platforms already for voicing ‘their side’ of the issue. A woman asked what the ramifications will be for health science student education at University of Washington with the merger/affiliation with PeaceHealth. Two of the panelists were UW faculty members and one replied, laughingly, that they weren’t authorized to answer that question. How sad and how telling and oh how political health care is in our country.

Health Insurance: Good Luck

Insurance
Insurance (Photo credit: Christopher S. Penn)

If anyone ever questioned whether or not US healthcare is political, they should now be convinced that it is. What with the drama of Obamacare, that Texan Tea Partier/Green Eggs and Ham reading/White Castle hamburger loving/Obamacare hating Senator Cruz, and then the looming shutdown of the federal government.  Not to mention Vanderbilt Medical Center’s recent creative administrators’ cost-cutting move to require nursing staff to take over housekeeping duties, for which they invoked the ghost of Nightingale (yes, HER again!) as the rationale behind their decision. Oh Nightingale! Rise up and smite them with a mop!

And then there is the desperate, mostly behind-the-scenes scramble for state health exchanges to be up and working by this coming Tuesday, October 1, when they are all slated to open for business. As described in today’s NYT article, many state exchanges will most likely be delayed. I especially like the article’s photograph of a roomful of intensely-working computer programmers trying to fix things for Oregon’s health exchange. I wonder how many of those workers have health insurance, and if not, how many of them now understand how to shop for and purchase health insurance once the system they’re working on is functional. Many of them do not look healthy.

My son, age 26, recently aged out of my health insurance plan. He was able to stay on my plan thanks to that provision of Obamacare. For the past few months he has been one of the many ‘young invincibles‘ (or ‘young invisibles’ perhaps?) who has no health insurance. Of course, I bug him constantly about this and want him to be insured. He’s now in graduate school at the University of Washington and is now eligible to purchase their student health insurance plan. The annual fee for one student (including 2014 ACA fees/whatever that means) is $2,748. School started this week, the earliest he would qualify for the insurance. I just checked their website and it has a statement marked urgent: “due to a system error some students who registered for Autumn quarter have had their coverage cancelled.”

This is complex stuff. I have a doctorate in health policy, teach, live and breathe health policy, and I can’t figure it out. Our healthcare system, especially the health insurance scene, has always been complicated, but I’m convinced that this specific part of Obamacare is creating more problems than it solves. It adds layers of administrative complexity and a huge burden (time and frustration–heart attacks anyone?) on consumers to ‘shop and pick a plan.’ These add up to a substantial increase of costs and inefficiencies in our already overly costly, inefficient, ineffectual healthcare system.

The best (mostly fully functional that I’ve seen) interactive tool for consumers ‘explaining’ ACA/Obamacare in more or less vernacular (English and Spanish), is Consumer Report’s Healthlaw Helper. Good luck.

Quick Toes in Stinky Shoes

The Old Running Shoes
The Old Running Shoes (Photo credit: Mike Spray)

Way to go to Heather Boyle, RN who just had her wonderful Narrative Matters essay included in the latest edition of the health policy journal Health Affairs. Her essay is entitled “As Sports Fees Rise, A Young Athlete Learns That If You Can’t Pay, You Can’t Play.” Heather is a nurse at the Center for Change, an inpatient treatment center for adolescents with eating disorders in Orem, Utah. I had the pleasure of teaching Heather for two of her nursing courses at the University of Washington, where she graduated in 2012.

As she mentions in her essay, Heather grew up in rural Washington State, near the Olympic rainforest. She took up running in elementary school by helping her family members deliver newspapers. A star high-school runner, Heather encountered financial barriers to participation in her school’s track team. Heather advocates for elimination of the “pay for play” rules in order to increase access to school sports. For my health policy course, Heather wrote a health policy essay/personal narrative on school sports, using the format of Narrative Matters. She now has her essay published, plus there is a link to her reading her essay. “Quick Toes in Stinky Shoes” was her original title for the essay, and in the published piece the editors retained it as a subheading. Heather I am so proud of you!

University Bullies

The U-District, looking northeast from Queen A...
The U-District, looking northeast from Queen Anne. UW Tower is the tall building in the center, with the Hotel Deca (originally the Meany Hotel) to its left. The Interstate 5 Ship Canal Bridge is in the foreground. (Photo credit: Wikipedia)

Urban universities seem to have a long history of being bullies in the communities in which they reside. There’s the fact that universities are big businesses, with all the power that money brings. Then there’s the influence of the widely held belief that universities are a public good and are, therefore, above reproach. People typically don’t want to be seen as blockers of progress, as being against the building of classrooms, scientific labs, and hospitals—and all the additional jobs that go with them. But are universities good for the health of their own communities?

I’m thinking about the university campus-community where I currently live and work: the University of Washington and the U-District. In the past two decades I have seen the university steadily creeping westward through the heart of the U-District neighborhood, building palatial new student dorms, new research and technology buildings, branch medical centers, and even taking over the hulking Tower of Saurumon—oh wait, it’s really called the UW Tower. This is the former SAFECO insurance company building, which at 22-stories is the tallest building in Seattle outside of the downtown business core. You have to be here to understand just how much of a commanding presence this building has for the surrounding neighborhood. There is no place to hide from it. Fittingly, back in the 1960’s or 70’s, the SAFECO tower had a 96-foot long reader board with flashing light messages such as “Big brother is watching you.” Now the top of the tower just says “UW” in big purple letters (the ‘is watching you’ part is, perhaps, understood.)

There is a new U-District revitalization group working on ways to reduce crime, increase (legitimate) businesses, and make the U-District healthier and more livable. The group has representatives from the University of Washington, the U-District business groups, residents of the U-District, and at least one community service provider who works with homeless people in the U-District. I have a personal interest in the success of this group since I own a home near the University, I bike to my office at the University, I dine and shop in the U-District, and I do some volunteer work at a U-District homeless shelter. Mine is a cautionary optimism about the success of the revitalization group. My caution comes from looking at the community-campus ‘revitalization’ that has happened recently in the city I moved to Seattle from: Baltimore.

I lived, worked and went to school in the East Baltimore area where Johns Hopkins Hospital is located. As a neighborhood, East Baltimore certainly had its problems—mainly deeply entrenched poverty, stemming in large part from historical racism. It was a majority African-American community. But it was a community in the true sense of the term, and I found from working with the residents that there were amazing sources of community resiliency and pride. These sources of community resiliency could have been built upon for the mutual benefit of the ‘real’ community and of the Johns Hopkins community. Although there are small examples of this happening, they are all dwarfed by the following facts:

In 2002, spurred on by an Irish-American Baltimore City mayor, Johns Hopkins University partnered with the city and state governments, and with the Annie E. Casey Foundation to begin a 20-year $1.8 billion East Baltimore revitalization effort. Approximately 90 acres of residential area just north of the Johns Hopkins Hospital were bought up, 800 families were displaced, and their houses torn down. These houses are slowly being replaced by life sciences buildings, student dorms, and high-end townhouses and apartment buildings.  Various sources of Johns Hopkins University publicity for this project that I’ve reviewed, gleefully state that the ‘urban blight’ has been wiped out and that crime in the area has been reduced by 87% since 2002 (well duh, you need people to have crime, right?). None of the reports mention what has really happened to the 800 displaced African-American families, nor what they think of this seemingly non-participatory (or bullying) university neighborhood ‘revitalization’ project. (see “The changing face of East Baltimore” by Greg Rienzi, Jan 1, 2012/JHU Gazette.)

I hope that my own university and community can do better than this….

For a brief and fascinating history of UW/U-District relationships, see the Washington State Historylink file “Seattle Neighborhood: University District Thumbnail history.” Who knew that the world’s largest single university building, the UW Health Sciences Building, came about because the UW football team won the Rose Bowl in 1960? Now I know why it’s so important for the UW to be building a new $261 million Husky football stadium.

 

Hospital Quality: A Different View

Paul Farmer (of Partners in Health fame) has an easy-to-apply formula for DSC00749quickly assessing the quality of hospitals or clinics anywhere in the world. He says that given the resources of the country, he looks at the quality of the hospital/clinic bathrooms and the gardens surrounding it. Based on just those two items, he claims he can accurately assess overall hospital/clinic quality—and afterwards correlate it with more ‘objective’ measures of quality and safety. Try out his quality assessment at your own hospital/clinic work-site, and maybe as a New Year’s resolution try to influence improvements.

My office at work is in the world’s largest university building: the Warren G. Magnuson Health Sciences Building at the University of Washington. The building has close to 6,000, 000 square feet of space and is composed of over twenty wings whose hallways are connected, but in a haphazard, disorienting way. The building is an Escher-esque sort of place, with faceless people wandering the hallways and strange concrete staircases going everywhere and nowhere. Ten thousand or so people work (or are hospital patients) in this building. At any given time at least half of the people are lost. I am usually one of them. The building includes a hospital and four health science schools—medicine, nursing, public health and dentistry. The fifth health science school—social work—was lucky and is far across campus in its own (very small) building.

The Health Sciences Building is sandwiched between three busy streets and one busy ship canal. Many of its courtyards are completely covered in concrete, with only a few stalwart and scraggly rhododendrons popping up in places. The bathrooms are tiled and painted a sickly yellow-beige that reminds me of public high school gym locker rooms.

My office is in the ugliest wing of the world’s largest university building. My office has a fault line running through it. There is a 6-inch wide grey rubber seam that bisects my office in two—it runs up one wall, across the ceiling, down the other wall, and across the floor. This rubber seam is the building’s earthquake shock absorbers. I often wonder what it would be like to stand on the fault line during an earthquake. Would I be safer there than ducking under my fake-wood desk? My office also has a door that goes nowhere. Supposedly it allows access to various pipes and electrical wires in the concrete-encased outer phalanges of the building. This door is perpetually locked and I have hung a silk scarf over it to make it seem less weird. I tell students it’s where old faculty members go to die. I often want to crawl in there and take a nap.

The particular part of the Health Sciences building I work in, the T-wing, was built in the late 1960’s and is a prime example of Brutalism. It is also a prime example of why Brutalism is not an architectural style suited either for Seattle weather or for being attached to a hospital. Outside and inside it appears to be made of crumbling, damp and moldy concrete. In one staircase I use there are arm-sized stalactites forming on the ceiling and liquid is perpetually dripping from their pointed ends into a black and green puddle in one corner of a stair landing. It has a bizarre beauty. Over Winter Break the stalactites were removed and the ceiling painted over. I find that I miss them.

University of Washington Medical Center does fairly well on most quality measures included in Medicare’s Hospital Compare. Under ‘patient satisfaction survey’ they include an item on cleanliness of bathrooms. (Gardens aren’t included). If you haven’t used this website before, I encourage you to do a search of hospitals in your area. They have recently added a section on hospital readmission rates.

The Baby And The Bathwater

Midwife and Jessica Breese, a Certified Nurse ...
Image via Wikipedia

And the mother and the midwife.  If you haven’t heard the news on this, the nursing faculty at the University of Washington voted to eliminate their nurse midwifery program. News of the pre-Christmas faculty vote is now making headlines and creating controversy. Several weeks ago there was an impassioned opinion piece about the faculty’s decision, circulated by the listserve for the American Association of University Professors. Today in the Seattle Times, Danny Westneat published a column “UW School of Nursing’s Priorities Can No Longer Bear Midwives.” (1-15-12).

I love nurse midwives and tried to have one deliver my son a quarter century ago. But since I lived in the south—and did I mention it was a quarter century ago?—and had an extremely benign heart arrhythmia and maybe had been exposed to TB by a homeless patient, I was deemed too high risk to rate a midwife. In labor, I went to a birthing center to have my son and was doing just fine with the nurses there and with no real medical intervention—until some uptight female OB/GYN who I’d never met came clicking down the hallway in insanely high heels, yelled at me not to push until she returned—she had to go park her car—and clicked back down the hallway. I wanted to kick her or at least fire her. I’m sure it would have been a better birthing experience if I’d had a nurse midwife.

I’ve worked with nurse midwives in a variety of community-based health settings and they provide wonderful women-centric primary care. It will be interesting to see what emerges in the continuing—hopefully public—debate over the fate of nurse midwives at the University of Washington.

Making America Healthier

http___www.michigan
Image by Sacred Heart Rehabilitation Center via Flickr

This week I attended the John R. Hogness Symposium on Health Care at the University of Washington. This year’s speaker was Daniel R. Williams, PhD, Professor of Public Health/African and African-American Studies/Sociology at Harvard University. Dr. Williams is a sociologist who studies the social determinants of health, including racial and socio-economic health disparities. He is prominently featured on the excellent PBS series, Unnatural Causes, being interviewed on a variety of topics related to his research.

The title of Dr. William’s talk was, “Making America Healthier: Surprising Steps for Every Health Professional.” While Dr. Williams is an excellent public speaker and delivered a cohesive lecture, most all of the information he covered was the same/similar to what is in Unnatural Causes—so it wasn’t really surprising. I suppose though that it is surprising that the information is surprising to health professionals in the US. He was mostly preaching to the choir here in Seattle. I was also surprised (and bemused) by the pre-lecture conversational content of a group of young students sitting beside me. While looking around at the increasing crowd, one student exclaimed, “Wow! So this is like a big deal!” OK, so we have work to do in our educational system.

Dr. William’s main talking points were as follows: 1) the US ranks near the bottom of all industrialized countries on most all health measures—and we are losing ground; 2) immigrants to the US become less healthy the longer they live in the US (“life in the US is bad for your health”); 3) the racial gap for blacks/whites in health is larger for higher educational levels; and, 4) racial segregation in large US cities in the 2000 census was close to the level of racial segregation in South Africa in 1991 under Apartheid. He stated that health care reform is crucial but insufficient—that we also need to address the social determinants of health in order to make America healthier. He included health behaviors/individual lifestyle choices as something we all need to work on—we are now supposed to eat at least nine servings/day of fruits and vegetables and not just five—while acknowledging how poverty and lack of access to healthy choices makes it more difficult for some to ‘do what’s right’ health-wise.

What can we as health professionals do to make America healthier? Of note is that Dr. Williams is not a health care professional, and that fact was reflected in some of his recommendations. He gave examples of successful programs that incorporate social determinants of health into mainstream health care. Heading his list (yeah!) was the Nurse Family Partnership. Then he talked about the Boston Medical Center’s Medical Legal Partnership, which links low-income families with lawyers—for instance to pressure landlords to remedy asthma-inducing mold and cockroach problems in apartments. The third program he mentioned was Health Leads, started by a Harvard undergrad. This is a service-learning project training college students to staff waiting rooms of safety net clinics, linking patients and families with needed social services.

Dr. Williams ended his talk by giving reference to four resources for further information: 1) Unnatural Causes videos, 2) Robert Wood Johnson’s “Build a Healthier America” report, 3) county-level health data at Countyhealthrankings.org, and 4) Biology of Disadvantage: Socioeconomic Status and Health (Annals of the NY Academy of Sciences, Feb 2010–free access to report–there is a companion report/also free/less academic, “Reaching for a Healthier Life: Facts on Socioeconomic Status and Health in the United States.“)

I was left thinking, “Yes-but?” This all sounds good, but what can individual health care providers such as nurses really do to change things in the health care system? How can we include any of Dr. William’s suggested programs? For instance, our local Odessa Brown Clinic, a safety net clinic in a traditionally African-American Seattle Community, had a grant to include legal services for patients. But once the grant ended, the program ended. Our Washington State Maternity Support Services are on the chopping block in the upcoming legislative session. I suppose we could try to replicate the Health Leads program locally, but with food banks and other basic services being cut, it is hard to know what the students would be linking patients to.

I try to maintain healthy skepticism as opposed to unhealthy cynicism in terms of health policy in general, and the social determinants of health in particular. But Dr. William’s talk left me with the vivid impression of all of us health care progressives spitting into the wind. Even the authors of the Biology of Disadvantage report have somewhat similar sentiments, “…thus we face with humility the task of identifying appropriate poverty-reducing strategies that improve health.” (p.247)