2019 Public Health Deep Dive Co-Chairs

PUBLIC HEALTH DEEP DIVE APR. 25-26, 2019 BOSTON, MA

PUBLIC HEALTH DEEP DIVE

APR. 25-26, 2019 BOSTON, MA 2019 Public Health Deep Dive Co-Chairs

Howard K. Koh, M.D. Harvey V. Fineberg Professor of the Practice of Public Health Leadership Harvard T.H. Chan School of Public Health Harvard Kennedy School Faculty Executive Committee Member Harvard Advanced Leadership Initiative

Meredith B. Rosenthal C. Boyden Gray Professor of Health Economics and Policy Harvard T.H. Chan School of Public Health Faculty Chair Harvard Advanced Leadership Initiative Report Credits

Bryan Panzano Assistant Director of Communications and Marketing Harvard Advanced Leadership Initiative

The Advanced Leadership Initiative (ALI) is a third stage in higher education designed to prepare experienced leaders to take on new challenges in the social sector where they have the potential to make an even greater societal impact than they did in their careers

ALI Deep Dive sessions highlight one major global or community challenge where ALI Fellows might fill a gap. Deep Dives include readings, outside experts, often faculty from relevant Harvard programs, and a focus on problem solving and practical applications of knowledge.

ALI Fellows contribute ideas based on their experience and knowledge for immediate solution-seeking with major figures in the field under discussion and with affected constituencies. Table of Contents

Executive Summary 1 Burden of Disease: Global and U.S. Perspectives 4 U.S. Health Care Policy: Coverage, Affordability, and Value 7 Health Systems around the Globe: Aspirations and Realities 10 Health Policy and Systems Discussion 12 The Politics of Health Reform: Where are We Headed? 14 New Partnerships for Health 16 Making Mental Health Matter 18 Global Syndemic of Obesity, Undernutrition, and Climate Change 20 Rethinking the Opioid Epidemic 22 Designing for Real User Needs 25 Synthesis 27 Medicine in the Shadows: Caring for Boston’s Rough Sleepers 28 Speaker Biographies 32 Executive Summary

The 2019 Public Health ture health in the broadest less. Deep Dive featured presen- sense, as noted by the World tations and discussions on Health Organization’s defi- Bringing together the con- global health frameworks nition of “complete physical, tent of the Deep Dive, with examples from low and mental, and social well-be- Rosenthal helped fellows middle-income countries, ing”, would require assets synthesize their thinking alongside an introduction to and partners outside of the around the complex issues the economics and politics health care sector. in public health. of health care reform in the United States. Although the The Deep Dive featured a Ultimately, ALI Fellows U.S. is one of the wealthiest panel discussion, dynamic seemed to agree that some nations in the world, it is far speakers, and a design work- degree of collaboration was from the healthiest and its shop. Presentations began necessary to address these challenges provided a useful with basic knowledge on issues. Change could happen lens through which to view health systems, and moved only by working with com- health system design chal- towards discussion of cur- munities to identify prob- lenges more broadly. rent domestic and global lems and potential solutions health priorities, including and by gathering stakehold- During the two day event, the nutritional consequenc- ers across sectors to imple- ALI Fellows conversed with es of climate change, addic- ment those solutions. Harvard Chan School fac- tion, and mental health. The ulty, community, and health cohort came together in the Howard Koh and Mere- care industry leaders about middle of the second day to dith Rosenthal, members the complex challenges as- design a solution to a specif- of the ALI Faculty Execu- sociated with improving ic health challenge, and the tive Committee and Facul- health systems, and ulti- Deep Dive concluded with ty at the Harvard Kennedy mately health, both in the an intimate conversation School and the Harvard U.S. and globally. A central with Jim O’Connell, found- T.H. Chan School of Pub- theme of the Deep Dive er and president of Boston lic Health, chaired the Deep was that improving fu- Health Care for the Home- Dive.

3 Burden of Disease: Global and U.S. Perspectives

To launch the 2019 Public of health is a fundamental nicable diseases—cardiovas- Health Deep Dive, Profes- right of every human being. cular disease, cancer, respira- sor Howard Koh of the Har- Public health, then, was en- tory diseases, diabetes, and vard T.H. Chan School of suring that all individuals dementia—accounted for Public Health and Harvard were able to experience the the leading causes of death Kennedy School discussed highest standard of health. around the world. the disease burden from a Citing the respected 20th global and U.S. perspective. century British author and Koh explained that the 2017 He highlighted some of the systems thinker Geoffrey GBD report showed that challenges in health and Vickers, Koh said that pub- “we live in a fragile world health care and presented lic health was also “succes- that is gradually improving.” some pathways forward to sive re-definings of the un- According to the report, make progress. Ultimately, acceptable.” global adult mortality rates he explained, public health had decreased, and life ex- needed the support and en- With that foundation in pectancy had increase over gagement of the broader place, Koh described the time. Nonetheless, there population. Global Burden of Disease were significant disparities Project (GBD)—an effort around the world. Koh began his session by to measure global public explaining the definitions health and the effects of dis- In an effort to address these of both health and public eases and injuries on a coun- disparities and the glob- health. “Health is a state of try-by-country basis. Started al burden of disease more complete physical, mental, in 1990, the GBD published generally, the United Na- and social well-being, and its most recent report in tions developed the 2015 not merely the absence of 2017, cataloging more than Sustainable Development disease or infirmity,” he ex- 359 diseases and injuries Goals (SDGs). While the plained. He added that the and 84 risk factors for dis- SDGs examine how to World Health Organization ease in 195 countries and make the world better in a has stated that enjoying the territories. The 2017 report broad sense—eliminating highest attainable standards showed that non-commu- poverty and hunger—many of these goals in fact in- plained that the U.S. need- doctor’s office,” Koh said. volve health and wellbeing. ed to pay more attention to He said as a country, we Koh described his own ef- the social determinants of needed to also consider the forts as the 14th U.S. Assis- health. “Health starts where effects of income, education, tant Secretary for Health to people live, learn, labor, play, housing, and the other so- achieve similar goals in the and pray.” cial determinants of health. U.S. He oversaw Healthy He also described his own People 2020, continuing a He further explained that efforts to build cross-sector decade-by-decade metric to health outcomes varied con- collaboration and promote a evaluate the country’s prog- siderably in the U.S. from “culture of health”— by en- ress toward achieving higher state to state. As an exam- couraging business to sup- standards of public health. ple, overall life expectancy port their employees, con- at birth in Hawaii was 81 sumers, communities, and Like the rest of the world, years, while in Mississippi the environment. “Health is the U.S. had made progress it was 75 years. In addition, too important to be left to in overall life expectancy, for the first time since 1993, the health experts alone,” he but Koh highlighted one life expectancy was shown said, “we need all of you to major problem: health care to be declining in the U.S. weigh in on this issue.” spending far outpaced im- in 2017. Koh attributed this provements in health care troubling statistic to a rise in outcomes. This disparity has obesity, substance use dis- been attributed in part due orders, and mental health to a relative lack of social challenges, including sui- services in the U.S.: for ev- cide, across the country. Ad- ery $1 spent on health care, dressing these issues would OECD countries spent $2 require a reframing of public on social services; for every health in the U.S. $1 spent on health care, the U.S. spent less than $.50 “Health is much more than on social services. Koh ex- what happens to you in the

U.S. Health Care Policy: Coverage, Affordability, and Value

Professor Meredith Rosen- physicians more, pays more expectancies and health in- thal of the Harvard T.H. for a hospital day, and pays surance coverage across the Chan School of Pub- more for fixed services. “In country. “Coverage in the lic Health brought a sys- essence, we get less health U.S. is voluntary and frag- tems-level perspective to the care and we spend quite a bit mented,” she said, “We have Public Health Deep Dive, more,” she explained. a patchwork system of both looking at health care policy public and private health and insurance in the United To complicate matters, life insurance.” While this vol- States. Rosenthal discussed expectancy varied widely untary system respected the the state of U.S. health and across the U.S. Rosenthal rights of individuals to make health care and gave an talked about the “Eight decisions, it also led to ad- overview on the country’s Americas,” a concept first verse selection—people who insurance model after the described by Chris Murray, buy health insurance tend passage of the Affordable director of the Harvard Ini- to be sicker and have more Care Act (ACA). She also tiative for Global Health: planned expenditures. helped ALI Fellows think different regions across the about the balance between country have vastly different In the U.S., most individu- quality and value in health life expectancies. “There is a als under the age of 65 re- care delivery and advocated 10-year gap in life expectan- lied on employer-sponsored for value-based health care cy depending on where you coverage. While people over payments in the U.S. live in the United States,” 65 were almost universal- Rosenthal explained. In fact, ly covered by Medicare, the Starting with the big picture, some states in the southern ACA attempted to provide Rosenthal explained that U.S. had life expectancies on coverage for the portion of the U.S. was spending far par with developing nations the under-65 population more than other countries around the world. that was not otherwise in- on health care and not see- sured. In practice, however, ing commensurate increases While not causal, Rosen- adoption of the ACA varied in life expectancy. She ex- thal noted that there was considerably among states plained that the U.S. pays its a correlation between life and, as a result, many indi-

7 viduals were underinsured— One potential solution in the health care sector and they had a health insurance to this problem was val- beyond needed to broaden plan but struggled to pay for ue-based payment—re- the scope of accountability medical care. These underin- forms that target both over- and consider the importance sured individuals were more all spending and quality. of the social determinants of likely to have skipped fol- Rosenthal said the current health. “We need to make low-up tests and treatments, way of paying for health the health system actually not filled a prescription, and care, fee-for-service, encour- focus on health instead of not received specialist care. aged more utilization and being a system where we fo- intensity but not necessarily cus on producing widgets.” Quality of care also var- an increase in quality. She ied widely state-by-state. encouraged the use of pay- Rosenthal explained that ment models that provide there was a fourfold varia- coordination and collabo- tion in the number of ICU ration: Accountable Care days in the last six months of Organizations, hospital val- life for patients depending ue-based purchasing, and on the region of the coun- merit-based incentive pay- try. Looking at a random ment systems. These models sample of charts across the encouraged a system-based U.S., for every recommend- approach to health care that ed service—even the most considered “episodes of care” basic—people received the and populations rather than evidence-based standard of individual services. care only about half of the time. “The problem is that Ultimately, Rosenthal said we spend a lot on coverage, the U.S. needed to break quality of care is sub-opti- down silos and move away mal, and use and quality of from paying for volume care vary widely,” she added. alone. She added that leaders 9 Health Systems around the Globe: Aspirations and Realities

Professor Margaret Kruk ditional healers, home care, of the Harvard T.H. Chan medication, health promo- School of Public Health tion and disease prevention, continued the discussion on and environmental safety in- public health systems, this terventions. Kruk explained time adding a global per- that her focus was primarily spective. Kruk first defined on how we as societies pro- a health system before ex- vide care to people. amining how health systems worked in lower- and Having defined health sys- middle-income countries tems, she added the goals of (LMICs). She also looked these systems were to im- at international goals to improve the health of popula- prove health care systems tions, respond to individuals’ and the practical realities in non-health expectations, realizing those goals. Finally, and provide financial pro- Kruk presented some po- tection against the costs of tential solutions to address- ill-health. She noted that ing challenges in health care other people thought that systems around the globe. health systems should be both efficient and equita- Kruk began her talk by de- ble; they serve as social in- fining a health system. As stitutions that communicate defined by the World Health governments’ commitments Organization, a health sys- to its citizens. tem constituted the activities whose primary purpose In an effort to meet these was to promote, restore, or goals, the UN developed its maintain health. This system Millennium Development included health services, tra- Goals (MDGs). The MDGs sought to reduce child mor- ed by all people; and four people believed their tality, improve maternal • Responding to changing health system worked well. health, and combat HIV/ population needs. AIDS, tuberculosis, and Kruk explained that to im- malaria. When these goals Under this new definition, prove quality, leaders needed expired, the UN created health systems needed new to look upstream—at struc- Sustainable Development goals. “If health systems are tural, systems-level changes. Goals with a broader scope for people, and we are judg- In particular, she advocated around ‘good health.’ These ing performance,” Kruk ex- for governing for quality, goals included addressing plained, “we need to focus redesigning service deliv- noncommunicable diseas- on more than managerial ery, transforming the health es, maternal mortality, sub- aspects.” She argued that workforce, and igniting de- stance abuse, and tobacco individuals care about pro- mand for quality among pa- control. Unfortunately, Kruk cess of care—competent tients. She noted that these said, many countries around care and services, positive improvements were large the world were not prepared user experiences—and qual- scale strategies that were to adapt to this new agenda. ity impacts—better health, slower to implement. “There confidence in the system, are no more easy fixes for As a result, Kruk argued and economic benefit. health care.” that the definition of health systems needed updating. Unfortunately, many healthy She said that health systems systems around the globe should be designed for peo- failed to meet quality stan- ple. A high-quality health dards and, as a result, lost system should optimize the trust of their commu- health in a given context by: nities. In the LMICs Kruk Consistently delivering care examined, nearly six in 10 that improves or maintains amenable deaths were due health; to poor quality of care. In • Being valued and trust- addition, fewer than one in

11 Health Policy and Systems Discussion

Following their individu- need to make change,” she system in the U.S. Rosen- al presentations, Professors said, “and an ability to set a thal explained that while a Margaret Kruk and Mere- bolder vision for health sys- single-payer system would dith Rosenthal of the Har- tems.” She also explained likely be more equitable and vard T.H. Chan School of that LMICs focused on pri- efficient, there were political Public Health had a discus- mary care much more seri- hurdles that made adopting sion about health policies ously than the U.S. such a system practically and systems, both globally impossible. “In my opinion, and in the United States. Rosenthal said the data the closest we will get in the Through their conversation, shows that there is a strong U.S. is single-stream financ- Kruk and Rosenthal looked correlation between ac- ing with private insurers to for lessons from the inter- cess to primary care and create a mandatory system,” national arena that could high-quality health out- she said. be applied in the U.S. and comes. Nonetheless, driving vice versa. The two profes- change in primary care had Kruk added that the lack of sors also answered questions proved difficult. “We haven’t trust in government in the from fellows and outlined yet been able to show that if U.S. made the situation con- potential solutions to health you pour money into prima- siderably different than in care problems. ry care, you will be able to other countries she studied. change things throughout “This is a uniquely skeptical Rosenthal began the discus- the system,” Rosenthal ex- country around the role of sion by asking Kruk what plained. government,” she said. By health systems in low- and contrast, she explained that middle-income countries After Kruk and Rosenthal in many developing coun- (LMICs) might teach lead- opened up the discussion to tries, leaders were following ers in the U.S. Kruk ex- questions from the audience, the best practices laid out plained that in her experi- ALI Fellows asked the two by economists to institute ence the boldness of vision experts about the effective- models of universal cover- in many countries impressed ness and feasibility of a sin- age. her. “There is a sense of deep gle payer health insurance Fellows also asked Kruk and to address the amount of Rosenthal how they saw the big-money interests driving role of primary and special- the politics around health ist care in health systems in care in the U.S. Rosenthal the U.S. and LMICs. Kruk explained that the U.S. had shared her experience work- made considerable advanc- ing as a physician in Can- es to shift the conversation ada to highlight the coun- around health care over the try’s emphasis on “watchful last 20 years—the American waiting.” She said this sort Medical Association and of practice was viewed neg- health insurers both sup- atively in the U.S. and a high ported the passage of the volume of care tended to be Affordable Care Act. seen as the best medical response. Even so, she said true reform for health policy in the U.S. Rosenthal agreed, noting required broad public sup- that U.S. payment policies port. Rosenthal explained: contributed to the empha- “The notion that the health sis on volume of care rath- care system will heal itself er than quality of care. “We without public intervention need to think about pay- is untenable.” ment reform as a way to in- centivize watchful waiting and other best practices,” she said.

In a final question, one ALI Fellow asked the professors what leaders could do

13 The Politics of Health Reform: Where are We Headed?

Professor Robert Blendon of the Harvard T.H. Chan School of Public Health talked about the important role that politics play in health reform in the United States. Blendon explained that political polarization in the U.S. led to inaction around health care reform. He also described the rea- sons for the widening political divide and outlined an array of possibilities sur- rounding health care policy following the 2020 U.S. presidential election.

Blendon started his session by explaining that the wide and growing divide between the two political parties in the U.S. had led to a stand- still on health policy. He said that the primary system in the U.S. created a political environment that ca- tered to extreme viewpoints. Politicians must respond to the wishes of voters, and centrists tended not to vote opinion of experts is being sue in the 2020 presidential in primary elections. crowded out by the quanti- election. In particular, voters ty of voices online.” He also would be interested in pol- Blendon also noted that the said that the information iticians’ views on insurance presence of lobbying organi- available online was subject for individuals with pre-ex- zations and private political to strong political bias. “Tell isting conditions. He also contributions influenced the me the site you go to, and I’ll noted that Americans gen- outcome of elections, and tell you the facts they’ll give erally saw the primary prob- often, health policies. He you.” lem with the health system said that nearly 1,800 or- as the cost structure and the ganizations in the U.S. lob- Because of these factors, the prices associated with medi- bied on health policy issues. partisan gap around health cine, insurance, and medical “There are five registered care policy continued to care. health care lobbyists for ev- grow in the U.S. Blendon ery member of Congress,” explained that the likelihood Blendon concluded his re- he explained. Moreover, the that Republicans and Dem- marks by explaining that private sector contributed ocrats would vote for the major changes in health nearly $6.5 billion in the same policy bill was roughly policy would only occur if 2016 presidential election; two percent. Public opinion one political party held the the third largest contributor on the roles and responsibil- presidency and both houses among private sector donors ities of government in health of Congress. “If one party was the health care sector. care reform, the Affordable wins, we are going to move Care act, and the possibili- in one direction or the other Finally, he explained that ty of single-payer insurance very quickly,” he said. Dra- there was growing skep- was entirely split by political matic changes to health care ticism in the U.S. toward party. and insurance policies would policy experts when it came hinge almost entirely on the to public decision making. Nonetheless, Blendon said 2020 election. “This is one negative side of that health care reform the internet,” he said, “the would be an important is-

15 Beyond Health Care: New Partnerships for Health

Lending important perspec- that employers need to care “and we are now advocating tive to the Public Health about health and well-being for making the business case Deep Dive, speakers from because it is good for the behind this model.” the public, private, and non- bottom line and because it is profit sectors shared their the right thing to do. Finally, Sánchez then offered his work to effect change in she explained that her work perspective, both growing the health care system. Kay at CVS Health involved up in a disadvantaged neigh- Mooney, vice president of shifting paradigms: redefin- borhood in Boston and as health at CVS Health, Mas- ing health as flourishing, not chair of the Massachusetts sachusetts State Represen- just the absence of illness. Committee on Ways and tative Jeffrey Sánchez, and Means and the Joint Com- David Waters, CEO of non- Next, Waters talked about mittee on Public Health. profit Community Servings, his organization, Commu- As young man, he saw first- talked about their efforts to nity Servings, a nutrition hand the disparities in the address the various social delivery program that cre- health care system: people in factors that impact public ates meals for individuals his community worked me- health. ALI Faculty Chair with challenging and com- nial jobs in some of the city’s and Deep Dive Co-Chair plex food plans. Community best hospitals but were not Meredith Rosenthal moder- Servings fed 2,500 people able to access the high-qual- ated the discussion. in Massachusetts annually, ity care within these hospi- creating meals from scratch tals. After a successful career The session started with tailored to over 15 medi- in the private sector, he en- Mooney describing her cal diets. Initially launched tered city government and work to lead well-being as a response to the AIDS worked to insure the entire transformation at CVS epidemic, the nonprofit had state population. Despite Health. She said that in the evolved to manage diets for recent trends in politics, he U.S., our environment, cul- the five percent of Ameri- noted the progress around ture, and lifestyles were neg- cans who account for 50% health care in Massachu- atively impacting our health. of health care costs. “We see setts: “Business, individuals, She also made the case food as medicine,” he said, and government are still committed to health care.” portance of spreading the word and involving others Following their opening re- in the discussions on public marks, Rosenthal asked the health. Whether discussing panelists what they saw as CVS Health’s work around the single biggest obstacle building a culture of health to improving health in their among employers or Com- communities. Mooney said munity Serving’s efforts to for CVS Health, the biggest increase understanding of challenge was changing in- the social determinants of dividual behavior; Waters health, conversation was key. explained that for Commu- “Ultimately, you need to in- nity Servings the biggest volve those who are impact- challenge was gaining val- ed by the problem in solv- idation; and Sánchez said ing it,” Sánchez observed, that for government the big- “Work with other people, gest challenge was promot- involve them in the process.” ing empathy. While their individual responses varied, all three panelists agreed that their efforts were meant to drive equity for individuals in their communities.

Turning the discussion to action, Rosenthal also asked the panelists what ALI Fel- lows could do to help them further their work. The panelists all highlighted the im-

17 Making Mental Health Matter

Examining one of the most to engage with the world pressing health problems in around us—to be able to the world, Professor Vikram experience the world and be Patel of the Harvard Medi- productive members of our cal School and the Harvard communities.” T.H. Chan School of Public Health explained that men- Yet too often, Patel ex- tal health presented one of plained, leaders in pub- the greatest challenges not lic health stressed physical just to science but to society health as a priority. “The more generally. “One of the common refrain is that there marvels of the world is that are more important things we have mapped the uni- to attend to before we can verse and mapped the atom,” attend to mental health.” he explained, “but we have The public perception that not mapped what’s between mental health care had no our ears.” tangible benefit, that it was expensive, and that men- Patel said that the concept of tal health problems were a mental health was imbued product of social and cultur- with an idea of madness al factors, made it even more and othering in societies difficult to promote effective around the world and was mental health interventions. implicit in the biomedical approach to mental illness. The lack of attention given Mental health was most of- to mental health was espe- ten associated with disorder cially distressing because or illness, but the mind is a of the prevalence of mental central asset for every indi- health disorders in com- vidual. “Our minds allow us munities around the world. Looking at the Global Bur- your biology,” he said. Trau- Finding solutions to mental den of Disease 2016 Report, matic events—for example, health challenges around the Patel explained that the bur- exposure to war or abuse— globe was an urgent matter: den of mental health prob- are important triggers for deaths due to mental health lems was increasing in all mental health problems. problems were on the rise countries. These problems globally, particularly among affected at least one in four To address the barriers to young people. Through people around the world and mental health care, Patel his work with the Global several of the most burden- said the most important Mental Health Initiative at some conditions involved priority was to address the Harvard, Patel was actively mental health—depression, shortage of skilled human working to build leadership, schizophrenia, and sub- resources. “When we think establish metrics, and build stance abuse. “Mental health about health, we only think a workforce to address men- problems are very common, about doctors in hospital health problems. He was and they are often chronic,” tals.” Patel added that lead- also working to protect the he said. ers needed to move beyond rights of people with men- the decade-long process of tal health problems. “Even Mental health problems af- training to a skills-based though we have a great deal fected people around the community provider ap- of knowledge, we still have a world regardless of socio- proach. Implementation long road ahead to put it to economic status or culture. researchers had shown that use.” While genetics were a part community-based providers of the puzzle behind the could provide safe, effective, origins of mental health clinical interventions and problems, Patel explained could be key human resourc- that environmental stresses es for mental health care in played a crucial role. “Men- places where there were no tal health is a combination physicians or mental health of circumstances happening care providers. in your life combined with

19 Global Syndemic of Obesity, Undernutrition, and Climate Change

Looking at another global tional deficiencies and obe- diabetes, hypertension, and public health crisis, Professor sity.” Having too little or too cardiovascular disease. To Lindsay Jaacks of the Har- much food, or a poor-qual- make matters worse, many vard T.H. Chan School of ity diet, could contribute to health systems around the Public Health talked about malnutrition. globe are not well-equipped obesity and its complex re- to address comorbidities as- lationship with undernu- Having established this sociated with obesity. trition and climate change, broader conception of mal- highlighting findings of the nutrition, Jaacks explained Jaacks said that obesity, un- recent Lancet commission that body mass index (BMI) dernutrition, and climate report. Jaacks argued that and obesity levels were on change represented a global a lack of political will con- the rise both in the U.S. and syndemic—a condition that tributed to the rising global around the world. From was exacerbated by social, trends of obesity and that 1975 to 2016, there was a economic, environmental, social mobilization would more than doubling of obe- and political factors. “Con- be required to address this. sity levels globally. While text is key,” Jaacks contin- She also made the case for there was huge variability ued, “Obesity is not just a responses that simultane- from country to country, and failure of individuals, but ously address sustainability even within countries, in rather the result of complex and undernutrition in food terms of absolute numbers, circumstances.” systems. obesity was a more serious problem among adults than While many organizations To begin her remarks, Jaacks undernutrition on a global developed evidence-based, explained that when it came scale. globally-agreed upon rec- to malnutrition, both the ommendations, there had quantity and the quality of While obesity itself was not been little progress in ad- food mattered. “Malnutri- a cause of death, Jaacks ex- dressing the obesity chal- tion is not just being un- plained that it was a risk fac- lenge. “So much has been derweight, or wasting,” she tor for other serious diseases. happening globally around explained, “It’s also nutri- Obesity could contribute to improving diets, encourag- ing exercise, and yet obesity To conclude her session, trends continue upwards.” Jaacks explained that obe- Jaacks explained that solu- sity was a serious problem tions must address norms, that was on the rise—it was economics, and policies and increasing in every region of that leaders had the oppor- the world and most solutions tunity to impact the three attempted to merely slow elements of the syndemic— increasing obesity rates. She obesity, undernutrition, and added that changes in health climate change—simultane- policy alone were not suffi- ously. cient to address the crisis. “Implementation of obesity In particular, Jaacks advo- prevention policies requires cated for taking a careful social mobilization,” Jaacks look at food systems, both said. The only way to drive in terms of quantity and change on the syndemic was quality of food produced. through public demand for “There is a fine line between government action. ensuring nutrient adequacy and avoiding excessive consumption,” Jaacks cautioned. She pointed out that 90% of the calories in the world came from just 15 crops. Potential solutions could involve increasing fruit and vegetable consumption and promoting sustainable dietary guidelines.

21 Rethinking the Opioid Epidemic

Professor Vaughan Rees deaths per day—account- viduals also developed rapid of the Harvard T.H. Chan ing for the leading cause of tolerance and could have se- School of Public Health death in Americans under rious withdrawal symptoms shifted the conversation the age of 50. Rees said that which could be powerful to another pressing public there had been three stages motivators to continue to health crisis: the opioid ep- in the opioid epidemic: the use the drugs. idemic in the United States. epidemic began in the 1990s In his session, Rees detailed with the rise in prescription The initial response to this the history of the opioid ep- opioid overdose deaths; the problem was “more beds”— idemic, described the unique second stage saw a rise in more short-term treatment challenges in treating sub- heroin overdose deaths at- facilities to help individuals stance abuse, and proposed tributed to those who had suffering from SUD. “The more integrated, long-term become addicted to opioids; problem with more beds is care as a potential solution. the third stage saw a rise in that a short-term stay does He also highlighted the im- synthetic opioid overdose not resolve a chronic, re- portance of destigmatizing deaths. lapsing disorder,” Rees ex- substance abuse and devel- plained. Individuals needed oping harm-reduction as a Rees said the challenge in persistent, evidence-based strategy to support individ- responding to the opioid care—a years-long approach uals. epidemic was the nature that involved structures and of substance use disorder systems of support. Rees explained that from (SUD). He defined SUD as 2003 to 2014 there was a a chronic, relapsing condi- Rees also highlighted the dramatic increase in the tion characterized by com- need for a multi-level ap- prevalence of opioid over- pulsive drug seeking and proach to addressing the dose deaths in the U.S. use, despite harmful con- opioid epidemic. At the first The crisis seemed to have sequences. “This can often level, public health officials reached its peak in 2016, involve individuals replacing needed to change prescriber with 50,000 deaths that year all of their activities with behavior, reduce the opioid from opioid overdose—91 substance use,” he said. Indi- stockpile in communities, and promote better health Holding up Vermont’s “hub and alternatives to use, and communication. At the sec- and spoke” model as an ex- supervised injecting facili- ond level, officials needed to ample, Rees explained that ties. With that said, he chal- identify high risk individu- the treatment of SUD must lenged the notion of an ei- als and institute prescription happen over an extended ther-or solution. “There does drug monitoring programs. period of time and must not need to be a dichotomy At the third level, care pro- have a basis in primary care. between harm reduction or viders needed to focus on “Treatment of substance use abstinence-based programs,” treatment and, potentially, problems is not a quick fix,” he explained. “Recovery harm reduction. he added. In Vermont, offi- happens on a spectrum and cials had integrated MAT context matters.” Historically, this third services—the hub—with stage—treatment—had of- ongoing primary care, med- ten been ineffective because ical specialists, and nurses— it did not meet the needs of the spokes. Vermont was individuals with a chronic, also one of the only states relapsing disorder. While in the country to have sta- models of substance use and bilized the opioid epidemic. dependence had changed over time, most approach- Rees challenged the audi- es focused exclusively on ence to consider harm re- abstinence with a moral, duction as an approach to spiritual, or psychological taking on the opioid epi- foundation to care. Instead, demic around the country. Rees encouraged the use of Recognizing that not all in- medication-assisted treat- dividuals are ready to abstain ment (MAT) as one part of from substances, he advocat- a long-term, holistic model ed for access to clean inject- of care. ing equipment, provision of information on safer using

Designing for Real User Needs

Patrick Whitney, Professor protocols for medical re- sign was originally manufac- in Residence at the Harvard sponse, the children were turer centered. Standardized T.H. Chan School of Public not seeing improvement in parts were easy to fix, and Health and former dean of their condition. ease of production was the the Institute of Design at the only consideration designers Illinois Institute of Technol- While the strategies, pro- took to mind. Soon, how- ogy, made the case that de- cesses, and offerings for ever, design had evolved to sign was an essential com- asthma treatment aligned, be market centered. Users ponent to creating solutions they did not take into con- had choice on certain di- in public health. As prob- sideration the user and his mensions—shape and col- lems became more ambigu- or her environment. Whit- or—when buying products. ous, and solutions more un- ney highlighted the mold Eventually, design had shift- certain, Whitney explained on walls, the dysfunctional ed again to experience cen- that leaders were turning ventilation ducts, and other tered: businesses were com- to design and new ways of factors as key inhibitors to peting against alternatives to thinking. His systematized progress in Chicago. “The their products, for example, approach to design thinking daily life of the people is dis- selling mobility rather than used frameworks and meth- rupting the best laid plans simply a motor vehicle. ods to amplify creativity and of the medical provider,” he imagination. said. Whitney challenged all of these conceptions of design Whitney began by tell- Complex problems, in public and instead promoted a using the story of children in health and beyond, required er-centered understanding. low-income neighborhoods human-centered design— “User experience is about in Chicago suffering from understanding human needs designing whole offerings,” asthma at eight times the rate and aspirations was key to he said. Whitney used the of children in middle-class understanding users and acronym POEMS and the suburbs. Despite there be- why they were disruptive. example of Disney to encap- ing clear process for treating sulate this framework: asthma, and well-developed Whitney explained that de-

25 • People—Disney char- ney added, was discover- acters; ing users’ unmet needs. To • Objects—Disney’s do this, providers needed clothes, toys, and games; to connect with users. He • Environments—Disney also noted that speed was theme parks; important in this work: it • Messages—Disney forced individuals to address movies; questions early in the pro- • Services—Disney hotels cess and could become an and restaurants. accelerator for research.

To better understand user When developing solutions experience, Whitney shared or products, Whitney cau- two frameworks for think- tioned against information ing: Five Stages and Five pollution and reflection defi- Modes. He said the Five cit disorder. “Over time, the Stages of user experience speed of creating, finding, were: entice, enter, engage, and sharing information has exit, extend; the Five Modes increased rapidly,” he said. were: physical, cognitive, so- “The problem is the invisible cial, cultural, and emotion- resource called ‘down time’ al. While not every product has been decreasing rapidly.” would occupy all five modes In closing, Whitney high- of experience, Whitney ex- lighted the importance of plained that there must be reflection and encouraged alignment in user experi- the use of prototypes to test ence. ideas.

The key in developing any solution or product, Whit- Synthesis

Bringing together the con- project work moving for- change in public health. tent of the two-day Deep ward. Dive, ALI Faculty Chair Ultimately, ALI Fel- Meredith Rosenthal helped As the fellows reflected on lows seemed to agree that fellows synthesize their the Public Health Deep some degree of collabora- thinking around public Dive, many felt both over- tion was necessary to ad- health. She observed that whelmed and reinvigorated; dress these complex issues. public health touches nearly overwhelmed initially by Change could happen only all elements of our lives. “We the magnitude of the prob- by working with commu- are talking about the fabric lem but reinvigorated by the nities to identify problems of our lives and our commu- importance of these issues. and potential solutions and nities,” she said, “Many of Fellows also highlighted by gathering stakeholders the drivers of public health the importance of drawing across sectors to implement problems are social factors lessons from all of the ALI those solutions. that have deep, systemic di- Deep Dives, for example, mensions.” considering how successful action on climate change To effect change along these might be replicated to ad- dimensions required a firm dress challenges in public understanding of the fun- health. damental drivers of health behaviors. “Making a dif- Other fellows questioned ference in these complex the presenters’ emphasis systems depends on a deep on the social determinants understanding of the com- of health, emphasizing the plexity of the problems you need to consider personal want to solve,” she added. responsibility in individual She encouraged fellows to health. Others still pointed consider how the sessions to the business community would impact their own as best-positioned to drive

27 Medicine in the Shadows: Caring for Boston’s Rough Sleepers

To close the 2019 Pub- Johnson Foundation to ad- lic Health Deep Dive, Dr. dress the rising health care James O’Connell, president costs of the homeless in the of the Boston Health Care city of Boston. for the Homeless Program (BHCHP), discussed his From the start, O’Connell efforts over more than 30 saw that it was essential years to provide health ser- to get out of hospitals and vices to some of the city’s emergency rooms to address most vulnerable individuals. problems before it was too O’Connell shared anecdotes late. Working at the Pine and lessons learned from Street Inn, he saw that he his career serving Boston’s had much to learn from the homeless population and nurses who had spent their left fellows feeling inspired careers working with the to take action. homeless. Namely, he under- stood that he needed to slow O’Connell said that early in down and listen. “You’ve his career working with the been trained to go fast and homeless, he realized that efficiently, but it doesn’t he needed to rethink every- work,” O’Connell said, “The thing he had learned about nurses pointed out how lit- medicine. “When working tle the doctors and hospitals with the homeless, new eyes had done to help the home- and new ways of looking at less up to that point.” things are always necessary,” he said. He had first become O’Connell spent months involved with the BHCHP soaking patients’ feet, earn- program following a grant ing their trust before he from the Robert Wood could treat their other mal- adies. Over time, he came less individuals in the orga- lem. “If you hold a prism to know the individuals nization’s decision-making up to society, homelessness he treated, and he realized process. At the time of his refracts the weaknesses in that he needed to rethink presentation, a third of BH- each of our sectors.” He en- his approach to caring for CHP’s board were homeless. couraged fellows to think of the homeless. “We started the issue as a broader public to figure out where people O’Connell told the group health problem, with links were and went to treat them about lessons he had learned to education and poverty. where they lived.” Through working with patients suf- Only by working across sec- these efforts, O’Connell en- fering from tuberculosis tors could we hope to bring gaged with local businesses and AIDS. Through each of an end to the challenges of and nonprofits, and saw that his stories, it was clear that homelessness. it took a true community O’Connell and his team effort to help homeless indi- showed a level of compas- viduals in Boston. sion and dignity that was a rarity to their homeless pa- O’Connell explained that tients. In the early 2000s, BHCHP had always worked BHCHP established a re- to provide continuity of care spite room with a dental and in its health care delivery psychiatric clinic and started model. “Fragmentation is to provide more end of life such a part of homelessness,” care for the homeless popu- O’Connell explained, “We lation. Recently, the organi- didn’t want to duplicate this zation had started securing feeling in their health care housing opportunities for delivery.” Instead he worked their patients. with a multi-disciplinary team—psychologists, social Ultimately, O’Connell said workers, physicians and oth- that he saw homelessness ers—and he involved home- as a truly intractable prob-

31 Speaker Biographies Robert Blendon

Dr. Robert J. Blendon is cur- Public Radio and POLIT- rently the Richard L. Men- ICO. Previously, he co-di- schel Professor and Senior rected a special polling series Associate Dean for Policy with the Washington Post and Translation and Leadership Kaiser Family Foundation, Development at the Har- which was nominated for a vard T.H. Chan School of Pulitzer Prize. Addition- Public Health. He holds ally, Blendon co-directed a appointments as a Profes- special survey project for the sor of Health Policy and Minneapolis Star Tribune on Political Analysis at both health care that received the the Harvard T.H. Chan National Press Club’s 1998 School of Public Health Award for Consumer Jour- and the Harvard Kenne- nalism. He also co-directed dy School of Government. a project for National Public In addition, he directs the Radio and the Henry J. Kai- Harvard Opinion Research ser Family Foundation on Program, which focuses American attitudes toward on better understanding of domestic policy. The series public knowledge, attitudes, was cited by the Nation- and beliefs about major so- al Journal as setting a new cial policy issues in the U.S. standard for use of public and other nations. He cur- opinion surveys in broadcast rently co-directs the Robert journalism. Wood Johnson Foundation/ Harvard T.H. Chan School Between 1987 and 1996 he of Public Health project on served as Chairman of the understanding Americans’ Department of Health Pol- Health Agenda, including icy and Management at the a joint series with National Harvard T.H. Chan School

33 of Public Health and as Blendon is a member of the J. Mitofsky Award for Ex- Deputy Director of the Har- Institute of Medicine, of the cellence in Public Opinion vard University Division of National Academy of Sci- Research given by the Roper Health Policy Research and ences and of the Council Center. Education. Prior to his Har- of Foreign Relations, a for- vard appointment, Blendon mer member of the advisory He is a graduate of Mar- was senior vice-president at board to the Director of the ietta College. He is also a The Robert Wood Johnson Centers for Disease Con- graduate of the School of Foundation. In addition, he trol and Prevention, and a Business at the University has served as a senior faculty former member of the ed- of Chicago, with a Masters member for the U.S. Con- itorial board of the Journal in Business Administration. ference of Mayors, the Na- of the American Medical As- In addition, he holds a Doc- tional Governor’s Associa- sociation. He is also a Past toral degree from the School tion, and the U.S. Congress President of the Association of Public Health of Johns Committee on Ways and of Health Services Research Hopkins University, where Means. and winner of their Distin- his principal attention was guished Investigator Award. directed toward health pol- Blendon teaches courses He is also a recipient of the icy. on both Political Strategy Baxter Award for lifetime in Health Policy and Pub- achievement in the health lic Opinion Polling at the services research field. He Harvard Kennedy School has also received the John of Government and the M. Eisenberg Excellence Harvard T.H. Chan School in Mentorship Award from of Public Health. He also the Agency for Health- directs the Political Analy- care Research and Quality sis track in the University’s (AHRQ) and the Mendel- Ph.D. Program in Health sohn award from Harvard Policy. University. In 2008, he was the recipient of the Warren Lindsay Jaacks

Dr. Lindsay Jaacks’s research phosphate metabolites, and focuses on improving our perfluorinated chemicals understanding of the global among youth with diabetes drivers of the epidemiolog- in the United States and es- ical transition from commu- timation of their association nicable to non-communica- with cardio-metabolic risk ble diseases. Specifically, she factors; and analysis of me- is interested in the complex diation of the association be- interactions between nutri- tween cookstove fuel use and tional and environmental blood pressure by dietary in- exposures within the food take in rural Chinese wom- system and the role that en. She is a co-investigator these interactions play in the for a large, multi-country etiology of obesity, diabetes, (India, Rwanda, Guatema- and cardiovascular disease. la, and Peru) household air pollution intervention trial. She has worked on a num- She is also working on sev- ber of epidemiological stud- eral projects relating to un- ies in China, India, and the derstanding drivers of food United States. Current proj- choice among overweight ects include the quantifica- women in low- and mid- tion of circulating levels of dle-income countries, and persistent organic pollutants new approaches to quantify- among adults in urban India ing the nutrition transition. and estimation of their association with incident diabe- Jaacks has served as a con- tes; the longitudinal assess- sultant for the UK Depart- ment of circulating levels of ment for International De- persistent organic pollut- velopment on addressing ants, pyrethroids, organo- overweight and obesity in

35 low- and middle-income countries and for RTI Inter- national on policies to pre- vent diabetes in the United States. She is a Visiting Pro- fessor at the Public Health Foundation of India. Howard Koh

Dr. Howard K. Koh is the offices, including the Office Harvey V. Fineberg Profes- of the Surgeon General and sor of the Practice of Public the U.S. Public Health Ser- Health Leadership at the vice Commissioned Corps, Harvard T. H. Chan School 10 Regional Health Offic- of Public Health and the es across the nation, and 10 Harvard Kennedy School. Presidential and Secretarial He is also Co-Chair of the advisory committees. He Harvard Advanced Leader- also served as senior public ship Initiative. In these roles, health advisor to the Sec- he advances leadership edu- retary of HHS. During his cation and training at the tenure, he promoted the Harvard T.H. Chan School disease prevention and pub- of Public Health as well as lic health dimensions of the with the Harvard Kennedy Affordable Care Act, ad- School, the Harvard Busi- vanced outreach to enroll ness School and across Har- underserved and minority vard University. populations into health insurance coverage and was From 2009-2014, Koh the primary architect of served as the 14th Assis- landmark HHS strategic tant Secretary for Health plans for tobacco control, for the U.S. Department of health disparities (including Health and Human Services Asian American and Pacific (HHS), after being nomi- Islander health) and chronic nated by President Barack hepatitis. He also led inter- Obama and being con- disciplinary implementation firmed by the U.S. Senate. of Healthy People 2020 and During that time he over- the National HIV/AIDS saw 12 core public health Strategy as well as initiatives

37 in a multitude of other areas, ert Wood Johnson Founda- Governor William Weld. As such as nutrition and physi- tion-funded grant “Mak- Commissioner, Koh led the cal activity (including HHS ing a Culture of Health A Massachusetts Department activities for Let’s Move!), Business Leadership Im- of Public Health, which in- cancer control, adult im- perative.” He has published cluded a wide range of health munization, environmental more than 250 articles in the services, four hospitals, and health and climate change, medical and public health a staff of more than 3,000 women’s health, adolescent literature, addressing broad professionals. In this capaci- health, behavioral health areas such as disease preven- ty, he emphasized the power and substance use disor- tion and health promotion, of prevention and strength- ders, health literacy, multiple health reform, health equity ened the state’s commitment chronic conditions, organ (including Asian American, to eliminating health dis- donation and epilepsy. Native Hawaiian and Pacific parities. During his service, Islander Health), health and the state saw advances in ar- Koh previously served at spirituality, health literacy eas such as tobacco control, Harvard School of Public and public health leadership. cancer screening, bioterror- Health (2003-2009) as the He has also written about ism response after 9/11 and Harvey V. Fineberg Profes- more specific areas such as anthrax, health issues of the sor of the Practice of Pub- tobacco control and cancer homeless, newborn screen- lic Health, Associate Dean control, melanoma and skin ing, organ donation, suicide for Public Health Practice oncology, the opioid crisis, prevention and international and Director of the Harvard health issues of the home- public health partnerships. School of Public Health less, chronic hepatitis, organ Center for Public Health donation and epilepsy. Koh graduated from Yale Preparedness. In an academ- College, where he was ic career where he has been From 1997-2003, Koh was President of the Yale Glee Principal Investigator (PI) Commissioner of Public Club, and the Yale Univer- for over $24 million in re- Health for the Common- sity School of Medicine. search grant activities, he is wealth of Massachusetts He completed postgradu- currently the PI of the Rob- after being appointed by ate training at Boston City Hospital and Massachusetts ican Public Health Associ- Distinguished National General Hospital, serving as ation (the highest honor of Leadership Award from the chief resident in both hos- the organization), and five National Colorectal Cancer pitals. He has earned board honorary doctorate degrees. Roundtable, the Baruch S. certification in four medical President Bill Clinton ap- Blumberg Prize from the fields: internal medicine, he- pointed Koh as a member Hepatitis B Foundation, matology, medical oncology, of the National Cancer Ad- the National Leadership and dermatology, as well as visory Board (2000-2002). Award from The Communi- a Master of Public Health He is an elected member of ty Anti-Drug Coalitions of degree from Boston Uni- the National Academy of America (CADCA) and the versity. At Boston Univer- Medicine (formerly the In- Dr. Jim O’Connell Award sity Schools of Medicine stitute of Medicine.) A past from the Boston Healthcare and Public Health, he was Chair of the Massachusetts for the Homeless Program. Professor of Dermatology, Coalition for a Healthy Fu- He was named to the K100 Medicine and Public Health ture (the group that pushed (the 100 leading Korean as well as Director of Cancer for the Commonwealth’s Americans in the first centu- Prevention and Control. groundbreaking tobacco ry of Korean immigration to control initiative), Koh was the United States) and has He has earned over 70 named by the New England received the Boston Univer- awards and honors for in- Division of the American sity Distinguished Alumnus terdisciplinary accomplish- Cancer Society as “one of Award. He has been recog- ments in medicine and the most influential per- nized by Modern Health- public health, including the sons in the fight against care as one of the country’s Dr. Martin Luther King Jr. tobacco during the last 25 Top 100 Most Influential Legacy Award for National years.” He has also received People in Healthcare as well Service, the Distinguished the Champion Award from as one of the Top 25 Minori- Service Award from the the Campaign for Tobac- ty Executives in Healthcare. American Cancer Society, co Free Kids, the “Hero of He enjoys the distinction of the 2014 Sedgwick Memo- Epilepsy” Award from the throwing out the ceremonial rial Medal from the Amer- Epilepsy Foundation, the first pitch on two different

39 occasions: at Nationals Park in Washington DC on be- half of HHS (2011), and at Fenway Park where he was designated a “Medical All Star” by the Boston Red Sox (2003) in recognition of his national contributions to the field of early detection and prevention of melanoma.

He currently serves on the Board of Directors of the Journal of the Amer- ican Medical Association ( JAMA), the Network for Public Health Law, Com- munity Anti-Drug Coali- tions of America (CADCA), the Josiah Macy Jr. Founda- tion and New England Do- nor Services. Koh and his wife Dr. Claudia Arrigg are the proud parents of three adult children. Margaret Kruk

Dr. Margaret E. Kruk is As- implementation science sociate Professor of Glob- to evaluate policies and al Health at the Harvard interventions to promote T.H. Chan School of Public appropriate utilization Health. Kruk’s research gen- and high quality care in erates evidence for improved resource-constrained health system quality and systems. responsiveness in low- and • Reframing health sys- middle-income countries. tems: applies findings Her research is at the inter- from empirical work to section of health systems update conceptual mod- and populations and brings els of health systems that together data from users and optimize production of systems. She collaborates health and can respond with colleagues in Tanzania, to emergent population Ethiopia, Liberia, and India, needs. among other countries. Her work is in three areas: Kruk is currently Chair of the Lancet Global Health • Analyzing health system Commission on High Qual- performance: studies ity Health Systems in the how health system qual- SDG Era (HQSS Commis- ity influences population sion), a global effort to rede- utilization and prefer- fine and measure quality in ences for health care and the health systems of low- measures the compe- er-income countries. Previ- tence and user experi- ously, Kruk was Associate ence of care that people Professor of Health Policy receive. and Management and Di- • Testing solutions: uses rector of the Better Health

41 Systems Initiative at Colum- bia University. She has held posts at the United Nations Development Program and McKinsey and Company and practiced medicine in northern Ontario, Canada. She holds an MD degree from McMaster University and an MPH from Harvard University. Kay Mooney

As VP, Well-Being, CVS sumers and communities Health, Kay Mooney leads achieve their best health. a team responsible for integrating the company’s ho- In nearly 30 years with Aet- listic well-being approach na, Mooney served in var- into the products and expe- ious leadership roles. Most riences it creates. The team recently, she led Workforce is guided by the belief that Well-being & Inclusion, “health” is broader than the where she introduced inno- traditional definition of “the vative benefits and well-be- absence of illness” and fo- ing programs to support cuses on all aspects of indi- Aetna’s strategy and drive viduals’ lives that help them engagement. thrive and flourish. Prior to joining the Human Mooney is at the helm of the Resources organization, company’s groundbreaking Mooney led Aetna’s nation- research collaboration with al Health Care Reform Ex- Harvard’s School of Public change Program Manage- Health to understand the ment Office, where she was determinants of well-being, responsible for driving the correlations to engagement development and imple- and productivity, and effica- mentation of Aetna’s strat- cy of various interventions. egy for public exchanges, With this data and machine and she previously served learning, she is leading the as chief of staff for the Of- development of engaging fice of the Chairman and solutions that reflect the CEO. She has held a variety company’s holistic approach of senior leadership roles at and help employees, con- Aetna, focused on pricing,

43 underwriting, product man- health benefits of animal-as- agement, mergers & acquisi- sisted intervention. This tions integration and medi- aligns with Mooney’s strong cal cost analytics. belief in the healing power of pet therapy. Mooney’s passion for well-being extends beyond Mooney graduated with a her position at Aetna and bachelor’s degree in mathe- includes leadership roles matics from Penn State. She with the American Heart is a Fellow of the Society of Association. Most recent- Actuaries, and is a member ly, she served as co-chair of of the American Academy of the 2018 Greater Hartford Actuaries. Heart Walk, and chair of the 2017 Greater Hartford Heart Ball. In previous years, she chaired the organization’s Go Red for Women cam- paigns, where she helped drive awareness of the risks of heart disease among women and raise money for this life-saving movement.

In 2018, Mooney joined the Board of Directors for Pet Partners, the nation’s largest and most prestigious organization committed to connecting people with the James J. O’Connell

Dr. James O’Connell gradu- Shattuck Shelter. This in- ated summa cum laude from novative program now pro- the University of Notre vides acute and sub-acute, Dame in 1970 and received pre- and post-operative, his master’s degree in theol- and palliative and end-of- ogy from Cambridge Uni- life care in the freestanding versity in 1972. After gradu- 104-bed Barbara McInnis ating from Harvard Medical House. Working with the School in 1982, he complet- MGH Laboratory of Com- ed a residency in Internal puter Science, O’Connell Medicine at Massachusetts designed and implemented General Hospital (MGH). the nation’s first comput- In 1985, O’Connell began erized medical record for a fulltime clinical work with homeless program in 1995. homeless individuals as the founding physician of the From 1989 until 1996, Boston Health Care for the O’Connell served as the Homeless Program, which National Program Direc- now serves over 13,000 tor of the Homeless Fami- homeless persons each year lies Program of the Robert in two hospital-based clinics Wood Johnson Foundation (Boston Medical Center and and the U.S. Department of MGH) and in more than 60 Housing and Urban Devel- shelters and outreach sites in opment. O’Connell is the Boston. With his colleagues, editor of The Health Care of O’Connell established the Homeless Persons: A Manu- nation’s first medical respite al of Communicable Diseas- program for homeless per- es and Common Problems in sons in September, 1985, Shelters and on the Streets. with 25 beds in the Lemuel His articles have appeared

45 in the New England Journal sary. O’Connell is president of Medicine, the Journal of of BHCHP and an assis- the American Medical As- tant professor of medicine at sociation, Circulation, the Harvard Medical School. American Journal of Public Health, the Journal of Clin- ical Ethics, and several other medical journals.

O’Connell has been featured on ABC’s Nightline and in the feature-length documentary Give Me a Shot of Anything. He has received numerous awards, including the Albert Schweitzer Hu- manitarian Award in 2012 and The Trustees’ Medal at the bicentennial celebration of MGH in 2011. O’Con- nell has collaborated with homeless programs in many cities in the USA and across the globe, including Los Angeles, London, and Syd- ney. O’Connell’s book Stories from the Shadows: Reflections of a Street Doctor was published in 2015 in celebration of BHCHP’s 30th anniver- Vikram Patel

Vikram Patel, MBBS, PhD Government of India com- is The Pershing Square Pro- mittees. His work on the fessor of Global Health in burden of mental disorders, the Department of Global their association with pov- Health and Social Medicine erty and social disadvantage, at Harvard Medical School. and the use of community He is an adjunct professor resources for the delivery and joint director of the of interventions for their Centre for Chronic Con- prevention and treatment ditions and Injuries at the has been recognized by the Public Health Foundation Chalmers Medal (Royal of India, honorary profes- Society of Tropical Medi- sor at the London School of cine and Hygiene, UK), the Hygiene & Tropical Medi- Sarnat Medal (US Nation- cine (where he co-founded al Academy of Medicine), the Centre for Global Men- an honorary doctorate from tal Health in 2008), and is a Georgetown University, the co-founder of Sangath, an Pardes Humanitarian Prize Indian NGO which won the (the Brain & Behaviour Re- MacArthur Foundation’s search Foundation), an hon- International Prize for Cre- orary OBE from the UK ative and Effective Institu- Government and the Posey tions in 2008 and the WHO Leadership Award (Austin Public Health Champion of College). He also works in India award in 2016. the areas of child development and adolescent health. He is a fellow of the UK’s He was listed in TIME Academy of Medical Sci- Magazine’s 100 most influences and has served on ential persons of the year in several WHO expert and 2015.

47 Vaughan Rees

Dr. Vaughan Rees is Di- hookah (tobacco waterpipe); rector of the Center for and novel smokeless tobac- Global Tobacco Control, co products such as snus. whose mission is to reduce Clinical research methods the global burden of tobac- are used to evaluate the in- co-related death and disease fluence of tobacco product through training, research, design features on consum- and the translation of sci- er responses, and their role ence into public health pol- in promoting initiation or icies and programs. He di- maintenance of use among rects the Tobacco Research targeted populations. Find- Laboratory at the Harvard ings have been used to in- Chan School, where the form tobacco control policy, design and potential for de- develop resources for com- pendence of tobacco prod- municating risks of tobacco ucts are assessed. Studies products, and to enhance examine the impact of de- understanding of factors pendence potential on prod- that contribute to tobacco uct use and individual risk, dependence. to inform policy and other interventions to control to- Other research involves de- bacco harms. Current re- velopment of strategies to search uses conventional and reduce secondhand smoke innovative strategies to eval- (SHS) exposure in domestic uate new and novel tobacco environments, with a focus products. Examples of these on evaluating interventions products include modified for reducing domestic SHS risk tobacco products such exposure among children. as e-cigarettes; reduced ig- Rees also leads an NIH nition propensity cigarettes; funded study which seeks to reduce secondhand smoke also published research on exposure among children the role of cue reactivity in from low income and ra- tobacco and alcohol abuse cially/ethnically diverse and dependence; and clin- backgrounds. This research ical trials on interventions utilizes the principles of for alcohol and cannabis de- community based participa- pendence. tory research (CBPR) to develop and evaluate a cognitive behavioral intervention to help caregivers maintain a smoke free home environment. He has conducted studies on SHS emissions of tobacco waterpipe, and SHS monitoring in indoor environments, including private homes and cars.

Rees’ academic background is in health psychology (substance use and dependence), and he trained at the National Drug and Alcohol Research Centre at the Uni- versity of New South Wales in Sydney, Australia, and did postdoctoral training through the National Insti- tute on Drug Abuse. He has

49 Meredith Rosenthal

Dr. Meredith Rosenthal tising of prescription drugs received her B.A in Inter- and pay-for-performance national Relations (Com- and in legislative hearings in merce) from Brown Univer- California and Massachu- sity in 1990 and her Ph.D. setts concerning healthcare in Health Policy (Econom- provider payment and ben- ics track) from Harvard efit design policies. University in 1998. Rosenthal’s work has been Her research focuses pri- published in the New En- marily on policies that will gland Journal of Medicine, help slow the growth in the Journal of the American healthcare spending and Medical Association, Health improve value. These efforts Affairs, and numerous other include changes in payment peer-reviewed journals. In incentives, benefit design, 2014, Rosenthal was elected and the provision of in- to the Institute of Medicine formation and behavioral (recently renamed the Na- “nudges” to both patients tional Academy of Medi- and providers. Her research cine). has influenced the design of provider payment systems Rosenthal is a member of in both the public and pri- the Committee on Higher vate sectors. She has advised Degrees in Health Policy, federal and state policymak- the Massachusetts Center ers in healthcare payment for Healthcare Informa- policy and implementation. tion and Analysis Over- She has also testified in sight Board, and Board Congressional hearings on Chair of Massachusetts direct-to-consumer adver- Health Quality Partners, a multi-stakeholder quality improvement organization. As Associate Dean for Di- versity she works closely with the Dean’s Advisory Committee on Diversity and Inclusion (DACDI) on strategic planning and issues related to equity, diversity and inclusion affecting all members of the School community.

51 Jeffrey Sánchez

Born in Washington Heights Throughout his time in the in New York City, Jeffrey Massachusetts House of Sánchez was raised in the Representatives, Sánchez Mission Main Housing De- has emphasized bringing velopment in Boston. He has people together to work out represented Mission Hill, their differences and pass Jamaica Plain and Brook- laws that improve the lives line in the Massachusetts of residents in the Common- House of Representatives for wealth, especially the most 16 years where he has been vulnerable. Most recently lauded as a leader in health- in 2018 he was successful in care reform, housing and nearly unanimously passing infrastructure, gun laws, vi- a $41.8 billion budget that olence prevention, criminal was applauded by individu- justice reform, the environ- al citizens, stakeholders, and ment and youth empower- business and fiscal watch- ment. He finished his last dogs. He also drafted the term serving as the first Lati- largest Housing Bond bill no Chairman of the House Authorization in the Com- Committee on Ways and monwealths history, $1.8 Means in the history of the billion. Under his leadership, Commonwealth. Previously, Massachusetts continued to Jeffrey served as Chairman lead on gun control by im- of the Joint Committee on plementing a ban on bump Health Care Financing and stocks and passed legislation the Chairman of the Joint allowing for courts to issue Committee on Public Health extreme risk protection or- as well as the Vice-Chair of ders while at the same time the Joint Committee on Eco- ushering wholesale criminal nomic Development. justice reform. Sánchez has been advocat- joining a thriving econo- as complicated as rehousing ing for healthcare reform for my. He proudly fought and those who lost their home in over sixteen years. In 2006, successfully defeated efforts fires and floods. He played he worked to pass landmark to repeal gay marriage, he a key role organizing the legislation which affirmed championed comprehensive Jackson Square Coordinat- health care as a right in Mas- front-to-back criminal jus- ing Group, which created sachusetts. Since then, he tice reform and he is a suc- the community vision to re- has crafted laws that support cessful advocate for English develop the neighborhood, and enable the Life Sciences language learners. After 15 and as State Representative industry to grow and thrive, years of advocacy, Chair- fought for state dollars to establish a statewide health man Sanchez’s Language make that vision a reality: care cost benchmark, and Opportunities for Our Kids over 600 units of affordable worked to protect and en- (LOOK) bill was signed into housing have since been de- sure 98% of the state’s pop- law, overturning a failed veloped in Jackson Square, ulation has health insurance one-size-fits-all policy to and another 500 units are to this day. He authored and educating English language in the pipeline. Sánchez also successfully ushered into learner (ELL) students and ran Boston’s 2000 Census, law comprehensive legisla- creating a pathway to ensure ensuring that everyone, es- tion to close the racial health ELL students receive a quali- pecially those who spoke disparities gap, compound- ty education. another language, were ing pharmacy practice, and counted in the Census. Prior improve school nutrition Before running for State to working in government programs. Representative in 2002, he worked in banking and Sánchez worked for Bos- finance. In all of his endeavors, Sán- ton Mayor Thomas Michael chez has sought to find eq- Menino. During that time, Sánchez attended Roxbury uity and opportunities for he took a crash course in city Community College and re- those most vulnerable and services, working on initia- ceived his Bachelor of Arts those who often get over- tives as simple as ensuring in Legal Education from the looked in opportunities in potholes were filled to those University of Massachusetts,

53 Boston before earning his Masters of Public Admin- istration from the John F. Kennedy School of Govern- ment at Harvard Universi- ty. He is currently a Rich- ard Menschel Fellow at the T.H. Chan School of Public Health and Principal of Sán- chez Strategies which focuses on strategic impact in leadership, health care policy and finance, communications and government relations. He currently lives in Jamaica Plain with his wife, Brenda, and two daughters. Sánchez will not engage in discussions relative to the Yankees and Red Sox but will happily talk about the art of grilling, classic movies and Salsa (the music not the sauce). David Waters

David Waters has been in- care and social services, de- volved with Community signing some of the coun- Servings since its inception try’s first health insurance in 1989, moving from volun- contracts for prescription teer to board member, Board meals. Chair, Director of Develop- ment, and eventually CEO, With 35+ years experience in 1999. in food service management, Waters also created Under Waters’ leadership, the highly cost-effective Community Servings has fundraising events, Life- evolved from a small neigh- Savor and Pie in the Sky, a borhood meals program de- Thanksgiving pie sale du- livering dinner to 30 people, plicated in cities around the to a critical regional pro- country. gram providing 15 medically-tailored meals plans He is the former Board to 2,300 people with acute Chair of the Association of life-threatening illnesses, Nutrition Service Agencies, their dependents, and care- and is a founding mem- givers in 21 Massachusetts ber of the national Food Is communities. Medicine Coalition. In recognition of his leadership An advocate for integrating at Community Servings, accessible, medically tailored Waters was named a Barr meals into the healthcare Foundation Fellow in 2017. system, Waters has formed A resident of Cambridge, he partnerships with leading holds graduate degrees from healthcare payers and pro- Middlebury College and viders to better link clinical Boston University.

55 Patrick Whitney

Patrick Whitney has pub- “master of design” for link- lished and lectured through- ing the creation of user val- out the world about ways ue and economic value, and of making technological Global Entrepreneur named innovations more humane, him one of the 25 people the link between design and worldwide doing the most business strategy, and meth- to bring new ideas to busi- ods of designing interactive ness in China. communications and products. His writing is generally He is the principal inves- about new frameworks of tigator of several research design that respond to three projects at the Institute of transformations: linking in- Design, including “Glob- sights about user experience al Companies in Local to business strategy, the shift Markets,” “Design for the from mass-production to Base of the Pyramid,” and flexible production, and the “Schools in the Digital Age.” shift from national markets His recent work has been to markets that are both supported by several grants, global and “markets of one.” including funding from the John D. and Catherine T. BusinessWeek has profiled MacArthur Foundation, Whitney as a “design vision- SC Johnson, the Steelcase ary” for bringing together Foundation, and numerous design and business, Forbes corporations. named him as one of six He is a trustee of the Global members of the “E-Gang” Heritage Fund, which sup- for his work in human-cen- ports restoration of heritage tered design, Fast Compa- sites and local communities ny has identified him as a in the developing world. advancedleadership.harvard.edu 14 Story Street, Suite 100 Cambridge, MA 02138 617-496-5479