An article for my graduate students

July 14, 2014

Dr. Richard B. Gilbert
DIGGING DEEPER INTO STORIES AND PRACTICES IN PUBLIC HEALTH
< With special attention to our veterans >
A front page story in todays USA Today (July 14, 2014, p. A1) bore this headline: VA
under fire over benefits backlog: IG report finds flaws in program to reduce delays.
The article was an update on the mess the VA system has become in the rush to
bring our women and men home. While the article did not categorize the nature of
the injuries, we know many have lost one or more limbs. Others have sustained
serious head injuries that prompt many other challenges. Mental health issues
abound, some from previous mental health histories, but many others from the
sheer horror of what they have observed, experienced and initiated.
Early
last
year the backlog was 611,000, according to Allison Hickey, undersecretary for
benefits. This year compensation for injuries or wounds incurred during military
service is expected to consume $73 billion this year.
While the referenced article did not mention it, does need to be said that the VA
system, if not already in trouble with long waits and lack of access, has faced this
problems for years. A friend was just starting his work as director of respiratory
care in a major VA urban hospital. When I called to see how his first day went, he
commented, We are already at capacity and I am down to one infusion pump
and the vets arent even home yet. A local friend is a vet and regularly engages
the VA system for care. Routine things required a trip to Iowa City, a 5-6 hour
round trip. However, just before his trip for open heart surgery, they transferred
him to Minneapolis, which adds a minimum of a dozen more hours in the car. And
they call this quality case management and patient care? It is staggering.
All of my graduate students are in counseling, psychology or public health
programs. This touches all of them in some way. Teachers have the children of
many of the vets, including those who have died in service and those who have
come home with volatile disabilities. Hospitals are fighting for more dollars and
dollars they have control over. Their losses for unreimbursed care are staggering,
and still growing! The reimbursements continue to shrink and the dollars awarded
are taking much longer to reach the providers. It isnt unusual for nursing homes to
wait 1-2 years for reimbursement. This has affected not only hospitals but
emergency responders, long term care, the growing numbers with Alzheimers and
other forms of dementia, the physically and/or mentally disadvantaged,
undocumented aliens and the many who flood the emergency rooms, often waiting
hours, because there is no other place for them to go for care. In the summer
months it is not unusual (in Chicago) to have three or four hospitals on bypass.
Medicare is investigating the number of patients who laid around in hallways and
the ER, often for days, and then sent home. This lack of an admission can void
Medicares responsibility for payment. Rules. Rules. Rules! Do our actions and
reactions support the issues on the table or defeat them? Rules, papers, and

debates should be defending the best interest of all concerned. When the reverse
happens we find integrity yielding to rules for the sake of the rules. That is
backwards and it is unhealthy. It stretches competition and crushes collaboration.
We all lose. It forces us to spend more and do more, but it quickly becomes selfpromoting and equally self-defeating.
I am a proponent for peace. The attacks on our own soil violated human laws and
values. Is the logic of they bomb us we will bomb them is a satisfactory solution?
There are times when we have kicked enough and must put ourselves back on top.
We need to begin to listen to each other, respect our differences and set aside
future time to delve more deeply into this story. We have to begin somewhere.
We need all of the players in partnerships of mutual support and respect. We are
not happy cheerleaders but people, individually and collectively, and organizations
who know what is at stake. If we are to get back on track, even we limit it to better
services for the veterans and better access for all Americans. Of course we also to
consider the reimbursement rates and the payment delays that to exasperate the
problem.
Enter public health. All too often we treat public health like the easily overlooked
stepchild. We know they are and that they do some work. The test water in
swimming pools, help fight STDs, offer well-baby and WIC programs and try to fill
gaps of people currently undertreated.
Public health has been around for years. It touches the lives of individuals, families,
practitioners and organizations that goes about the valiant work even when the
majority of people, even the people who are benefiting from their programs, have
no clue about who or what is the health department.
Public health often has a different sense of visibility. They are always in the
trenches, though I have no doubt that they have dug many of them as they go
about their work. They also are very, very political. It is not necessarily their style
but, for many, it represents the people who sign their paychecks and approve their
budgets and programs.
We all have mission statements, we all have goals, we all have mostly good people,
and we all fall short of what we are expected to accomplish (realistic or otherwise)
and we all have personal and corporate agendas. Sometimes how we observe
things. Nurses often see things that might not catch the eyes of the social workers.
It doesnt make one a better professional. It is about bringing to the table that
which we were trained and called (I take spiritually seriously!) to be and to do.
Here are some suggestions as closing thoughts. They could serve you as agenda
for your next staff and/or Board meeting.
1. Territorialism must go. We have avenues we prefer to travel or that

seem to serve well because it feeds into goals and tasks familiar to
us and possible ego needs.

2. Know all of your potential audiences: veterans, of course, illegals,

the chronically ill, pregnancy, WIC, and parent training, STDs, those
who live alone or who are otherwise isolated. Children. And lets not
forget that sanitary engineer. The best friends of this territorial
display are control and fear. Control may only be a nave sense of
control of our own place and routine in the organization. We really
see ourselves as safe. After all, I have the highest credentials
offered, am fiercely loyal to my job and the organizational
leadership and frequently receive special recognition at
departmental meetings for a special activities or projects
completed. I am in control.
3. Your inner voice is speaking loud and clear. No one is really safe in

this organization, not even the CEO. She serves at the discretion of
the Board and they havent been particularly pleased with recently
monthly reports.
You are smart and perceptive.
The line,
Physician, heal thyself! shares a level of appreciation that, in
some way, deserves to be shared with your colleagues and, quite
possibly, your clients. Common sense?! Of course. However, we
seem more content arguing that none of this applies to us. We have
a proven track record. We are untouchable.
This is fear. It overwhelms us. It enslaves us. Certainly much like
clients you serve in your program, and much of public health is
primary care to the marginalized, among others.
They dont
need you to be frightened. It has nothing to do with the clients
directly, but it does shove them deeper into the margins. That
cannot be a contribution of public health.
Public health serves the health of the public. There are grants and some
specified population groups in response to a particular grant or program. It
is not permission to push away those who come to you for help. They may
know nothing about the health department and even less about their
problem or need. They may not even know your name. You may be a
sanitary engineer walking through the building. The visitor needs help and
probably needs anyone but a sanitary engineer. You are there! You are with
that person at least spatially. We are quick to say, You are in the wrong part
of the building.
Maybe we can say, I am and around here I am an
engineer. I am here to help you. There some good people here who
provide direct care to our guests here. I would like to walk you to one of
those special people so we can get you the help that you need.
Our veterans wait and wait some more. They have a centralized system that
requires us to travel to a hospital best equipped for a procedure. A friend
required open heart surgery. His normal center is Iowa City. There was no

room and was rescheduled for Minneapolis. He went from a 2.5 hour drive
(each way) to 8-9 hours (each way). Is the system working?
Public.
Health.
A compelling partner for healthy living in healthy
communities. Public health. It may well be the starting point for a new
approach to medical care for veterans. On the national level the risks are
staggering and the wheels of medicine simply halt. The bureaucratic
nightmare is evident, it is bad practice and our veterans, our defenders,
deserve so much more. They have defended our country. Is it too much to
expect our nation to care from effectively and efficiently? Can we rethink
public health? Can we build on its proven track record of being community
within communities?

Richard B. Gilbert, PhD, CT

Adjunct Faculty
July 15, 2014