Medical Care
Section Newsletter
Spring 2010

Health Affairs -- Special Issue on Primary Care

By Mona Safarty

HEALTH AFFAIRS recently released a new issue called Reinventing Primary Care during a well-attended press conference at the National Press Club on April 10, 2010 in Washington, D.C.  To highlight the importance of the topic, HHS Secretary Kathleen Sibelius led off with an update on the implementation of health reform. Authors of many of the articles in the issue gave brief presentations summarizing key points from their work. 

In the first panel of speakers, Larry Casalino from Cornell University said that substantial restructuring is the only way the nation can provide enough primary care services to accommodate the new insured population. He believes only one third of current appointments require in-person face to face care. He suggested that other patient visits could be supplanted by communication via e-mail, telephone, or dealings with other office staff; and that medical offices encourage providers to communicate this way.      

Kavita Patel and a group of researchers reviewed differing models of patient centered medical homes. They found differing definitional criteria and conclude that improved reporting measures are needed, as is information on how to structure payment.  They draw attention to a model in North Carolina that was effective with a large Medicaid population and succeeded in decreasing emergency department use and hospitalization. Other successful models have been developed by Group Health -- and in North Dakota.      

Paul Grundy of IBM is a proponent of the patient centered medical home (PCMH).  He contends that businesses that purchaser health care want PCMHs for their employees. He emphasizes team care that is integrated not fragmented.    Medical schools must take the responsibility for training the doctors to deliver such care. He described the transformations of the Spanish and Danish medical care delivery systems, which emphasized primary care and have made dramatic progress in reducing duplicative and unnecessary visits and improving outcomes.  Seventy percent of Danish medical encounters are now asynchronous. The reimbursement system supports a strong relationship between doctor and patient rather than voluminous diagnostic testing.   

Katie Merrell of Social and Scientific Systems said payment incentives will shape the delivery system. There are many possible ways to shape the reimbursement system. She spoke in favor of integrating quality, payment and recognition within the patient centered medical home.    

Troyen Brennan of CVS Caremark reported that retail clinics are now accredited by the Joint Commission on Organization of Hospitals. They employ only Board Certified nurse practitioners.  He estimates there will be a deficit of 40,000 primary care physicians by the year 2020.  He said currently 50 percent of children and 60 percent of adults have no primary care physician. Retail clinics seek to coordinate with the primary care doctors for each patient.

Eric Holmboe of the American Board of Internal Medicine Foundation discovered through his research that teams are not explicitly defined or recognized in medical practice, and it is not clear how they work. His group found little inter-professional teamwork. Other staff collaborated with each other but not with physicians.  Patients often feel disoriented and "in limbo" and do not benefit from shared decision making.   

Expanding the focus on teams, Joanne Pohl spoke about nurse practitioners who graduate at the rate of 8,000 per year, James Cawley spoke about physician assistants; and Marie Smith spoke about why pharmacists belong in the medical home. She said that at her academic institution, they teach what a team is. A team involves clearly defined roles; everyone knows what the roles are.    

The last panel of speakers presented practice profiles.  Susan Edgman-Levitan from Massachusetts General pointed out that there is virtually no training out there about how to make changes. She asked: Where is the patient in the medical home?  Medical care looks to them like it is all done to them. They don’t know what this new model is supposed to do. Richard Larsen, an internist from Pennsylvania who participated in the chronic disease collaborative, reported that his practice hired a health educator who trains their medical technicians so they can do self management exercises with patients.   

Eric Larsen of the Group Health Research Institute spoke about their successful efforts at practice change. They looked carefully at health delivery in Denmark and came up with an entirely new model. They decreased clinician panel sizes, increased visit slot times from 20 to 30 minutes, and started paying for the time that physicians spend making phone calls, sending e-mails, and writing letters. Their two-year results with this approach were so encouraging that they expanded to all 26 of their clinical sites.   

Alice Chen from the Family Health Center at the University of California at San Francisco discussed their work to change their computerized referral system. They reduced the time to referrals and warded off unnecessary referrals by assuring better communication back and forth between specialist and primary care doctors.  Karen Nelson, from the UNITE HERE Health Center funded by 32 unions, shared her perspective on training people to work as a team, and promoting team members to work as health coaches. 



Fron Sonny Patel


Do you want to help the future of public health? Want to share your experience and lessons learned to the public health students and professionals as they embark early in their career? Now you can, as the Medical Care Section and the Student Assembly are teaming up to create a Sunday session of Student Mentoring at the APHA Annual Meeting that will highlight the best and most diverse members of the Medical Care Section. It will consist of a short panel session along with a round-table thematic discussion tables afterwards with members of the Medical Care Section.


Tp volunteer your time to be on the panel and/or support the session, please e-mail Mona Sarfaty ( and Sonny Patel ( It's time for the rest of APHA members and students know what's the Medical Care Section members are all about. Hope to hear from you all!

Advocating for Human Rights – Role of the Provider

By Kawika MKI Liu, MD, PhD, JD

For all concerned about health equity, a human rights based approach to health (HRBA) provides a set of metrics by which to measure the progress of individuals and populations towards health equity. For those unfamiliar with the human right to health, it is the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.[1] States party to the International Covenant on Economic, Social and Cultural Rights, including the United States, have agreed to take steps including the reduction of infant mortality and for the healthy development of the child; the improvement of all aspects of environmental and industrial hygiene; the prevention, treatment and control of epidemic, endemic, occupational and other diseases; the creation of conditions which would assure to all medical service and medical attention in the event of sickness. Particularly important, this right, perhaps the most inclusive human right, is dependent on other fundamental rights, such as the rights to housing, education, food, an adequate source of income, privacy and access to information.[2]  The obligation to actualize these rights are not instantaneous, but subject to progressive realization.1  States are, however, under obligations to continue to take steps to realize the rights.1


If the highest attainable standard of health is the goal, the indicators of the achievement of this goal can be both quantitative and qualitative, and measure structure, process and outcome.[3]  Structural indicators determine whether a particular government’s laws are in compliance with its international obligations. Process indicators determine if a state’s institutions and policies fulfill its obligations under international law.  Finally, outcomes indicators measure the actual result of the implementation of a state’s laws and policies, and thus whether the conditions which people face on a daily basis are in compliance with its international obligations. States thus have the most control over structure and process, whereas other factors (for example, international events or disasters) could influence outcomes indicators.


One area that individual practitioners can play a role in is accountability.[4]  Particularly in the United States, systemic accountability monitors for the human right to health are either extremely weak or non-existent; thus, non-governmental organizations and concerned individuals can play a part in maintaining the accountability of actors in the human right to health to its realization.  Health care providers are not only intimately knowledgeable about the realization of the human right to health, but are often given a privileged position from which to speak about health. Thus, health care providers can speak about the determinants of health and their role in the attainment of the highest standard of health. They can speak about how these determinants are improving or deteriorating for the populations whom they serve. They can advocate at local, state and national levels for knowledge about the human right to health, its related human rights, and the prerequisites for the fulfillment of those rights. Most importantly, they can speak of how attaining social justice, through realizing the human right to health, is essential to attaining health equity.


(Dr. David Liu (“Kawika”) is a physician and lawyer committed to health and human rights. Recently appointed to the APHA Science Board, he lives in Hawaii)

[1] International Covenant on Economic, Social and Cultural Rights, adopted 16 Dec. 1966, G.A. Res. 2200 (XXI), U.N. GAOR, 21st Sess., U.N. Doc. A/6316 (1966), 993 U.N.T.S. 3 (entered into force 3 Jan. 1976).  Available at  Accessed June 3, 2010.

[2] International Covenant on Economic, Social and Cultural Rights,

1966 (art.12, General Comment 14).

[3] Kalantry S, Getgen JE, Koh SA.  Enhancing Enforcement of Economic, Social and Cultural Rights Using Indicators: A Focus on the Right to Education in the ICESCR.  Human Rights Quarterly.  2010;32:253-310.

[4] Report of the Special Rapporteur on the Right of Everyone to the Enjoyment of the HighestAttainable Standard of Physical and Mental Health, Paul Hunt, U.N. ESCOR, Comm’n on Hum. Rts., 62d Sess., U.N. Doc. E/CN.4/2006/48 (2006).



Submitted by Ellen Shaffer. This was submitted to C-PATH this Spring and should be of interest to our members.



May 25, 2010

Submitted online via



International Trade Administration

Docket Number ITA-2010-0001

Request for Public Comment on the Scope of Viewpoints Represented on the Industry Trade

Advisory Committees


We appreciate the opportunity to comment on the appropriate scope of representation on Industry Trade Advisory Committees, on behalf of our organizations representing a wide scope of public health professionals and advocates.


Our views, in summary, are:

1. The forces that shape our modern world have transformed both the way we conduct trade, and our ability to protect and improve the public’s health. Since the Trade Act was adopted in 1974, there have been dramatic changes in financial markets, communications technology and transportation that affect the prosperity and well-being of individuals and nations. In response, trade agreements have moved beyond tariffs and now address a wide range of issues that directly affect our health and our economic and social sustainability. Trade

agreements now address:

·         Domestic regulations, including measures to protect the environment, safeguards against the deadly effects of tobacco consumption, and limits on exploitive practices of internet gambling companies

·         Services, including clinician licensing, access to health care, patient privacy, and

distribution of hazardous substances

·         Intellectual property rights, including patents and trademarks, that affect access to

affordable and safe medicines, and advertising and marketing of tobacco and alcohol


·         Consumer goods and food processing

·         Government procurement affecting public functions such as water supply and health care, as well as local economic development

·         Agriculture, affecting food safety and the fate of traditional livelihoods in rural areas

·         Investment rules, affecting national sovereignty over public health protections, as well as the movement of finance capital


It is critically important to assure that the U.S. trade advisory committee system keeps pace with these developments, and provides for effective and timely communication among trade policymakers, and public health advocates and professionals.


2. Trade agreements have important implications for public health. We have identified the following arenas of particular concern:

·         Sustainable economic development

·         The rights of national, state and local governments to regulate on a wide range of issues to protect public health

·         Occupational and consumer safety and health

·         Health care services

·         Movement and licensing of health care workers, including clinicians

·         Access to affordable medicines, including incentives for innovation that de-link the cost of research and development from prices

·         Alcohol control

·         Tobacco control

·         The environment


3. U.S. trade policy on public health issues is substantially influenced by trade advisory committees. These committees are mandated by law to represent a range of public interests. Currently there is wide representation on these committees by industries that influence health: pharmaceuticals, tobacco, chemicals, alcohol, health care services, and processed foods.  There is virtually no representation by public health.


4. The Administration has the authority by law to expand the membership of Industry Trade Advisory Committees. Greater transparency and accountability in public policy on trade and health will be beneficial. According to the Government Accountability Office, “Congress established the trade advisory committee system in Section 135 of the Trade Act of 1974 as a way to institutionalize domestic input into U.S. trade negotiations from interested parties outside the federal government. This system was considered necessary because of complaints from some in the business community about their limited and ad hoc role in previous negotiations. The 1974 law created a system of committees through which such advice, along with advice from labor and consumer groups, was to be sought.


“The trade advisory committees are subject to the requirements of the Federal Advisory

Committee Act (FACA), with limited exceptions pertaining to holding public meetings and

public availability of documents. One of FACA’s requirements is that advisory committees be

fairly balanced in terms of points of view represented and the functions the committees



5. Public Health Representation would add value and contribute to the ITACs’ mission to provide information and advice to assist USTR and DOC in developing trade policies and negotiating positions. Such viewpoints could be effectively incorporated into the existing ITAC structure. In addition, they should be incorporated into the Tier 1 ACTPN, and effectively expressed through a Tier 2 Public Health Advisory Committee on Trade.


6. We support the following improvements, which are well expressed and proposed in H.R. 2293/S.1644:


A Tier 2 trade advisory committee dedicated to public health representatives: the Public Health Advisory Committee on Trade.


Appointment of at least one public health representative on the Tier 1 Advisory Committee on Trade Policy and Negotiation (ACTPN).


Appointment of public health, labor, environmental, and consumer representatives to all Tier 3 trade advisory committees.


Greater transparency and accountability by all advisory committees.


American Cancer Society Cancer Action Network (ACS CAN)

American Medical Student Association, John Brockman, President, Elizabeth Wiley, JD MPH, and Shazia Mehmood, Co-Legislative Directors

American Public Health Association (APHA) International Health Section, Miriam Labbok, Chair; Malcolm Bryant, Chair-Elect

APHA Medical Care Section, Mona Sarfaty MD MPH, Chair

APHA Occupational Safety and Health Section, Katherine McPhaul, Chair

APHA Public Health Education and Health Promotion Section, Johanna M. Hinman MPH, CHES, Chair

APHA Forum on Trade and Health, Shelley White MPH, OTR/L, Chair

California Public Health Association- North, David Spath, Chair

Center for Policy Analysis on Trade and Health (CPATH), Ellen R. Shaffer PhD MPH, and Joe Brenner MA, Co-Directors

Consumers Union, DeAnn Friedholm, Director, Health Reform

Edmonds Institute, Beth Burrows, President/Director

Friends Fiduciary Corporation, Connie Brookes, Executive Director

Global Health through Education, Training and Service (GHETS)

Health Alliance International, Mary Anne Mercer DrPH, Deputy Director

Health GAP, Asia Russell

Institute for Agriculture and Trade Policy, David Wallinga MD, Director, Food and Health, Karen Hansen-Kuhn, International Program Director

Knowledge Ecology International, Judit Rius San Juan

Maquiladora Health & Safety Support Network, Garrett Brown MPH, CIH, Coordinator

Maryknoll Office for Global Concerns, Kathy McNeely

Midwest Coalition for Responsible Investment, Barbara Jennings, CSJ, Coordinator

Missionary Oblates of Mary Immaculate, Justice Peace/Integrity of Creation Office, Christina Cobourn Herman

Mothers of Marin Against the Spray (MOMAS), Debbie Friedman

National Nurses United, AFL-CIO, Karen Higgins, Jean Ross and Deborah Burger, Council of Presidents

National Women’s Health Network, Cynthia Pearson, Executive Director

National Legislative Association on Prescription Drug Prices, Sharon Treat

NETWORK: A National Catholic Social Justice Lobby

Our Bodies Ourselves, Judy Norsigian, Executive Director

Oxfam America

Physicians for Social Responsibility, San Francisco-Bay Area Chapter, Robert M. Gould MD, President

Sisters of St. Francis of Philadelphia, Tom McCaney, Associate Director, Corporate Social Responsibility

SSM International Finance, Inc., Sister M. Cecile Paulik



Martin Donohoe, MD, FACP, Adjunct Associate Professor, School of Community Health,

Portland State University, Portland, Oregon


Nicholas Freudenberg, DrPH, Distinguished Professor of Public Health, Hunter College/City

University of New York


Joyce Lashof, Dean Emerita, School of Public Health, University of California at Berkeley


Kevin Outterson, Associate Professor of Law & Co-Director of the Health Law Program, Boston University School of Law


Larry J. Platt, MD


Theodora Tsongas, PhD, MS, Adjunct Associate Professor, School of Community Health,

Portland State University, Portland, Oregon


Karen Valenzuela, Chair, Thurston County Board of Health, Washington


1 Government Accountability Office. International Trade. Prior Updates of the Trade Advisory System Offer

Insights for Current Review. Statement of Loren Yager, Director, International Affairs and Trade. Tuesday, July 21,

2009. GAO-09-842T




At the Annual Meeting of the California Public Health Association – North, Dr. Ellen Shaffer was presented the Helen Rodriguez-Trias “Lighting the Way” Award. Ellen received this award for her “… work in public health, specifically her efforts in mobilizing multiple constituencies to action to assure universal access to a quality health care and public health system. Ellen has made a tremendous difference in the fight for achieving the most progressive, equitable national health reform legislation possible, under less than ideal circumstances. She has been a leader in articulating the special needs of women and children in this process and has gone out of her way to include women’s advocacy groups in the process of developing positions and making their presence felt within Congress and the Obama administration. Finally, she has been a tireless advocate, promoting public health and environmental and occupational health concerns within the context of our international trade agreements that has also furthered the interests of women within and without the United States.”


Congratulation,s Ellen! Your leadership, persistence and passion are rewarded with this distinguished award.




Dr. Alison Hughes is one of the recipients of the Rosa Parks Living History Makers Award for improving the lives of others in the Tucson community. The League of United Latin American Citizens (LULAC) and the National Association for the Advancement of Colored People (NAACP) recognized 25 honorees for their contributions to the Tucson community through advocacy, health, education, arts and environment, public government service, business, and faith-based efforts. The honorees from the Mel and Enid Zuckerman College of Public Health at the University of Arizona ( were recognized for their community advocacy and leadership contributions in the area of health.

Dr. Hughes is director emeritus of the Rural Health Office where she also directed the Rural Hospital Flexibility Program for a decade prior to shifting her focus toward community development activities. She is an active faculty member at the Zuckerman College of Public Health and manages a graduate student rural policy practicum project.  Hughes remains associate director of Outreach for the Arizona Telemedicine Program, a position she
has held since the program's inception.  She is an active member of the Black Women's Task Force of Southern Arizona, and serves on the boards of the Arizona Commission on the Arts, Borderlands Theater, the National Organization of State Offices of Rural Health, the Arizona Rural Health Association, the Pima County-Tucson Women's Commission, and the Catalina Vista Neighborhood Association.


Congratulations, Alison on this tremendous honor!

A Poem to Complete Your Day

I leave you with a portion of a poem from Walt Whitman's SONG OF THE OPEN ROAD, forwarded by Linda Tsan...


Afoot and lighthearted I take to the open road,

Healthy, free, the world before me

The long brown path before me leading wherever I choose.


Henceforth I ask not good fortune, I myself am good fortune,

Henceforth I whimper no more, postpone no more, need nothing,

Done with indoor complaints, libraries, querulous criticisms,

Strong and content I travel the open road.


The earth, that is sufficient,

I do not want the constellations any nearer,

I know they are very well where they are,

I know they suffice for those who belong to them.