An ounce of prevention

April 2, 2014

In health care circles, John O'Brien is known as a "turnaround guy." He takes something that's struggling and makes it succeed, or he takes something that's already working and makes it work better. O'Brien has been the CEO of two hospital systems, served as the commissioner of public health for the city of Cambridge, Mass., and spearheaded the creation of the Cambridge Health Alliance, a coalition of hospitals, clinics and specialty centers that has been hailed as a national model for integrated health care networks. Every step of the way he has strategized, innovated, expanded and enhanced facilities, services, accessibility and employee rolls. He has been lauded as an industry leader, earned national awards, and he and the Cambridge health system were profiled by Tom Brokaw on the NBC Nightly News. His rolodex is a Who's Who of health and government at the highest levels.

Despite the impressive career trajectory, O'Brien remains conscious of the example set by his mother, who as a widow with 10 children struggled to keep the family afloat on her salary as a secretary at MIT. Times were lean, yet she never failed to show a kindness to someone in worse circumstances or give food from her table to others.

"My mother instilled in all of us a sense of giving back; that to whom much is given, much is expected," O'Brien says.

As such, he is a man with feet planted firmly in two worlds, balancing the successful management of sprawling institutions with improving the delivery of health services to the most vulnerable populations — a voice in the executive suite and an advocate in the street. When a state or city law was proposed that he deemed harmful to the poor in Massachusetts, O'Brien never hesitated to "fight it to the death," raising hell at press conferences and taking his case straight to the policymakers.

Last year, after retiring as CEO of UMass Memorial Health Care, one of the largest health systems in the Northeast, O'Brien joined the Mosakowski Institute for Public Enterprise at Clark University as the Jane '75 and William '76 Mosakowski Distinguished Professor of Higher Education. He's now putting his turnaround talents to work for the city of Worcester.

Following months of negotiations and planning, and with the assistance of faculty and the blessing of the administration, he has launched a unique town-gown collaboration that is positioning Clark as a player in the evolving field of public health. University and Worcester officials in February signed an agreement to create the Academic Health Department, partnering Clark students and faculty with the city's Division of Public Health to launch a full-on offensive against some of the most pernicious health issues plaguing the city, from poor nutrition to untreated mental illness, to violence and injury. The goal is to foster healthy behaviors that will curtail more serious illnesses later on — in effect improving lives, cutting treatment costs and preserving communities.

"If you look at the data, health is defined as the complete physical, social, emotional and economic well-being of an individual. Genes and biology only account for a portion of it; a lot involves social determinants and behavior," O'Brien says. "The greatest predictor of poor health is poverty and whether you have a health insurance card in your wallet. Health is quality housing, it's the quality of public education, it's healthy eating and increased physical activity. What we need are interventions, and we need to engage the community. We need transformation."

O'Brien has recruited UMass Medical School as a partner, giving students access to its doctors, researchers and resources. Other Worcester-area universities and colleges also will participate in varying capacities, but Clark will be the lead institution.

"I'm trying to tug at the self-interests of various stakeholders, because it's a challenging time economically for health care systems and universities," he says. "So I see, for instance, the Department of Quantitative Health Sciences at UMass being able to take advantage of our GIS mapping abilities to apply for a National Institutes of Health grant they may have otherwise passed on. It's a lot easier to pull people into the future than kick them out of the present."

Says Mosakowski Institute Director Jim Gomes: "John is that rare person who combines the ability to envision a major change, has a detailed understanding of what needs be done, and possesses leadership qualities to bring together people to make his vision a reality. The world needs more John O'Briens, and we are so fortunate to have him at Clark."

Marianne Sarkis, professor in the department of International Development, Community, and Environment, has long immersed her students in the Worcester community to do research on issues like infant mortality and the impact of prostitution on neighborhoods. While the experience has been productive, she found that Clark was often bumping into other colleges and universities doing their own projects, which was fomenting "research fatigue" among over-studied residents.

"This agreement will formalize things, make it seem less ad hoc. We were doing all this work, but there was no centralization, no coordination," Sarkis says. Students now have the added advantage of doing meaningful internships and capstone projects with the Division of Public Health while getting properly trained in community-based public health research. In return, Worcester residents will be active participants in their own health care, she says, rather than regarding themselves as subjects inside a "living lab."


John O'Brien, Distinguished Professor of Higher Education at the Mosakowski Institute, has spearheaded the creation of the Academic Health Department

"It is an exploitive process," Sarkis explains. "We're getting all this information from the residents, but the feedback was not getting back to them. By having the DPH involved, there is more of a feedback loop, and more benefit to the community. Now the community will influence policy, programming and outreach."

When O'Brien and Worcester Public Health Director Derek Brindisi, M.P.A. '03, opened a dialogue about forming a partnership, Sarkis and fellow IDCE professors Laurie Ross '91, M.A. '95, and Ellen Foley brainstormed with O'Brien about maximizing the benefits of this pioneering arrangement for both the city and Clark. Professors from other disciplines, like John Brown and Jacqueline Geoghegan from Economics, and Yelena Ogneva-Himmelberger from IDCE, added crucial perspectives.

Brown, the Jane '75 and William '76 Mosakowski Distinguished Faculty Research Fellow, said that at its fundamental level the partnership allows students to apply quantitative skills to concrete situations.

"In my mind, this is real Mosakowski Institute research, where we're doing high-quality assessments to determine the impact of interventions," he says. "This is an opportunity for us as researchers, and for the city, to get more bang for the buck."

Last year, Worcester announced its Community Health Improvement Plan, a roadmap to making Worcester "the healthiest city in New England by 2020," particularly by improving outcomes among residents gripped by the twin demons of substandard living conditions and lack of access to consistent, high-quality care.

It was a daring, ambitious, and daunting claim that would require community collaboration — with hospitals, health centers and academia — to have any chance of succeeding.

Brindisi believes he's found the perfect partner in Clark.

"Clark students want to dive in and do tangible work, and the faculty members are just as engaged," he says. "We have a natural connection to Clark."

He recalls accompanying John O'Brien to an elementary school where the then- CEO of UMass Memorial motioned to a kindergarten student and said, "If we don't take care of that child today, we'll be bearing the costs of caring for him as an adult."

Says Brindisi, "Everything is pointing in one direction: prevention."

The Community Health Improvement Plan pinpoints five priorities: healthy eating/ active living; behavioral health; primary care/ wellness; violence/injury prevention; and health equity/disparities. Brindisi anticipates Clark's intellectual resources and boots-on-the ground work ethic will make the University a valuable ally for administering, documenting and evaluating the programs his department is rolling out. For instance, he can envision students being deployed to identify so-called "food deserts" in urban neighborhoods, or tapping faculty expertise to increase the city's chances of landing federal grants.

"People may say, ‘Why Clark?' I say, look at everything Clark already does in the areas of GIS, urban planning and global health. Their programs touch on everything we're doing in public health. When John O'Brien said ‘Let's do this,' I knew it would be successful."

Academic Health Departments are not new — O'Brien points to a successful longstanding example in Knox County, Tenn. — but they are relatively rare nationwide. An AHD represents a formal affiliation between an academic institution and a state or local health department, pooling the intellectual capital of the former with resources of the latter to deliver essential public health services. The Clark-Worcester tandem is an even more uncommon version in that it doesn't involve a university with its own school of public health, as is typical in these partnerships, and instead weaves together resources from various institutions and the city and puts them into practice in an innovative way.


Worcester Public Health Director Derek Brindisi, M.P.A. '03, says Worcester has found the perfect partner in Clark

An Academic Health Department can be invaluable for a city like Worcester, which has only 18 employees in its health department compared to 1,100 in Boston, O'Brien says. "Cambridge, which is smaller than Worcester, dwarfs this place [in number of staff]," he marvels. "Worcester has all kinds of initiatives going, but it doesn't have the manpower to follow through. What we will be able to do for Worcester, I believe, will be a real differentiating thing for Clark University and for the city."

The Mosakowski Institute for Public Enterprise was established in 2008 around the mission of conducting research that will catalyze social change in a variety of areas, including education, mid-sized cities, the environment, and health and wellness. William Mosakowski '76, who, with his wife Jane Mosakowski '75, is the institute's benefactor, views the Academic Health Department as "a move in the right direction" toward fulfilling that early vision.

"What's very interesting here is the opportunity to have the institute do the testing on health care policy reforms, public health initiatives and even behavioral reactions at the local level, with broader applications regionally and nationally," Mosakowski says. "Plenty of research is being conducted in many universities and institutes, but little of it moves from lab to practice — we wanted to be able to have a mechanism to do that. It's not an easy translation, and it takes time, but under Jim Gomes' leadership, and with the addition of John O'Brien, a lot of progress is being made."

Mosakowski, founder and chief executive officer of Public Consulting Group, Inc., has worked with O'Brien on health care-related matters for many years, dating back to O'Brien's tenure at Cambridge City Hospital, where he was named CEO at the age of thirty-five.

"The reason John is viewed as a change agent is that he's able to put together the pieces and pull together the constituencies so that change not only occurs, but it sticks."

O'Brien is adamant that public health is a critical frontier in the reform discussion. The headlines have fixed on the troubled rollout of the Affordable Care Act, but the hidden story is how increased prevention and early intervention will boost positive health outcomes and contain costs. Attacking the problem of dust mites, which exacerbate asthma, or finding ways to get nutritious foods to families to fight childhood obesity before it blossoms into heart disease, will strengthen the sustainability of a health care-medical complex that for too long has viewed treating catastrophic bodily failures as its primary mission, he insists.

O'Brien, Mosakowski and others interviewed for this story agree that no one can accurately predict how the health care system will reinvent itself in the coming years. The path is long, O'Brien acknowledges, but he was involved in the reform movement in Massachusetts and he's optimistic that the nation will see dividends from widespread change.

"Seven or eight years ago I attended a lunch with [then-Federal Reserve chairman] Alan Greenspan, and he said then that reform was coming because the system was unsustainable," O'Brien says. "People have said we have the greatest health care system in the world, and it is if you're affluent, you're literate and your doctor can help you navigate it. Very few people I know in health care don't think we can't do it better and cheaper."

Within the fog of uncertainty about health care's future lies an unassailable truth: career prospects in the health sector will continue to grow. O'Brien is bullish on the prospect of Clark students receiving the kind of experiential learning through the Academic Health Department that will gain them a foothold in an evolving economy where health spending now is nearly a fifth of the national GDP. He foresees the day when Clark has a formalized curriculum that will channel students into health fields.

"Ten thousand people in this country are turning sixty-five years of age every day, and that will continue for another fifteen years," O'Brien says. "Young people today might not know it now, but they'll be ending up in health-related careers. I'm hoping this will whet Clark students' appetites for that challenge and those opportunities. This is a changing time, but it's also an exciting time."


Professor Marianne Sarkis welcomes a more organized approach to public-health research in the city

To your health

From front-line physicians to policy influencers, Clark University alumni are richly represented in the field of public health. We caught up with several alumni to get their thoughts about the changes, challenges and opportunities they're seeing on the job.

Dr. Lewis Goldfrank '63, director of emergency medical services, Bellevue Hospital Center, New York, N.Y.

Dr. Lewis Goldfrank doesn't like the word "accident." As director of emergency medical services at Bellevue Hospital since 1979, he knows that with proper prevention strategies and education, far fewer people would end up in his ER and instead be living healthier, happier lives. In the past he has fought for the placement of seatbelts in taxicabs, the elimination of lead paint in homes, the use of helmets for bikers, and the placement of protective guards in windows to prevent children from falling to their deaths. These days, in collaboration with the state of New York, faculty in his department are leading a study of pedestrians and bicyclists injured or killed in crosswalks or in the streets.

"Things sometimes float to the surface, and sometimes they recede because of public attention," Goldfrank notes, "but the way public health works is you do the basics forever." It's crucial to improve people's health literacy and numeracy, he says — getting them to learn about risk and the nuts and bolts of prevention as early as possible. That means putting doctors, nurses and college students into the schools to educate on such topics as proper nutrition, dental care and tobacco avoidance. By way of illustration he cites a chilling New England Journal of Medicine article that maintains, for many, obesity is determined within the first years of life. Overweight 5-year-olds were four times more likely as normal weight children to become obese.

"Once a child is overweight you can't retrieve that; they're overweight the rest of their lives," he says. "You've got to help people early on because, by the time they come into your office at age 15 or 20, the die has been cast."

Goldfrank lauds Clark's formation of the Academic Health Department, likening it to the pioneering University Park Partnership with the Worcester Public Schools — a committed, proactive effort to work with and for the community in which Clark is both resident and contributor.

John Auerbach '72, director of the institute on urban health research, Northeastern University

Optimism. That's the word that emerges frequently in a conversation with John Auerbach when he speaks about the future of health care. He was on the phone recently from Washington, D.C., where he was attending a conference that featured a groundbreaking meeting between leaders from clinical medicine and from public health, both looking at potential areas of compromise and collaboration as they work through the shifting sands of health care reform.

"There's been an effort in the last few years to strengthen the partnership between the people who work on the public health side and those who work on the clinical side, to see if it's possible to develop a new model of care where there's a greater emphasis on connecting patients to the non-clinical services in their communities that might be useful for promoting good health," he says.

The former commissioner of health for Boston and later for Massachusetts, Auerbach was on the ground floor of the successful statewide health care reform legislation passed by then-governor Mitt Romney and implemented by Governor Deval Patrick. He says that, while red states and blue states may be at odds over the best strategy for federal reforms, he sees general agreement "that expanding access is a good thing; that people's health improves when they see clinicians, and there needs to be a consolidated effort to improve quality of care and control costs.

"There are bumps in the road, but I'm optimistic the rest of the country will see what we've seen in Massachusetts."

Dr. Stephanie Bailey '72, Dean Of the College of Health Sciences, Tennessee State University

Effecting change in public health is an evolutionary, rather than revolutionary, process, involving long-held behaviors that are often rooted in cultural mores, political expediency and a societal preference for the quick fix over gradual improvement, says Dr. Stephanie Bailey.

"Why is prevention so hard?" she asks. "It's because the culture and experiences we grew up with lead to beliefs, which lead to actions, which lead to results. We as a society always focus on the actions — to change the law to do something now. But that does not change the behavior that will create a culture where health is the default, which takes a lot more effort." She notes that dramatic treatment measures such as bariatric surgery and medication "cocktails" have in many cases supplanted healthy preventive behaviors for obesity and AIDS/HIV respectively.

Bailey (at right) is the former chief for public health practice at the Centers for Disease Control and Prevention and for 12 years was the director of public health for the city of Nashville, where her department took chances and made inroads. She cites a particularly innovative initiative which virtually eliminated syphilis in Nashville after the city had been ranked number one in the nation for the disease. Communities, she says, "should own their own health rather than be dictated to from the top down."

Bailey will be launching an Academic Health Department linking Tennessee State University's resources with the needs of the Nashville community, similar to the Clark- Worcester partnership. She describes Clark's move as "very opportunistic, given the health care conversation going on. The health departments are not going to be the leaders; you've got to go outside the government. So when I hear about Clark doing this, I say, Yeah! I'm excited," adding with a laugh, "I want to come out there and run it."

Miranda Katsoyannis '78, Senior Program Analyst, Centers for Disease Control and Prevention

"Health is more than the absence of disease," says Miranda Katsoyannis. "Every part of life must be focused on creating health." In her position at the CDC, Katsoyannis knows that protecting and preserving the wellness of communities involves numerous factors, including access to care and the promotion of healthy behaviors. As a liaison between the CDC and Capitol Hill, she is a translator of sorts, helping Washington's congressional leaders understand complex public health issues that are informed by hard science, with the goal of shaping effective policy.

Getting there isn't always easy.

"Scientists aren't necessarily concerned with what's happening in Washington, so it's our job to take what they're doing and bring it to the policymakers so they can better assess and review the work," she says.

The CDC touches numerous disciplines, ranging from epidemiology to nutrition to emergency medical services, and is often a voice on such national issues as gun violence and the growing epidemic of prescription drug overdoses. The agency's best work is often its quietest, like the viral outbreaks that don't occur because of CDC research and intervention in all 50 states (and in more than 50 countries) — supporting local health departments with the tools, education and funding to protect their populations. "The outbreaks you never hear about are our biggest success," she says. "Bad things didn't happen, the nation went about its business, and you weren't affected."

When the Affordable Care Act was passed, Katsoyannis and the CDC worked to ensure prevention was made a priority, and explained to representatives and senators how their constituents will benefit.

As for Clark's partnership with Worcester? "The CDC has another partner in arms," she says.

Maria Fernandes '05, Government Relations Specialist, Boston Children's Hospital

Negotiating her way through the thicket of state government to achieve healthier communities has become a way of life for Maria Fernandes. She has worked with legislators, the governor's office and state agencies to enact policies that counteract widespread childhood obesity and instances of concussions among young athletes. She now has her eyes set on improving dental health among children, reinstituting recess and supervised physical activity in the schools, and getting parents to buckle up their kids in cars.

Fernandes (below) is proud of the progress made. For instance, junk food has virtually been eliminated from the schools, and a bill passed in 2010 mandates training for coaches and other adults to spot concussions and initiate proper procedures to ensure an athlete does not return to the field until he or she has been medically cleared.

She acknowledges that change is difficult. Despite the uptick in nutritional foods at schools, many inner-city children still live in "food deserts," areas served largely by bodegas and convenience stores that lack fresh produce. Even if healthier options are available, they can be unobtainable.

"Clinicians are hearing from parents that they would love to institute healthy eating in their homes, but they can't afford to," Fernandes says. "The gallon of soda is cheaper than the vegetables."

Like Dr. Stephanie Bailey, Fernandes sees resistance to change shaped by ingrained cultural behaviors. She points to the pushback from the Hispanic and African-American communities on instituting a "primary" seat belt law, which allows a person to be cited for not wearing a seat belt absent any other infractions. The fear, she says, is that police will profile and harass young men of color.

"We haven't been able to disconnect the law from the fear of racial profiling, but the National Highway Safety Association studies show that blacks and Latinos wear seat belts at lower rates than whites, and that passage of a seat belt law does not increase harassment," she says. "We understand the deeply rooted conflict between the community of color and law enforcement, but we're in the business of health equity and, if the law passes, those who stand to benefit most are African-Americans and Latinos."

— This story was originally published in CLARK Magazine, spring 2014.