APA Past President Don Bersoff recently took the wintery Amtrak Acela from Philadelphia in order to address my health policy class at the Uniformed Services University of the Health Sciences (USUHS), continuing his personal commitment to those who "place themselves in harm's way." Our next generation of military psychologists and advanced practice nurses learned of his ROTC and Children Defense Fund experiences, as well as his service as an Air Force psychologist during the Vietnam War. Reflecting upon his international travels during his Presidential year, Don described how the training models for psychology in the United States and around the world are of different lengths, and that this has led to collaborative efforts to tease out commonalities and essential competencies. APA is very well respected internationally – as one quickly appreciates during our annual convention Opening Ceremonies.
Earlier this year, the Institute of Medicine (IOM) released its report "U.S. Health in International Perspective: Shorter Lives, Poorer Health." Our nation is among the wealthiest nations in the world, but it is far from the healthiest. Although Americans' life expectancy and health have improved over the past century, these gains have lagged behind those in other high-income countries. This health disadvantage prevails even though we spend far more per person on health care than any other nation. The IOM panel which developed this report was struck by the gravity of its findings in reviewing data from 16 "peer" countries – other high-income democracies in Western Europe, Canada, Australia, and Japan. For many years, Americans have been dying at younger ages than people in almost all other high-income countries. This disadvantage has been getting worse for three decades, especially among women. Not only are our lives shorter, but Americans also have a longstanding pattern of poorer health that is strikingly consistent and pervasive over the life course – at birth, during childhood and adolescence, for young and middle-aged adults, and for older adults. This includes faring worse for injuries and homicides, obesity and diabetes, and disability. Many of these conditions have a particularly profound effect on young people, reducing the odds that Americans will live to age 50. For those who reach age 50, these conditions contribute to poorer health and greater illness later in life.
The U.S. health disadvantage cannot be fully explained by the health disparities that exist among people who are uninsured or poor. Several studies are now suggesting that even advantaged Americans – those who are white, insured, college-educated, or upper income – are in worse health than similar individuals in other countries. No single factor can fully explain the U.S. health disadvantage. For example, although individual behaviors are clearly important, they do not explain why Americans who do not smoke or are not overweight also appear to have higher rates of disease than similar groups in peer countries. Without action to reverse current trends, the health of Americans will probably continue to fall behind that of people in other high-income countries. Americans are dying and suffering from illnesses and injury at rates that are demonstrably unnecessary. From a public policy and public health perspective, as a nation we can and must learn from other countries. Over the years that I served on the U.S. Senate staff, I came to appreciate that two agencies in particular within the Department of Health and Human Services (HHS) have a significant international presence: The John E. Fogarty International Center (FIC) at the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC). The Health Resources and Services Administration (HRSA) plays a smaller, but still significant role.
The Fogarty International Center: The Fiscal Year 2014 budget request of $72.864 million for the Fogarty Center provides an intriguing glimpse of potential opportunities for early career colleagues, as well as the ongoing HHS efforts to develop a comprehensive strategic approach for world-wide health care. Director's Overview: From leading the call for an AIDS-free generation to developing vaccines and therapeutics for diseases that affect populations worldwide, the United States is a global leader in health research and scientific advances that improve the lives of Americans and people across the globe. These discoveries are often made by U.S. and foreign scientists working in close collaborations that enable the best and brightest minds to tackle complex health challenges together. The FIC therefore supports innovative training and research programs for U.S. and low- and middle-income country (LMIC) scientists that strengthen the research capabilities and catalyze the international scientific partnerships that lead to research discovery and improved health. By investing in current and future leaders in global health research and strengthening the long-term capacity of research institutions to provide robust and sustainable platforms for cutting-edge science, FIC advances the goals and extends the leadership of the NIH and the U.S. government in science and research, while playing a vital role in building the capacity needed to successfully tackle critical health challenges.
* Recruiting and Retaining Diverse Scientific Talent and Creativity. FIC programs have supported long-term research training for over 4,500 scientists worldwide, in collaboration with over 230 U.S. and LMIC research institutions. These investments provide unique training opportunities for early-career global health researchers, and aid in the retention of this diverse scientific talent in the research enterprise. The Framework Programs for Global Health Innovation brings together teams of postdoctoral trainees from many disciplines to produce fresh insights into global health problems, and innovations for implementation in low-resource settings. For example, a medical, engineering, and architecture team from Boston, South Africa, and Peru is receiving the training needed to design and validate effective, affordable prototypes for air disinfection that can help prevent airborne infections, such as tuberculosis and influenza, from spreading in low-resource settings. The Medical Education Partnership Initiative, co-administered by HRSA, is transforming medical education and research training for medical students in 12 African countries utilizing e-Learning and resource-sharing to train the next generation of scientific leaders to solve their country's most pressing health problems – from HIV/AIDS to maternal and child health, and to non-communicable conditions, such as mental health and cardiovascular disease.
* Translational Science FIC programs support researchers who are generating critical scientific evidence and applying this research to specific interventions, policies, and programs. Infectious disease outbreaks from human and animal hosts post significant potential health and economic threats in the U.S. and other countries. The Research and Policy in Infectious Disease Dynamics program – cofunded by the Department of Homeland Security – brings together senior infectious disease modelers and postdoctoral fellows to conduct the research and develop infectious disease modeling approaches that can help the U.S. and other policymakers plan for and respond to potential infectious disease threats. These models have explored, for example, how the Avian Influenza can develop into outbreaks from an initial case and how these outbreaks can be controlled effectively.
* Today's Basic Science for Tomorrow's Breakthroughs initiative supports catalytic basic biomedical and behavioral research that can lead to tomorrow's breakthroughs. The FIC Brain Disorders program supports cutting-edge research in LMICs on nervous system development, function, and impairment throughout life – research that could lead to new diagnostic, prevention, and treatment strategies. In India, grantees are exploring why Alzheimer's affects Indian populations less than populations in developed countries. In Uganda, research is creating a base of knowledge on dementia in those with long-term HIV infection.
Future Challenges -- the need for sustainability poses a significant challenge for investments in global health research and research training. FIC investments continue to evolve with increasing research capabilities in LMICs in order to build on successes and support the training of individual scientists and strengthen research institutions. In addition, FIC will increase support for institutional networks and hubs for data collection and sharing. When such sharing platforms are built around a core of trained individuals and strengthened institutions, they can effectively harness the different strengths of these institutions, and promote enhanced efficiencies and more robust, collaborative science. FIC envisions that its U.S.-LMIC GEOHealth hubs will become global leaders in the collection, management, synthesis, and interpretation of data on environmental and occupational health, serving the larger multi-national regions in which they reside, as well as supporting research of great relevance to both these LMIC regions and the U.S. In sub-Saharan Africa, universities supported are emerging as regional training centers and upgrading the technology to enable distance learning and resource-sharing among institutions. This model is revolutionizing African medical education and research training by enabling partner institutions across Africa to pool their areas of expertise, sharing teaching tools, and ensure that all students receive the highest-quality instruction from the continent's best qualified faculty and researchers. These efforts will ensure that the U.S. will continue to compete and lead in science. The behavioral sciences have much to contribute to the underlying FIC mission. The key question is whether psychology and nursing faculty appreciate their potential contributions and are they appropriately engaged?
Change Always Takes Time: In March, 2005 then-HHS Secretary Michael Leavitt testified before the Senate Appropriations Committee: "Influenza. Since the H5N1 strain of Avian Influenza first appeared in 1997, public health officials have grown increasingly concerned about the possibility that a pandemic strain will emerge that could cause an additional 90,000 to 300,000+ deaths in the United States. Avian Influenza has reappeared in Southeast Asia again this year, indicating that the virus has become endemic. The FY 2006 budget continues to expand HHS's efforts to be prepared in the event this or another deadly influenza strain changes in a way that makes it easily communicable from person to person. Since FY 2001, HHS has increased its direct expenditure related to influenza vaccine from $42 million to $439 million in FY 2006, in addition to insurance reimbursement payments through Medicare…. Increasing the use of annual influenza vaccinations will both reduce annual morbidity/mortality, and make the Nation better prepared in the event of a pandemic. CDC estimates that 185 million people should receive annual immunizations – but fewer than half of that number have ever been immunized in a given year." The vision of FIC's leadership continues to be most timely. Secretary Leavitt also noted: "This year, for the first time ever, States spent more on Medicaid than they spent on education."
Reflections For The Future: ACA-- Coral Andrews served as the first Executive Director of the Hawaii Health Connector, the State of Hawaii's online health-insurance exchange that was established by the Hawaii legislature to implement President Obama's Patient Protection and Affordable Care Act (ACA). A former Navy nurse, she reports her two years building the Connector has been among the most challenging and rewarding chapters of her health-care career – even providing the opportunity to speak directly with President Obama on a conference call. She is currently a Regent for the American College of Health Care Executives (ACHE). "Healthcare executive competencies in the era of healthcare reform reflect the confluence of shared industry expertise. In this wake of social change, psychologists and advanced practice mental health nurses are positioned as core contributors in evolving organizational dynamics and multi-stakeholder policy formulation. To establish a competency baseline, ACHE has published a tool entitled 'ACHE Healthcare Executive Competencies Assessment Tool, 2013.' The tool serves as a resource for executives to use in assessing their expertise in core areas of healthcare management. The application of the assessment allows it to be applied in diverse disciplines and settings.
There is a central role that psychologists and advance practice nurses may play in assisting organizations, leaders, diverse stakeholder groups and human resources professionals in the successful application of these competencies in an operational environment. Human resources, for example, has historically been the primary industry responsible for human capital management in organizations. However, the lines between human capital management and psychology/nursing as applied are blurred when discussing organizational psychology principles. Human capital management within the human resources domain can include the administrative activities of payroll and benefits administration, but it also includes applied organizational dynamics. Similarly, psychology and nursing span many different applications: clinical, behavioral, organizational, etc. As I reflect on the preparatory implementation of the ACA and engaging in its post-implementation, I would suggest that psychologists and advanced practice nurses can be innovative in the contributory roles that they can play in the following: organizational readiness for change, integration with other disciplines, public-private partnership business models, and beyond that the innovation of tools that organizations can leverage for assistance beyond the in-person consultative services. Is there a role that psychology and psychiatric nursing can play in developing online software for organizations that provides resources at varying price points? We are working with the University of Hawaii to explore a healthcare executive graduate program. The competency tool is a 'universal' resource regardless of discipline. I suggest our next generation should be imaginative as they contemplate clinical acumen transported into this new era of reform. They may be on to something…. "
"As I reflect on the ACA implementation in Hawaii, there are wonderful learnings that can be carried forward as implementation continues through the 'phase in' of ACA. The learnings are only possible if the environment allows for an opportunity to comfortably mine for insights and to openly discuss them. When implementing new policy, there is risk. Risk should not be viewed as a negative but as an opportunity. Managing risk is simply a part of achieving change and creatively pursuing innovation. Hawaii has a rich culture that provides for a solid value base which serves as a beacon for consensus. Given the policy debate in a multi-stakeholder environment, the host culture's values serve as the framework by which consensus can be guided… a baseline to go back to when policy discussions become spirited. Passion for policy is a good thing provided the motivation behind it always leads back to purpose. The purpose is to achieve long term value in the health of the population. It requires a consumer oriented design as contrasted to an organizational, top-down design. This methodology requires adjustments by leaders and policy makers as the human tendency is to design toward one's organizational advantage. In a multi-stakeholder environment, everyone needs to put a 'marble in the circle' to achieve success. It minimizes dominance and leans toward sharing wins and losses in order to achieve collective success. A risk adverse culture can constrain the openness to reflect, evaluate, and learn especially if there are strong political influencers which can occur in an election year. To leapfrog through change, an important starting point necessitates that individuals and organizational cultures evolve to embrace success as defined in a new way. Implementing change is not indifferent to space exploration. We need leaders who are willing to navigate through and be alert to the cognitive and behavioral responses to change. Often, evolving to the future state is enabled when the people and organizations involved are supported with educational insights about how to change. It does not come naturally for all but is an important skill and capability that is required to successfully achieve the optimal implementation of the ACA for long term value. Implementing systems is the easy part. Bringing the people, organizations and cultures along in support of, is where organizational psychologists and clinical nurse specialists can facilitate the process."
VA -- Heather O'Beirne Kelly, who was born at Tripler Army Medical Center and whose grandfather was stationed at Pearl Harbor on that fateful September 7, 1941 morning, recently assumed APA's lead for military and Veterans policy, including coordination of APA-wide clinical and training activities related to DoD and VA, in addition to their research portfolios, as well as that of the National Science Foundation (NSF). She sits on the Executive Committee of the Friends of VA Medical Care and Health Research Coalition (FOVA); represents APA on the VA Office of Mental Health Services Stakeholders Group; has testified before Congress regarding funding for VA research and mental health services; and has coordinated numerous Capitol Hill briefings on topics of interest to the Veteran population, including suicide prevention, PTSD, and traumatic brain injury. She also directs APA's Executive Branch Science Policy Fellowship Program.
Most recently, Heather has been advancing APA's Veteran-focused priorities on Capitol Hill through hearing testimony, meetings with Congressional staff, and intensive behind-the-scenes collaboration with several key offices particularly interested in Veterans' mental health care and research. She worked to successfully include APA's language providing for psychologists' system-wide prescribing authority within the VA, increased collaboration between VA medical centers and local enforcement crisis intervention teams, and expansion of VA lethal means reduction for suicidal Veterans which are included in draft legislation proposed by Senator Patty Murray (D-WA).
A graduate of Smith College, Heather has worked in non-profit development for clients including the Children's Defense Fund, UNICEF, and the March of Dimes before becoming director of corporate relations for Wolf Trap Foundation for the Performing Arts. Her clinical internship was at Children's National Medical Center in Washington, DC. Her interest in military and Veteran issues is longstanding; her father and both grandfathers were career military officers and her mother has worked for many years in military family policy. Aloha,
Pat DeLeon, former APA President – Division 42 – February, 2014
