Economic development and health outcomes: The case of the Dominican Republic

March 24, 2015 by


The World Bank classifies the Dominican Republic (DR) as an upper-middle income economy with a $5,770 gross national income per capita (WB, 2015). The country is one of the top performers in terms of economic growth in Latin America. Paradoxically, after analyzing main social indicators one wonders why this economic development has not been translated into notable social progress over the years. In this blog I will focus on public health.

Aiming towards universal health coverage would contribute to reducing the incidence of catastrophic health expenditure. High health costs often have severe consequences in increasing poverty headcounts. In the DR there are important obstacles that prevent the country from reaching universal health coverage, such as very low government health expenditures and a big informal sector. Public health expenditure was 2.4% of GDP (WB, 2015) on average during 2000-2012, one of the lowest in Latin America.

Despite some achievements in health outcomes over the last decade, basic public health indicators such as infant mortality rate remain way above the Latin American average and worse than countries with similar levels of economic development like Costa Rica. In 2013, it stood at 23.6 per 1,000 live births, as compared to 8.4 per 1,000 live births in Costa Rica (WB, 2015).

Meeting the goals of the 2001 health reform and achieving universal health coverage is not an impossible task. For example, Thailand has had a universal health coverage scheme since 2002, when it had similar levels of public health spending as DR has today. It is a matter of designing the correct payment incentives based on performance indicators to improve quality in the system. Also, reforms should be piloted focusing on the most vulnerable populations that are affiliated to the national health insurance, SENASA. Currently, 29% of the population is affiliated through the subsidized regime (SISALRIL, 2015), but its expansion has been low given that it relies directly on budgetary appropriations. There is a significant opportunity for improvement if the mixed subsidized-contributive regime is fully developed, which allows for more poor people to be targeted into the subsidized regime.

The Dominican Republic is an amazing country with very favorable economic prospects. It is time to revisit the organization of the public health system and contribute to build a bridge between the status of upper-middle income country and its social indicators.

Being a graduate student instructor (GSI) v. graduate student research assistant (GSRA)

March 1, 2015 by

amy I have been fortunate enough to experience being both a graduate student instructor (GSI) and graduate student research assistant (GSRA) for the biostatistics department within my two years here. I was a GSI my first three semesters, and am currently a GSRA this last semester. While I think many graduate students incoming to UM, reputed as a large public research institution, are rearing to partner with faculty and partake in discovery, I see distinct pros and cons to both positions:

Pros and cons of being a GSI:


UM’s Center for Research on Learning and Teaching offers GSI resources

Pro:  Meeting new people. As a GSI my first semester–a time when everyone is a stranger!–I became close to four of my biostatistics classmates through long homework grading sessions, helping one another field questions during office hours, and managing class policy and administrative issues; moreover, I instantly met at least 70 fellow public health students from other, diverse departments within the School of Public Health (SPH), students with whom I would’ve never crossed paths if I were not their instructor. Because I met all these colleagues of mine on day 1, since then I’ve been able to smile, stop, and chat in the hallways when I frequently see a familiar face. It has made SPH a much more friendly place.

Pro: A fixed schedule. GSI-ing, as opposed to GSRA-ing, is a much more organized job affair in that there are dedicated times for your teaching responsibilities and you will rarely spend more hours than expected attending to them. Aside from the occasional request to meet outside of class for an extra tutoring session or overly in-depth homework question in email form (difficult to answer when that question is quantitative), GSI-ing doesn’t tend to spill outside the boundaries of your two laboratory sections, 2-3 office hours, and grading sessions.

Con: Student conduct issues. It is uncomfortable to encounter multiple assignments that are suspiciously identical, or seemingly copied from the solution manual. One might think that there is some satisfaction to catching cheating incidents, but I don’t think any teacher relishes the experience. No one likes to stir up drama surrounding academic dishonesty when the vast majority of students are attending class and diligently attempting assignments, struggling or not.

Pros and cons of being a GSRA:


Pro: Learning and applying new methodology. Research has allowed me to move past the theory of statistical methods emphasized in coursework to actually applying these analyses to real-life clinical investigations run by epidemiologists, professors, and physicians in SPH, the UM Health System, and health centers across the nation. It’s eye-opening interacting closely with one or two faculty members on a professional as opposed to instructive level, seeing how they approach problems and gaining insight into harsh work-life balance of academia.

Pro: A flexible schedule. Just as how GSI-ing is nice in that one’s schedule is very strict, GSRA-ing is nice for the very opposite reason in that one’s schedule is quite flexible. If you have a slew of midterms coming up, it’s okay to delay some research tasks for a few days and catch up later, while abandoning one’s section as a GSI is clearly not an option. GSRA-ing involves more time-management skills, but accordingly more leeway in when and where you do your work.

Con: More hours. I can only speak for my own experience, but GSRA-ing has required many more hours per week than GSI-ing. It’s easy to get absorbed in a coding problem, or sit for hours muddling through a “dirty” dataset. While research work is open-ended and thus intriguing, it leaves less time to complete the traditional but mandatory homework assignments and studying for courses.

Retail Clinics and population health

February 20, 2015 by


Retail clinics (RCs) initiated as a response of the market to unmet needs of healthcare consumers for accessible, convenient, and cost-effective basic health services. As the clinics become a popular means of treating minor medical conditions at lower costs, they have established a niche in the health care system based on their convenience and accessibility for both insured and uninsured patients. Retail clinics are typically located in store chains that patients already visit on a regular basis, such as CVS, Walgreens and Wal-Mart.


The clinics can operate under three different business models: 1) the clinic is owned and operated by the parent store that houses it; 2) an independent company owns the clinic and partners with a retail store to house it; and 3) an integrated model where the clinic is owned by a hospital, a physician group, or another health care provider. Nearly three-quarters of clinics follow the first model (RAND, 2010).

The rapid expansion of RCs is attributed to costumers’ favorable response to the model. Convenient hours and locations are major factors in choosing the clinics. RCs generally employ a nurse practitioner or a physician assistant with off-site supervision by physician medical directors, providing services at accessible locations, shorter wait times, and lower costs.


Despite being a relatively new phenomenon, these clinics have the potential to increase access to basic health services to the underserved population. RCs have the necessary infrastructure –capacity for 17 million visits a year (Bureau of National Affairs, 2009)– to alleviate the shortage of primary care physicians that is intensified by the increase in demand for health services as a result of the 11.4 million newly insured under the Affordable Care Act. However, retail clinics have faced financial barriers to establishing contractual relationships with Medicaid. Also, they have to deal with state-level regulatory constraints including scope of practice laws and prohibitions against the corporate practice of medicine. These restrictions tend to limit the clinics’ ability to operate in medically underserved areas (Bartlett, 2011).

Massachusetts became the first state that adjusted its regulatory framework to fit RCs into their health system, by enacting in 2008 new regulations that specify the medical conditions and age groups that may be treated at the clinics. This proactive approach to design a tailored regulation for the operation of RCs is a good example for other states to consider how to better integrate RCs with traditional models of care. States Departments of Health play an important role in the development of this model, which has the potential to improve population health outcomes and decrease healthcare costs.

Day in the life: grad school

February 19, 2015 by

amyI’ve always found “day in the life” posts in the blogosphere fascinating, since they are a peek into someone else’s schedule, habits, hobbies. Here’s the previous Friday (pardon the delay) of my charmed biostatistics graduate student life:

7:01am – Alarm goes off. As an early bird, I am usually pretty awake by this time anyway. I clamber out of bed, go through the morning routine, eat a hearty bowl of oatmeal, and enter the tundra leave for school.

7:58am – At the bus stop. Shortly after I snap this photo the bus comes rolling in and I make a mad dash down the rest of the path. Nothing like a sprint in the morning to wake one up!


The bus stop is the shelter straight ahead

8:15am  – It’s my stop. I get off the bus and walk the short distance to my office, which is in the basement of the School of Public Health II (SPH II), on the right. Unfortunately, the cool medieval building in front is Kinesiology, not part of SPH. I must be feeling anxious about a project due early next week, since I cram in some coding before my class at 8:40am instead of dilly-dallying on the internet as usual.


SPH is divided into SPH I, the Tower, Crossroads (the archway area), and SPH II

8:40am – Environmental Health 540: Maternal and Child Nutrition. Today we have a guest speaker, a gestational diabetes counselor from the UM hospital. As a biostats student, I really relish any non-quantitative courses I get to take as a breather from all the math-y stuff. I’ve built my cognate around reproductive health, as I find the physiological and social adaptations of pregnancy incredible.


Reppin’ it during class

10:30am  – Class gets out. Squeeze in some gym time. I’m usually an early-evening exerciser, but on Fridays I need to move early or else I go stir-crazy in my three-hour class in the afternoon. The Central Campus Recreation Building (CCRB) is only a few minutes’ walk away from SPH.


Try taking a photo on a treadmill some time. It’s difficult!

In general, I enjoy running outdoors, but…


Well hey, if they’ve paved a path everything is okay, right?

12:30pm – Lunch time! I normally bring lunch to school every day, but on this rare occasion I must visit the Glass House, our cafe situated conveniently within SPH I, for some midday fuel. It’s definitely a soup kind of day. I bring the food back with me to the office (plus ten minutes since I forgot a spoon and must make a return trip–sigh) and eat while chatting with an officemate.


1:10pm – Biostatistics 880: Statistics With Missing Data. This is a PhD-level class and thus a little overwhelming, but I feel privileged to be able to take it with an expert in the field. I get a tad sentimental thinking about how this is my last semester of school, and feel some pressure to make the most of it so no senioritis for me.

3:48pm – Class ends. I descend back to my office and crank away at my project.

5:40pm – Time to go home!


6:15pm - Arrive back at my apartment. Eat dinner. It’s the weekend–joy :)

Internship, Funding, Classes…Oh My!

January 30, 2015 by

aparna Hard to believe that almost an entire month has gone by since second semester started! It’s been a whirlwind of internship funding applications, internship conundrums in general and group projects for class galore. The Global Health Epid track has been super exciting thus far and I love the focus that my classes this semester have on preparing us for our field experiences this summer! Going abroad comes along with its own challenges – funding applications, budgets, housing and food solutions, and letters of recommendation are all any of us can think about right now as we scramble to prepare our proposals to secure the money to go on the adventures of our lives.

Fortunately, everyone here is super helpful and there have been lots of workshops to help guide us along, not to mention the amount of support we get from our professors…at least we’re prepared for everything that comes our way in a few months!

One of my favorite classes this semester has us studying the intersection between epidemiology and culture. In undergrad, I took a medical anthropology course, which I really, really loved, and I’m excited that I get to take a similar class again! Of course, data is the most common word in the language of epidemiology, but this class really puts a new spin on it and relates the projects back to the communities in which we will be immersing ourselves.
I will be going to India for my internship to work with an organization called iKure. International internships are usually secured in the first semester and the second semester is usually devoted to finding funding. I am excited to work with the rural population around Kolkata this summer to study trends in data already collected and to do some descriptive epidemiology to understand health trends in this particular population. Spending the rest of the semester preparing for this is going to be a lot of fun!

My other class this semester that is preparing me for “the real world,” is the Public Health 615 Course – part of PHAST’s Texas Spring Break trip! A group of nine of us are heading down to Brownsville, TX in early March to work with UT – PanAm professors on various projects. The class meets once a week and we spend our time diving into the work we will be doing in about a month! All of us will be writing in more detail about those adventures on the SPH Frontlines blog, so stay tuned…

It’s been a great month so far and can’t wait to see what else comes my way this semester!  Stay warm and, as always, feel free to reach out with any questions!

My Spell Check doesn’t recognize “Health Informatics”

January 18, 2015 by

My post title reflects microsoft word’s ignorance and also my own ignorance before I came to U of M.  At its most basic, health informatics studies, creates and utilizes technology to monitor, improve and communicate health information. This is a big undertaking and because of that, this field is rapidly expanding in knowledge and opportunities for individuals from a wide array of disciplines to contribute- Epidemiologists, Public Administrators,Information Technologists, Health Behavior specialists and many more.
In my introductory class for Health Informatics our study was as far ranging as the field itself. We studied the use of computers, programs, apps and tools within biomedical research, public health work, medical care, consumer healthcare and the work being done to improve health information infrastructure.

Health informatics in the United States is  rapidly growing partially because of the HITECH act passed by President Obama in 2009. This act provided money to the Department of Health and Human Services to fund hospitals and other medicare recipient agencies with the funding to implement electronic health records systems. Electronic health record (EHR) systems are medical files held in a set of interconnected computers and devices that allow doctors, practioners, and sometimes patients to edit and view those files. As a result, approximately 80% of all primary care facilities and hospitals in the United States now have digital medical records and computer systems to support them. Consequently, we now have the ability to more quickly exchange  health information within hospitals and primary care organizations, further improving quality of care by increasing communication speed amongst practitioners, decreasing drug interactions through timely notifications, and increasing medical computers’ ability to be a knowledge bank for everyone connected to them.

Public Health informatics was not included in the HITECH act, but that’s because it’s been ahead of the game for a while now. From 2000-2005 the CDC’s National Electronic Disease Surveillance System aided states in implementing their NEDSS system which would allow them to collect, forward and store the data that would  be reported to the CDC. 46 states are now a part of this system in which hospitals and doctors offices share a common network with local health departments, allowing them to pass on health data that eventually makes its way to the CDC. This is a great system, but not without its challenges, those being that not all states participate in the system and lack of interoperability. Interoperability is the ability of information from one computer system to be transferred to another computer system and have that information arrive in the way that it left. Think of it as a big game of telephone played between the local health department and the CDC computer system. Can the message “10 primary cases of varicella zoster virus this month” reach the CDC computers without it becoming “100 cases herpes zoster viruses this month” or “10 primary cases. Varicella zoster virus this month.”? That is a loose example of  measuring of interoperability.

If anything I have mentioned in this post has piqued your interest at all, I highly recommend seeking out more information on the exciting field of health informatics. There’s a place here for everyone, and there’s a lot of amazing work to be done!

Dental care for the underserved: the Michigan Community Dental Clinics (MCDC) approach

December 28, 2014 by


People with chronic diseases who are not well educated about their health status might delay health care, and they may gradually notice the bad consequences of this decision in the long term when it is usually too late and more expensive to access health services. In contrast, it is harder to delay care when people have dental problems that cause extreme toothaches. This will generally make people reach for an immediate visit to the dentist because it tends to be an unbearable discomfort. Now, what to do if your insurance does not cover dental care or if you are uninsured and low income? It is a very unfortunate situation faced by a lot of people who fall into these categories.

Access to dental care for Medicaid recipients and low-income uninsured persons is very limited. MCDC developed a social entrepreneur approach to address this important public health issue. The clinics offer dental care to adults and children on Medicaid, and to low income, uninsured individuals, integrating health education to modify health behavior in order to avoid dental visits under very painful emergencies, promoting preventive care. The model is unique because it meets two challenging goals at the same time: providing timely dental care to the underserved while maintaining a successful business model.

MCDC is a not for profit corporation that assists in the development of dental clinics by Local Public Health Departments (LHDs) in Michigan. It is a Private-Public partnership model: LHDs create the clinics based on MCDC requirements, and MCDC leases the clinics and provides qualified staff to manage the facilities, including the maintenance of dental equipment. MCDC receives an enhanced Medicaid dental services rate –through a mechanism created by the State of Michigan and Centers for Medicare and Medicaid Services– allowing for break even operation of the clinics. MCDC offers several programs including the Michigan Community Dental Plan for uninsured patients who are 300% below the Federal poverty line. These patients are charged with reduced fees that cover costs, and receive comprehensive dental services. In addition, the quality of services provided by the clinics is not compromised by this business scheme. The clinics are patient-centered, which is reflected in high patient satisfaction rates of 90% during 2013.

This interesting approach sets a good example for other providers to be able to include underserved populations in their practices. This way, quality dental care that places great emphasis in prevention meets an efficient and productive business model that could be escalated to other communities that have limited access to dental services.

The Built Environment, Environmental Justice and Ferguson/Mike Brown Case

December 10, 2014 by

A few weeks have passed since a jury decided that there should be no indictment of Darren Wilson, the cop who repeatedly shot and killed Mike Brown, a teen in Ferguson Missouri. Following the decision, I found myself explaining the term and real phenomena of environmental justice to my colleagues. After which I went to a class, which focused on the built environment.

These three events that seem so unrelated actually have a lot of overlap and point to a real structural problem in this country. For better understanding I will begin by explaining a few terms.

Environmental Justice is a movement that began in the 1980’s when a predominately black community protested the siting of a PCB(very harmful chemical) landfill in their community. The field evolved as Robert Bullard conducted research noting that most of the landfills (very harmful, toxic places) in the United States were located in primarily black communities. Environmental Justice is defined as the fair treatment and meaningful involvement for all people with regards to planning and polices related to the environment. The goal is to ensure that people live in environments that they feel are safe, nurturing, and productive.

However, environmental injustice, exist in many places in this country. In a community or city with environmental injustice a specific population like poor people or people of color may have an overwhelming burden to environmental pollutants like chemicals in the air water and soil. They may not have access to healthy food. They may not have access to health care and may have features of the community environment which make it unsafe. This compiled burden makes the situation unjust because other communities like predominately white communities may not have this same problem.

From the environmental justice movement came the term the “built environment.” The built environment refers to anything that is man-made– so the buildings we live in, parks in our neighborhoods, the way we design cities, transportation, the types of stores we have in our community, where sidewalks are located and so much more. In poorer and minority communities the built environment is not always conducive for healthy living. Much of this problem, research has shown, is structural, which means that a certain population has been oppressed to the point that it becomes difficult to get out of this hole.

Alongside this burden is administrative oppression, this is where Ferguson comes in. Ferguson is a  primarily black community with primarily white cops—somewhat misplaced representation between the people who “protect” and the civilian population. This is a problem, one which is linked with an unjust environment and with a unconducive built environment.

As a public health professional I hope to bring awareness and change to the barriers that significantly affect specific groups of people. That is what public health is about—helping people have healthier, happier lives, which are not ended by others who suffer no consequence!

#JusticeforMikeBrown #JusticeforALL #PublicHealth #BlackLivesMatter

#Turning a National Negative Into a Personal Positive

University of Michigan students protest against police gun violence

University of Michigan students protest against police gun violence


University of Michigan Students Stand Against Police Violence

University of Michigan Students Stand Against Police Violence


University of Michigan Students participate in Die In

“Hello, World!”

December 8, 2014 by

Hi guys! I’m Anita, a first year Master’s student in the Biostatistics program. I completed my Bachelor’s in Statistics-Mathematics at Rutgers University this past May and came straight here! (Personally, I’m really glad I didn’t take a break after undergrad – it definitely works for some people, but not me – I’d get distracted!) I can’t believe my first semester is almost over. It really does feel like I got here yesterday. And it certainly doesn’t feel like I have to start studying for finals (!!!) soon…

Speaking of school, it’s going well. Classes are challenging, but in a refreshing sort of way and not too much more so than I expected. I honestly feel like I’ve learned more in this first semester than I did during my entire undergraduate career (sorry RU!). There are also lots of schmantastic things about SPH that I love, like some really great places to study in natural light, the Reflection Room for anyone who wants a quiet place to meditate/pray, and the Biostat-kids-only computer lab. I’m sure all three will come in handy during FINALS (!!!!!!!) next week!

But let’s ignore finals for now… I’m super excited to be blogging for SPH! There’s just so much excitement in talking about oneself ;D Already I foresee myself blogging about my mess of hobbies (which includes extreme crafting, my love affair with yoga, marathoning Avatar, crying over the Starks and cooking unnecessarily extravagant meals for myself while dancing), and how I’m trying to balance everything with a full course load, a GSI position, applying for internships and oh yeah, sleep.

Even though I can’t wait to go home to New Jersey for winter break, I think I really do have a big crush on Ann Arbor. It’s a great, energetic city with so many fun, quirky stores that I love (has anyone been to the Robot Repair Store??). Plus, there are so many amazing restaurants, and that makes me happy. I live near Kerrytown, which is close to Central Campus and is less than a 15-minute walk from SPH. There’s also a great Farmer’s Market down the road every Wednesday and Saturday, although I think they’ve stopped doing that now that the weather is so cold. Regardless, I LOVE, LOVE, LOVE our little corner of property. I give it an A+++, highly recommend, would live here again (and I plan to!). Mostly because food, and also I don’t want to move again so soon in general. (But also because it’s awesome.)

Welp, that’s it for now! GOOD LUCK to everyone who is currently studying for exams, writing papers and finishing up final projects! I’ll be sending good vibes and best wishes your way :)

It’s Already December?!

December 4, 2014 by

aparnaCan’t believe that it’s been three months since I started my MPH journey….and can’t believe that I’m almost a quarter of the way through! It’s amazing how time goes by so quickly…

I’ve been away from the blogging world for a bit…it’s been a whirlwind of classes, exams, illness, and of course figuring out The Internship.

Michigan’s internship requirement is one of the reasons that I decided to study International Health Epidemiology. The 16 other students in my cohort and I will be traveling all over the world next summer for our required 10-12 weeks, immersing ourselves in data, data, and more data. Still finalizing the details on my own internship, but it’s been really exciting to hear about all my friends’ plans! It’s going to be a summer of adventure for sure, and I’ll most likely be in India! It’ll have been 6 years since I’ve been back to India and I’m pretty nervous – I’ve never spent time (outside of 2 weeks to volunteer) doing anything besides hanging out with my family there…I haven’t even seen the Taj Mahal yet! Nor have I ever stayed anywhere for more than 7 weeks….so I feel as though it’ll be an exciting journey.

I’ll be back post finals, but if you have any questions at all about Epidemiology, or International Health specifically, feel free to reach out!! Otherwise your thoughts may end up something like this….

epid blog  Source here

Happy Finals Season…err, Happy Holidays? :)


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