Twenty-six centuries ago, a Greek physician urged his medical colleagues to remember that a doctor does “not treat a fever chart [or] a cancerous growth, but a sick human being” who has a life and responsibilities outside of a hospital wing. That level of care — a tenet of the Hippocratic Oath — is already difficult to realize, but Gary Cohen, a travel writer turned healthcare advocate, is pushing medical centers to think even bigger, realizing the connections between a patient’s sickness and its roots in an unhealthy community.
Cohen, one of this year’s recipients of the MacArthur Foundation’s “genius” fellowships, co-founded the global nonprofit Healthcare Without Harm (HWH), which is headquartered in the Washington, D.C. suburb of Reston, Va., in 1996. As the organization campaigned to eradicate toxic chemicals from medical equipment — mercury in thermometers, dioxins in incinerated plastic IV bags and tubes — Cohen argued that healthcare providers shouldn’t be making people sick. After significant victories, Cohen recently decided to broaden the focus of HWH from “do no harm” (another classical dictum) to actively bettering community health. With more than 500 partner organizations in 53 countries, including three of the largest nonprofit hospital systems in the U.S.: Catholic Health Initiatives, Kaiser Permanente and Dignity Health, Cohen’s raison d’être is to help doctors heal their profession.
“When we started, we were trying to get hospitals to take the Hippocratic Oath internally, applying the same set of values to their environmental footprint: to reduce the use of fossil fuels, detox the supply chain, get rid of sugar-sweetened junk food,” Cohen says. “But the bigger questions are, ‘How can you be an anchor for community and planetary health? How can you move from being these cathedrals of chronic disease to being centers of community wellness and sustainability? How can you leverage your incredible moral authority, your mission and economic clout to support healthier communities?'”
Cohen’s first job after college was writing guidebooks for top tourist destinations — London, Paris, New York — until a friend asked if he would write a primer on toxic chemicals. Not knowing anything about the topic, Cohen conducted interviews to learn more. “I sat around kitchen tables with mothers and fathers. They had no political power, no money, no technical expertise, but they were fighting for their family’s lives,” he recalls. “Their kids were sick. ‘Why does my daughter have this rare form of cancer? Why does my son wake up in the middle of the night choking for air? Why does the water taste so bad?’” The political organizing manual Cohen subsequently wrote, “Fighting Toxics,” launched what has turned into a lifelong fight for environmental safety. In 1986, he helped pass the first national right-to-know law, alerting consumers about possible chemical exposure.
A decade later, a report by the U.S. Environmental Protection Agency that warned of on-site medical incinerators (which burn a portion of the 26 pounds of waste generated daily by each patient in a staffed hospital bed) turned Cohen’s attention to hospitals. Incineration removes one biohazard by burning pathogens, but the burning plastic sends other dangerous chemicals into the atmosphere. Tests found dioxin in children’s body fat and traces of mercury in infants’ blood. “The healthcare system is a major polluter,” Cohen says, realizing that, “the very institution devoted to healing people is poisoning them.”
Starting with a team of 28 organizers, Cohen’s advocacy has helped reduce the number of on-site medical waste incinerators in the U.S. from a high of 5,600 to just 70 a decade later. And those hazardous measuring devices containing mercury? HWH’s work has resulted in them, for all practical purposes, being eliminated from hospitals and pharmacies.
What’s unique about HWH’s approach is that these reforms went into effect “without basically any legislation at the federal level,” Cohen says. “We started, you might say, in the basement,” talking with the facility managers and architects. As the cause gained momentum and sustainability worked its way into hospital chains’ strategic priorities, Cohen now has access to meet with vice presidents and CEOs.
Recently, HWH worked with hospitals to reduce their greenhouse gas emissions, convincing medical facilities not only to buy solar panels for hospital rooftops, but also to subsidize them for employees’ homes. The organization has also helped school systems and hospitals partner to generate demand for local, sustainably produced food. And it’s demonstrated that the construction of new hospital wings can strategically promote economic development in poorer parts of a city.
HWH has also been bolstered by President Barack Obama’s signature healthcare legislation, the Affordable Care Act, which requires hospitals to conduct community health needs assessments (essentially tabulating why people come to the emergency room). “What conditions in the community are contributing to diseases? Is there food insecurity? Is there pollution? Is there poor housing, violence and poverty? These are the things that are making people sick in the first place,” Cohen says. He adds that the same principles apply to climate change. After witnessing Hurricane Katrina and Superstorm Sandy, doctors can’t avoid seeing that global warming’s added risk of flooding or extreme heat as essential to their work. “If you’re a person in Cleveland and you think climate change is all about polar bears and melting ice caps, then you’ve got other stuff to worry about. But when you understand that it has to do with [a patient’s] asthma, the spread of West Nile virus or dengue fever, that reality can no longer be ignored. Now I’m paying attention.”
Cohen’s larger hope is that changes in the healthcare profession, which accounts for $2.9 trillion in spending, resonates throughout the broader economy. Because hospitals must prioritize a patient’s wellbeing, they can invest the extra dollars needed to drive innovation and scale greener practices. Once they prove the business model is viable, other corporations might take notice.
If you ask American citizens which profession they trust most, as Gallup has since 1976, doctors and nurses consistently rank among the most honest and ethical. Eighty percent report high trust in nurses; compared to just 7 percent for members of Congress. Cohen believes medical professionals must live up to this respect by watching out for our health — even when we ourselves don’t want to. Not just whether we’re running a high temperature or have a cough, but the broad influences on the health of our cities.
“I will apply, for the benefit of the sick, all measures which are required,” doctors pledge in the Hippocratic Oath. “I remain a member of society,” they add, “with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.” Cohen will be holding them to their word.
Tag: MacArthur Foundation
How Turning Row Homes Into Works of Art Helps Single Mothers
This year’s class of MacArthur Foundation Genius Grants, which includes winning $625,000 with no strings attached, include an impressive offering of scientists, mathematicians and poets. But a Houston artist’s work on a small community — where an art experiment has led to economic revitalization over the last two decades — may be one of the more fascinating programs of note.
Rick Lowe, a Houston artist and recipient of this year’s MacArthur Grant, has been working on Project Row Houses since its inception in 1993. The conceptual project began began with just 22 houses in one of Houston’s oldest African-American communities and has grown to more than 70 buildings across the neighborhood, according to City Lab.
Lowe and a group of artists transformed the area into what he refers to as “social sculpture,” which includes housing for young, single mothers, an arts incubator for budding artists and a community support program. But that’s not all.
Project Row Houses also focuses on architectural and historical preservation, which include some of the 1930-era shotgun homes that comprise part of the properties.
“Houston is not a place that is accustomed to preserving its history. Or having a high cultural identity in its neighborhoods,” Lowe says. “Project Row Houses at least gives Houston an example of how that can happen.”
The Young Mother Residential Program, or subsidized transitional housing for single mothers between the ages of 18 and 26 with children under the age of 17, provides support to find employment and education.
The project launched a separate nonprofit in 2003. The community development corporation is a support center committed to “strengthening, sustaining and celebrating the life of the Third Ward community,” according to the site.
But more than anything, Lowe contends Project Row Houses is first and foremost an art project.
“Project Row Houses is an art project. I always tell people, creating anything, it’s art, especially if it’s something experimental. If it’s new, it’s always hard,” Lowe says. “To bring a painting into being on a blank canvas — if you think about it, that’s impossible. How can that happen?”
The project is also home to an arts incubator and has partnered with the Museum of Fine Arts, Houston, since 2004 to host the Glassell Core Fellow Artist residency. The recipient receives a one or two-year residency while the Summer Studios program exhibits work from selected local college or university art students. The project also serves as an arts venue for other artists.
But how will winning the grant help the thriving community? Lowe isn’t sure, but says that the project will look to food issues next and a possible “little small museum thing we’re playing around with.”
Project Row Houses has informed several other projects across the country including the Watts House Project in Los Angeles, the Transforma Projects in New Orleans and more recently, the Trans.lation: Vickery Meadow in Dallas. Lowe is also heading up the Pearl Street revitalization program in Philadelphia’s North Chinatown neighborhood.
The Death of the Hanging Chad: How to Build a Better Ballot
There were few hotter spots on the political map in 2012 than the state of Ohio. President Barack Obama and Republican Party nominee Mitt Romney visited the swing state no fewer than 83 times combined over the course of the calendar year. And for good reason: Ohio has picked the winning presidential candidate in every election since 1960.
Heading into Election Day, polls showed the president had a narrow edge. On election night, Fox News, among others, called Ohio for Obama, putting him over the top and effectively ending the evening. The veteran Republican operative Karl Rove flipped out. Angry Republicans demanded a recount, arguing that fraud had influenced the result. It could have been a replay of Florida 2000.
But it wasn’t — thanks, in some small measure, to the efforts of a design consultant named Dana Chisnell. She’s the person election bureaus call to create bulletproof ballots, ones that are clear enough and understandable enough to ensure that every vote counts. For the 2012 election, Chisnell had some specific thoughts for Ohio: Simplify the instructions on the ballot, for starters, and put all the candidates in the race in one column — elements that were missing in Ohio in the 2008 election, when many confused constituents ended up voting twice. “I was confident that the ballots were fine this time,” says Chisnell about the 2012 vote. “When I was talking to the TV on election night, I said, ‘I know it’s not the ballots, you can recount all you want.’”
Fixing how a ballot looks seems like it should be a simple task — choose a design, and stick to it — but in fact each state has its own voting culture, with unique laws and customs that influence its balloting. Oregon and Washington have gone to all vote-by-mail systems, while other states favor electronic touch screens or paper optical scan ballots. New York actually reverted to decades-old lever machines after having multiple problems with newer technology. The result: no one-size-fits-all ballot.
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Into this confusion stepped Chisnell. Fourteen years ago, she was living in San Francisco and running a private consulting business, advising firms on how to improve the language and look of their websites by talking to users and testing the results. The year was 2000, and the country was in the throes of its ballot woes.
The infamous butterfly ballot, a staggered two-page layout with candidate names on alternating sides of a central punch-button column, had caused much confusion among Florida voters. Palm Beach County’s election supervisor had made the fateful mistake of enlarging the type on the ballot to accommodate Sunbelt voters’ aging eyes — unwittingly throwing off the alignment in the process. “It was pretty easy to vote for Pat Buchanan instead of Al Gore,” says Chisnell, who observed the saga unfolding on TV. “All the crazy recounts were happening not because of a security problem but because of a basic design problem. People had voted for candidates they didn’t intend to because of the design of the ballots.
Chisnell watched, fascinated by on-the-street interviews with grannies complaining that they felt tricked because the ballot was difficult to use. (She has since learned that about 20 percent of Florida voters were exposed to hard-to-read ballots.) This got her thinking: Aren’t there any professional designers involved in creating ballots? She asked around and none of her peers were. She began to search the Internet for ways she could help.
After checking out various government websites, she came across a five-person Ballot Simplification Committee in San Francisco — “It’s like Iron Chef for editors,” says Chisnell — that was responsible for writing the plain-language descriptions of ballot measures. It took a few years, but she wangled her way onto the committee, obtaining an appointment by the mayor. Chisnell, then 43, was the youngest person in the group by far. “There aren’t that many people who can spend 10 weeks a year working for free on this,” says Chisnell, who served from 2005 to 2009 on the pro bono committee. (Luckily, her day-job clients cut her some slack during exhausting election weeks.)
“Dana was really beneficial to the committee,” says Barbara Carr, management assistant at the San Francisco Department of Elections who served as the clerk on the committee. “She was good at making things clearer without losing the meaning.”
Chisnell resigned from the committee when she moved in 2009 to Boston (for love — she’s getting married this spring), but she’s made ballots an ongoing passion project. She went on to work on the Design for Democracy project — a group dedicated to using design tools to make ballots and voting more understandable; it researched and set forth the best practices for creating printed ballots, optical scan ballots, signs and posters at polling places. But Chisnell realized that getting various state election officials to implement the project’s 300 pages of findings would be tough. What’s more, the Election Assistance Commission in Silver Spring, Md., the major government backer of ballot research, was being gutted; research money was drying up. Chisnell and her colleagues feared that their findings would just sit there, gathering dust.
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One day, in the summer of 2011, after Chisnell had given a speech about the issue at a conference in Portland, Ore., a man approached her — “I had hoped he was a wealthy donor!” says Chisnell — and suggested she do a Kickstarter project to make use of her findings. With his help, she did. Working with colleagues Whitney Quesenbery and Drew Davies, Chisnell came up with the idea of raising money to create tiny field-guide booklets with easy-to-implement, actionable tips — the boiled-down essence of their research. “It was a stroke of genius on Dana’s part to take the big pile of paper and get it down to something cute,” says Quesenbery. “If it’s cute, it can’t be that hard to implement.”
Among her colleagues’ suggestions: Don’t use all upper-case letters, because they’re harder to read. Avoid centered type. Pick one sans serif font instead of many. And use shading and contrast to help voters navigate the different races featured on the ballot. “Simple things have had the most impact,” says Chisnell.
Chisnell launched a successful Kickstarter campaign in April 2012 to fund the creation of the Field Guides to Ensuring Voter Intent series. Her slogan: Democracy is a design problem. She emailed her entire address book, begging family and friends for money and asking them to do the same. With the support of 320 backers, Chisnell raised $20,761, exceeding her goal of $15,000. “The payoff wasn’t really the funding, but meeting a community of people who are really interested in this topic,” says Chisnell.
The Kickstarter campaign also caught the attention of the people at the MacArthur Foundation, which awarded Chisnell and her team of 30 volunteers a $75,000 grant. The money went to the creation, promotion and distribution of eight booklets on topics such as designing usable ballots, writing instructions that voters can easily understand and sprucing up election department websites. The money also financed two more studies on creating more effective county election websites and printed voter education material.
The guides are now in their third printing, with 1,500 sets being used in 43 states and in four Canadian and European provinces. Demand has exceeded supply. Georgia requested one set for every county. So did Ohio. “The measure of success is whether we have fewer spoiled ballots, fewer calls to the call center and fewer recounts,” says Chisnell, who notes that outcomes have been anecdotal. “We do [have all that], although it’s hard to say this is all because of the field guides, but we are pretty confident they’re making a difference.”
Election officials certainly agree. In the fateful 2012 elections in Ohio, Chisnell’s counsel was a godsend. “We took as many of the suggestions as we could from her,” says Matt Masterson, deputy chief of staff for the Ohio secretary of state, who noted that almost all of Chisnell’s ideas involved no additional costs. “She really made the ballot easier to use.” And her ideas worked. “Based on what we saw with the 2012 election undervotes and overvotes, time in the ballot box and general feedback from the boards,” says Masterson, “we have no doubt that the suggestions Dana provided had a positive impact.”
These days, Chisnell is still working to make every vote count. She testified before the Presidential Commission on Election Administration in Pennsylvania and Ohio about using ballot design to improve the election experience, especially in response to the long lines at the polls in 2012. She and Quesenbery have started the Center for Civic Design, which they hope to make into a funded research center. She’s also looking for ways to make multilingual ballots easier to use.
“Dana is one of the entrepreneurs in this field,” says Lawrence Norden, deputy director of the Democracy Program at the Brennan Center for Justice at New York University, who has worked closely with her. “There is a huge need for the work she is doing and not a lot of support for it. She is making change happen through her own will.”
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