cc  >> Jeanan Yasiri: I hope you all  enjoyed a fabulous spring break.  This is a course that is offered  through the University of  Wisconsin School of Human  Ecology.  I'm Jeanan Yasiri.  As we begin today, I'd like to  extend thanks to our partners in  supporting this course, the UW  Office of Corporate Relations,  the UW College of Engineering  for their technical support, and  financial support which is  provided through the Ewing  Marion Kauffman Foundation which  is committed to advancing  academic education in  entrepreneurialism.  Additionally, we'd like to thank  our media partners, Wisconsin  Public Television and their  University Place crew for taping  today's lecture.  I'll begin our presentation  today by saying that a  remarkable thing happened here  in Dane County, Wisconsin at the  turn of this century.  National public health analysts  realized that a most dramatic  decline in the African infant  mortality rate had occurred  here.  It was particularly stunning  because Wisconsin, and this  region as well as others in our  state, had previously  experienced poor results as it  applied to the death rate among  African-American infants.  So the question became,  what happened?  Who contributed to this dramatic  outcome?  And are the answers worthy of  replication in other communities  around the nation?  With that introduction, I'm very  pleased to introduce two special  guests today.  The first, Dr. Thomas Schlenker,  director of Dane County and City  of Madison public health, and  former Madison mayor Paul  Soglin. 

 Dr. Schlenker is a pediatrician  by trade and was a practitioner  in rural medicine in Chiapas,  Mexico, before he received his  Masters in Public Health from  Harvard.  Then he returned to Milwaukee  and public service.  His public work led him to Salt  Lake City, Utah, and then back  to Milwaukee where he was in  hospital practice, and then  Dr. Schlenker became director of  public health for Madison and  Dane County in 2006.  Paul Soglin served six terms as  mayor of Madison.  He was first elected in 1973 and  concluded his public service in  April 1997.  Today Paul remains a community  force as a consultant, and he  also serves as an adjunct  professor here at the UW in the  La Follette School of Public  Affairs.  In Paul's work as mayor, he led  the creation of the Harambee  Center, south Madison's  community-based health  education, healthcare, and  family service center.  And this community partnership  remains a centerpiece of the  growing renaissance in Madison's  south side.  Now I've asked Tom and Paul to  talk with us about the  extraordinary circumstance that  I outlined earlier.  That associated with Dane  County's African American infant  mortality decline between the  years 2000 and 2007 and asked  them to share their perspectives  on the clinical, as well as the  community innovations, that led  to it. 

 We'll begin with Dr. Thomas  Schlenker, please join me in  welcoming him.  (applause)  >> Thomas Schlenker: Thank you,  Jeanan, it's nice to be here.  I actually have three sons  who go to UW.  Not one of them is here today.  But they probably feel they've  heard this many times before and  don't need to do it again.  When Jeanan asked me first to  speak for this course, I didn't  quite make the link or  understand what  entrepreneurialism had to do  with public health.  The Department of Public Health  for Madison Dane County, which  I'm director of, is a component  of local government, of course,  like the Parks Department or the  Fire Department, and any  governmental bureaucracy really  is not known for  entrepreneurship.  In fact, we often find ourselves  standing in the way of it.  So I looked up entrepreneur in  my dictionary, and it said that  an entrepreneur is someone who  sets up a new business.  And that was it. 

 And that seemed very limited to  me and not something that really  would include what I do in  public health, what our health  department does.  So I went to Wikipedia and, of  course, they had a much more  expansive treatment of what it  is to be an entrepreneur.  And they talk, not only about  business, but establishing a new  venture, a new enterprise or  even a new idea that someone  would champion.  And they also talk about the  qualities of recognizing  opportunities and taking risks  and taking responsibility for  outcomes.  They referred to the  entrepreneurial activity of  recognizing a problem or an  opportunity that maybe other  people don't and responding to  it.  Peter Drucker, who's one of the  gurus of organizational change  and quality improvement, talks a  lot about innovation and new  technologies.  And Joseph Schumpeter apparently  coined the praise of  "creative destruction."  Which is evocative of lots of  things.  But then at the bottom of the  page in Wikipedia, they  introduced the concept of the  social entrepreneur which goes  beyond business and really does  seem to include a lot of things  that public health does or at  least could be doing, and the  basis of social  entrepreneurship, according to  Wikipedia, is the creation of  social value.  Not necessarily a business but  anything of social value.  But going back to the original  definition of someone who sets  up a new business, I would pose  a question to you, take that in  kind of a metaphorical meaning,  and at the end of my talk today,  see if you can tell me what is  the new business that we in  public health have set up  through this process that I'm  going to be talking to you  about. 

 Mostly we'll be talking about  infant mortality and infant  mortality rates.  Infant mortality is a way to  measure the health of a  population.  If you regularly go to a doctor,  the doctor is measuring your  health every time you go and can  pretty much tell you whether  you're getting better or you're  getting worse.  But measuring the health of a  population can be very  difficult.  There's really no way to tell if  we cumulatively, as the city of  Madison, have gained more weight  or lost more weight in the past  year.  Or how our blood pressure is  doing.  Or, say, what the general mental  health of the community is.  For example, mental health,  there's no really good direct  measure of that to begin with.  And second of all, if we use an  indirect measure like, say, the  volume of sales of medications  that people use who have mental  health problems, then you have  to wonder, is that because  people's mental health is  actually in better or worse  shape or does that have to do  with marketing?  Or the availability of new  medications?  So it's a complex thing to  measure the health of a  population.  The wonderful thing about the  infant mortality rate is number  one, it's a combination of  deaths of infants, that is any  baby that dies before the 365th  day of his or her life, and live  births. 

 It's very easy to define both of  those.  And they are comprehensively  counted everywhere in the United  States.  It is almost impossible to miss  a birth or to miss a death in  the United States.  So it's a wonderfully  comprehensive and accurate  measure, and it's something that  is done and practiced in a  standardized way throughout all  the country.  And in addition to that, and  this is important, it's  meaningful.  It really has a deep meaning  that is not only about the  health of babies but, like this  slide says, the infant mortality  rate reflects the health of  infants, their mothers, their  families, and the communities in  which they are born, and it's  universally recognized as a key  indicator of the health of  populations.  So this is really kind of a  unique measure that says  something about the entire  community in which we live.  And so therefore it's well worth  studying and knowing and  understanding.  And, as Jeanan referred to, the  issue of black infant mortality  has been a dark cloud hanging  over the United States for the  last couple of decades.  And the problem is, and has  been, that an African American  baby born in the United States,  in general, has a three times  greater chance of dying during  the first year than a white  baby. 

 And that really has not changed  for as long as those statistics  have been kept, which started in  about the 1980s.  And this has been so constant  that it almost came to be  accepted as some natural  occurrence that was immutable.  Part of the natural law of the  way things are.  In fact, there were even many  people who spoke about African  Americans' genetic propensity  towards infant mortality.  That it was something just that  evolutionarily got built into  their genes.  A few years ago there was a  very, very good medical paper  published on infant mortality  called "What Does Genetics  Have To Do With It?"  The authors very, very cleverly  showed that genetics has nothing  to do with it at all.  And the way they did that was  that they looked at recent  immigrants to the United States  from Africa who presumably have  very, very similar genetic  material to African Americans  who presumably migrated 200 or  300 years ago.  And found that these recent  immigrants to the United States  had infant mortality rates that  were just as good as our white  population.  But if you looked at their next  generation after they had  acclimated to whatever it is  that's important in our society,  their infant mortality rates  joined the very high rates that  are prevalent among African  Americans who have been here for  some time.  So that was the problem. 

 And it was a problem that didn't  seem to have any solution and,  worse than that, even any  prospect of change.  But this is basically what  happened in Dane County over the  last couple of decades.  And this is a graph of the data.  So it's a picture that makes it  really easy to see, and it  doesn't have to do with whether  you have a minor in statistics  or you're even a science major.  Anybody can look at this graph  and see what's going on as long  as you understand the parameters  of it.  So the dots represent the annual  infant mortality rates that are  averaged over three-year  periods.  So that's just done to kind of  smooth out the natural variation  in the year-to-year changes.  And the dark blue lines on top,  the broken line is the African  American infant mortality rate  for the entire state of  Wisconsin from 1990 to the year  2009, I guess.  And the solid line is the  African American infant  mortality rate for just Dane  County.  And you can see the vertical  axis there is the rate. 

 And it goes from zero up to 22.  So what that means is that  deaths per thousand live births.  So the average over most of the  1990s, infant mortality rate for  African Americans in both Dane  County and Wisconsin, as a  whole, was around 18, 19, 20,  deaths per thousand live births.  On the bottom, the light blue  lines are the white infant  mortality rates for, again,  Wisconsin and the county of  Dane.  And they are fairly horizontal  but show slight improvement over  the years.  And they're fairly closely  pegged together, averaging five,  six, or so.  So as you can see, in general,  African American rates have been  three times the white rates in  Wisconsin up until about the  year 2000, and then the rates in  Dane County fell off this cliff.  That's very easy to see.  And you can see that over the  last couple years there has been  essentially no difference, no  significant difference between  black and white infant mortality  in Dane County.  Now, this is important even if  you're not in a health related  science because this has never  happened ever in the United  States in its history. 

 And it happened in Dane County.  And as we just heard, it's not  just about the health of babies,  it's about the health of the  entire community.  So this is a very important  event.  But getting back to  entrepreneurship, you have to  look at this and see something  there.  When I came to the health  department in 2006 and I asked  my former head of nursing what  infant mortality rates were like  here, she replied, well, same as  ever, no change.  And I said, well show me the  data.  She said, well I haven't looked  at it lately.  I said, well let's look at it.  So we gathered the data.  And I looked at it and it jumped  out at me. 

 And then I said, well what do  you see here?  And so this was in 2006 so there  would have been a few dots  missing on this graph.  But it was essentially the same.  And she didn't see anything.  She said, yeah, it's about the  same as it's always been.  There's some variation going on  here but it's about the same.  Why didn't she see it?  She didn't see it because she  had totally bought into the  inevitability and the  unchangeability of this  condition that we suffer from.  So I think that is probably the  first step for any endeavor that  becomes entrepreneurial is you  have to see what's in front of  your eyes.  You have to see it first.  And then you have to make sense  of it.  And then, of course, you have to  do something about it. 

 So one of the first things we  did is try to understand the  context of this change.  So this is a change that is very  measurable and very apparent,  but it's occurring in real life,  it's occurring in this community  in which all of us live.  So what's happening in this  community?  And this is Dane County over the  last 20 years.  In 1990, 95% of all babies born  in Dane County were white.  Right now it's about 70%.  And not only that is that our  total population has been  growing very rapidly.  So there's two things.  We live in a community that's  the most rapidly growing  community in Wisconsin and has  been for a number of years,  growing about three percent per  year.  So this is a dynamically growing  community.  That's one important aspect of  it. 

 The other one is it's becoming  more and more diverse.  Now about 30% of all babies born  in Dane County are from one or  another minority ethnic group,  African American, Latino, Asian,  and you can see how that has  risen over the years.  So our community is growing, our  community is diversifying and  changing and within that  context, things are not falling  apart, they're actually getting  better.  And isn't that interesting?  Something to think about.  Also the context for this change  in Dane County, let's put in the  context of the entire world.  We previously saw that the black  infant mortality rate in  Wisconsin since the late 1980s  was equivalent to maybe what you  would find in Africa or Asia or  various third world countries  around the world.  And even the white infant  mortality rate in Wisconsin was  not all that good.  It was about double of Sweden  and Singapore and Japan, the  countries that have the best  infant mortality rates in the  world.  So that's one thing to  understand that even though the  United States is the richest  country in the world, with the  greatest healthcare system in  the world, and more resources  than any other country in the  world, our infant mortality for  all races lags way behind and  especially for African  Americans.  And then within the United  States, and this was a big  surprise to me and to everybody  in public health, when we looked  at this data and found out that  Wisconsin ranks pretty much at  the bottom for black infant  mortality. 

 We're worse than Oklahoma.  We're worse than Mississippi.  It's mind-boggling.  But, in fact, it's true.  And it has been true for some  time.  But no longer for Dane County.  Now, why?  What happened?  We also were able to look at the  data from the rest of the state  and to see that this dramatic  improvement in Dane County did  not happen in Milwaukee, Racine,  Beloit, any of the other areas  where there are significant  concentrations of African  Americans stayed just as bad or  even got worse.  Now what does this mean,  actually, in concrete terms?  It's really much more than a  statistic because if this  improvement in infant mortality  had not occurred in Dane County,  we would be in a much different  situation.  And so because of that for the  five years, 2002 to 2007, 34  babies that would have died  survived.  34 lives. 

 And in addition to those babies,  34 additional babies that would  have been born extremely  premature, were not born  extremely premature, they were  born at term.  And I think most of you probably  know that extremely premature  babies, even if they do survive,  often have a lifetime of medical  problems, learning issues,  mental health problems.  So they often are fairly  severely disabled or just really  held back with a number of  problems.  And, finally, over this period  of five years, because of the  improvement in infant mortality  in Dane County, $7 million in  hospital charges just for the  first year of life for these  children, not their remedial  education, not their medical  bills beyond their first  birthday, was saved.  Over a million dollars a year.  And that's only in one county in  Wisconsin.  And it relates to only a  relatively small population  because our African American  population is not that big to  begin with.  So that really extrapolates into  an enormous number.  So is this a meaningful  occurrence?  Yes, very much so.  So we were very interested in  finding out, and we still are  trying to find out why. 

 The most important thing we did  was we acquired all the birth  and death records in Dane County  over the last 20 years, over a  hundred thousand records and  analyzed them according to all  the variables they contain.  And each birth and death record  contains about a hundred  different variables that pertain  to what we're studying, infant  survival.  And what we found more than  anything else, the prime mover  of infant death is being born  extremely premature.  And by that I mean babies that  are born during the sixth and  seventh month of pregnancy which  means they weigh about a  thousand grams, you can hold  them in the palm of your hand,  their lung development is  extremely undeveloped, and many  of them do not survive.  They go directly from birth into  the newborn intensive care unit,  they have lots and lots of  problems, they have to be on  ventilators, they have to be on  intravenous feeding and  medication.  Many of them live in the  intensive care unit for the  first two or three months of  their lives if they survive and  then graduate with lots and lots  of problems.  So that's what we found though,  that the main driver of infant  mortality are these babies who  are born so prematurely and not  Sudden Infant Death Syndrome,  some of you may have heard of  that, not babies that are not  using car seats and get in car  accidents, not babies who don't  get their baby shots when  they're supposed to and die of  infectious diseases.  Even though all of those things  are very important and very  real, they really are not  significant drivers of infant  death.  Infant death is driven by  extremely premature birth.  And this is the extremely  premature rate for Dane County  over these same years. 

 The blue is African American,  the green is white, and as you  can see, the white rate is  pretty stable and just moves  along at less than one percent  per year.  However, the black rate has  changed tremendously and is  approximating the white rate  which is really a revolutionary  thing.  And, of course, the big question  is why is this happening?  Why can pregnant African  American women now carry their  babies all to term much more  successfully than they could 10  years ago?  What has changed?  And that's something we're still  trying very hard to get to the  bottom of.  But one thing that really stands  out in my mind is another piece  of research that was published a  couple of years ago called  "Place Matters: Variation  in the Black/White Very  Preterm Birth Rate Across  US Metropolitan Areas."  So this is comparing  the rate of extremely  premature births by racial  groups, white, black, and  Hispanic, in 30 or 40 different  metro areas.  And then each bar represents a  different metro area.  So you can see that the average,  and of course the average would  be at the peak of the little  bump there, the average white  and Hispanic infant mortality  rate is about the same.  And so we already knew that.  And that's an especially  interesting thing because  Hispanics are pretty much as  poor and socioeconomically  deprived as blacks in the United  States.  And in addition to that, they  have other problems, challenges  like language and like culture  that they have to deal with,  which is not particularly an  issue with African Americans.  However, their infant mortality  rates are pretty similar to  whites. 

 And that's a separate question  but a fascinating one.  And here you see then that the  average black infant mortality  rate is about three times what  it is for whites.  But we already knew all of that.  So why is this interesting?  The reason this research is  interesting is because of not  the average infant mortality  rate but the variation among all  the metropolitan areas where  these statistics were drawn  from.  So it's the shape of the curve.  And you can see this by looking  at it that the variation among  African Americans is much  broader than it is for either  whites or Hispanics.  So the title of this paper could  be rewritten a little bit.  It could be rewritten,  "Place Matters, But Especially  for African Americans."  It had nothing to say about why  this was happening.  But I think it's clear evidence  that it is happening, that place  does matter.  So what about this place we live  in, Madison. 

 Well, we are very much  interested in the quality of  prenatal care because when we  investigated all of these birth  and death records, a surprising  thing we found is that prenatal  care, and the way that's  measured is the number of visits  to the doctor a pregnant woman  makes during her pregnancy,  there should be at least 10, and  they should begin during the  first trimester of pregnancy.  So any woman who meets that  criteria is considered to have  adequate prenatal care.  So what we found was that the  adequacy of prenatal care didn't  really make much difference.  That the proportion of African  American women who got adequate  prenatal care 10 years ago and  now was not that much different,  but at the same time the infant  mortality rates dropped and the  premature birth rates dropped  precipitously.  And not only that, the intensity  of that prenatal care, in terms  of how many diagnoses were made  and the treatments that were  applied didn't seem to make much  difference either.  And we've just recently looked  at data from Racine, Wisconsin,  and the same thing has happened  there.  There is no connection, obvious  connection, between medical care  and outcome as it relates to  premature birth and infant  mortality.  So what I believe is that maybe  it has something to do with not  how much medical care you give  but how you give it, the quality  of it.  And the interaction between  doctor and nurse and pregnant  woman and their families and all  the rest of the healthcare  system.  But that's just a hypothesis at  this point. 

 The question is, how do you  prove that?  Another thing is community  support.  Now, if you're a pregnant woman,  the best kind of community  support that you can get is to  have Dad around and for Dad  to be supportive.  And then the second best kind of  support you can have is to have  Mom around, your mother I mean.  And so that is the best you can  hope for, and some people  are lucky in that way  and some people are not.  But then beyond the immediate  family, the father and the  immediate family, there's also  maybe your neighbors, maybe your  extended family, maybe your  church, and the community  agencies that try to serve women  and families and children.  And how those agencies are  accessible to you.  Do your needs match what they  have to give?  Do you feel welcome there?  Do you feel invested?  Do those agencies work together  or are they in competition?  Do they help each other or do  they clash?  So community support may be a  key element here.  But again, that is proving  somewhat complicated to  investigate but we're trying.  Another issue is high-risk  interventions.  This is a public health nurse  doing a home visit. 

 Our public health nurses visit  300 or 400 pregnant women in  their homes regularly every  year.  And those are only high-risk  women that are referred to us.  But our nurses, on average, will  visit these women every single  month during their pregnancy,  will be there right after the  baby's born and will continue on  visiting for a few months.  So it's a kind of intensive  intervention for women who are  judged to be at special risk.  So maybe that makes a big  difference.  It's interesting to note that  this service became reimbursable  through Medicaid insurance in  the mid-1990s when the good  trend started to happen.  So who knows, that may have  something to do with it.  But relative to this and  relative to community support  and relative to what happens in  the healthcare system, I want to  mention that we made a video of  people in the community, people  in the healthcare system, people  working for the various  agencies, moms and dads, here in  Dane County to ask them what  their insights into this was.  And that is available on our  website, and I invite anybody  who's interested to take a look  at it.  Our web address is on a leaflet  which I left in the back, these  little brochures. 

 Pick up one if you'd like.  But it's only 23 minutes long,  and if you have an interest in  this, it's really quite  revelatory.  And then, finally, we really  need to think deeply about what  medical care is.  And if it's not the technology,  the machines, the medicines, if  there's something extra that  welcomes people into this  system, that supports them, that  somehow gives them what they  need, gives the pregnant woman  what she needs to carry her baby  all to term, what is that?  And it's fascinating to think  about that.  And one thing that strikes me as  I learned after I moved to  Madison that about around the  year 2000 our local hospitals  and healthcare systems, which  are in competition with each  other and continue to be and  healthcare is a competitive  business, they got together and  decided that they would not  compete in certain areas, and  the first area that they decided  not to compete on were pregnant  women.  And they decided that, you know  what, why don't we try to  cooperate for the good our  community rather than compete  with each other in these areas.  And who knows, that may have had  some difference too.  So that's kind of it.  One last point, there's been a  little twist in this story.  And the twist is that after  these several years of excellent  infant mortality rates, in 2008  the black infant mortality rate  shot back up to about 20 per  thousand, just as bad as it was  10 years ago. 

 And believe me, it is very  upsetting to all of us, and I  wish we could explain it at this  point but we can't yet.  However, I think we're in a much  better position now than we  would have been several years  ago because, number one, we have  an understanding of what goes  into this process of infant  death and infant survival.  And so one of the very first  things we did was look at the  birth records from this same  year, and specifically at the  main driving force of infant  mortality which is extremely  premature births to find out  that there wasn't a significant  change in those in 2008.  So that this caring community  that we're postulating was not  crumbling around us unbeknownst  to us.  In fact, that very important  trend continued despite this  very bad trend in the other  direction for infant mortality  rate.  And we will continue to try to  dig down in that, but at least  we know where we're going right  now.  And we could say pretty quickly  that regardless of what it may  look like, the sky is not  falling, we will figure this  out.  And the other important part is  that we could say with some  confidence, we will figure this  out together because over the  past three years what we've been  doing is building cadre.  We've been building cadre here  in Madison and Dane County of  people who understand this  issue, who care about this  issue, who know the terminology  and can discuss it because, as  you can see, it's a little bit  arcane, a little bit  complicated.  So there are people out there in  the community that we can  engage, and when we start  talking, they will understand  what we're saying, and when they  talk back, we will get it. 

 And we have then this potential  to solve this problem together.  And this cadre includes people  like Jeanan Yasiri and Paul  Soglin and all the people in the  video if you happen to go to  watch the video.  It includes healthcare leaders,  people working in community  agencies, and moms and dads  right in the community, and  they're the ones who care most  about the children and their  survival, and they also, too,  are becoming more and more aware  of this issue.  So with that, one last thing, I  would reiterate the question  that I posed at the beginning of  this, so what business do you  think we set up in this process?  What is that business?  Paul, all yours.  >> Paul Soglin: Am I live?  >> Yasiri: Is your mic on?  >> Soglin: I don't know.  I pushed the magical button they  told me to push.  I think that's on now.  >> Yasiri: Now it is.  >> Soglin: Yeah, that's on.  Okay, thanks. 

 Let's just get right into the  future which is 1989.  When I returned to office in  1989, the city had already spent  a couple of years applying the  teachings of Deming, the  industrial engineer who's noted  for his work with Japanese  industry.  Deming was generally considered  to be the guru in regards to  total quality in terms of  improvement.  One of the departments that was  applying those teachings was our  city public health department.  Coincidently, a former  organizational worker in the  city, Peter Scholtes, who passed  away a year ago, was to move on  and do work in quality in the  private sector, ended up writing  two books, "The Team Handbook"  and "The Leader's Handbook,"  which I'd recommend  both of those to you,  particularly  the leadership handbook.  He was not the only one  influenced by the concept of  quality.  Not only our public health  director, but my predecessor in  the mayor's office, several  other department heads and there  was some wider interest in the  community.  At the time, we were also  looking at some of work of John  McKnight.  Professor McKnight is at  Northwestern University.  He has some different,  challenging views on how to  bring about change in a  community. 

 For one thing, he's best known  for recommending that we be  asset builders.  Instead of looking at the glass  as half empty, he would  recommend that we look at the  full half of the glass and build  our neighborhoods and  communities based on what  skills, talents, and resources  are already there.  I wouldn't say that the work of  Deming and McKnight are perfect,  whether we're talking in the  private sector or in the public  sector or in nonprofits, but  there are very relevant  applications as to how we think  and how we implement programs.  The public health director at  the time, Pat Gadow, and her  staff were looking at the  creation of a new  community-based public health  facility on Madison's south  side.  We already had a couple in the  city but there was an extreme  demand and need on the south  side.  Several of us had the same view:  let's go beyond creating a  traditional public health  facility, and let's work on  something that is going to go  beyond health into the whole  area of building families.  I won't take you through the  process of the first couple of  years of design.  But we brought together a large  number of organizations from the  private sector, nonprofits, as  well as the public sector,  included the main hospitals,  some of the clinic providers, an  organization called Family  Enhancement.  When it was all said and done  after the second facility was  designed, we had close to a  dozen different organizations  working together.  Now, for those of you who are,  well, none of you are old enough  except for maybe two or three of  us, to recall Groucho Marx's  television show  "You Bet Your Life,"  the announcer would come on  and say that there was a  secret word, and if any of the  contestants would mention that  secret word, they'd win a  hundred dollars. 

 The word today is not a secret  and you win nothing except a  better understanding of what  happened.  And that word is collaboration.  But the question that challenges  anyone in regards  to collaboration:  who's collaborating,  whose collaboration is it?  And as we look at the evolution  starting around 1989-1990 when  we went into the planning  stages, you'll see that this was  a challenge because, as  Dr. Schlenker indicated, it  wasn't until the year 2000 that  the three hospitals come  together and say in certain  areas, particularly as it  relates to pregnancy and  infants, we're going to be more  cooperative than we have been in  the past.  What we set about to do then was  to involve all of these  different organizations that  traditionally provided services.  But here's what became key.  And for a moment you should  think about a private business.  Think about a private business  and its mission, its mission to  grow and be profitable and  successful.  And the fact that if that  mission, if that organization  needs a provider, a supplier of  widgets, what do you do if you  don't have any decent widget  makers to supply you in your  endeavor?  Your concept of quality, of  improvement, is going to have to  go beyond the boundaries of your  own plant.  And so what we did in this  endeavor is we brought together  all of these agencies, not just  healthcare providers, and we  broke down some traditional  boundaries.  Initially when we opened up, for  example, initially when we  opened up, the county health  department was not a  participant. 

 Yet we had many parents, many  mothers coming into the facility  who were not city residents  because so much of that south  side area is the town of Madison  whose service provider was the  county health department.  Now, logic says we shouldn't  serve those people.  After all, why should the city  of Madison incur the expense of  providing a service to a  non-city resident when the  county was available?  Of course there's a little  problem with that, which is  accessibility.  If the county resident, the  mother brought her  three-month-old infant in for  some immunizations, we could  give a referral to go to the  county facility or we could  immunize that child right then  and there.  Now what would you do?  How do you evaluate?  What are the externalities?  And externalities is what it's  all about.  If we're going to throw in a  second secret word today with  collaboration it's  externalities.  And so what would happen is that  infant would be immunized.  Now, as the facility grew, it  was more than just a provider of  healthcare.  And this gets to the point that  Dr. Schlenker made which is  maybe it's not, at least in  terms of infant mortality, maybe  it's not a question of prenatal  care in terms of statistically  measuring how frequently it  takes place.  Perhaps it has to do with the  quality and the involvement. 

 And one of the things that was  so critical in terms of the  collaboration was this: the  various organizations that  provided services had to  redefine their mission.  In other words, what was not  necessarily the mission of the  specific organization, but  rather the mission of a  community of organizations  designed to serve a specific  population.  A specific population which  covered about one and a half  square miles on Madison's south  side.  Needless to say, within a matter  of years the entire Madison  metropolitan area was now coming  to Harambee, and then,  subsequently, it covered the  entire county, and we've now got  people coming from as far as 50  to 75 miles away to this one  facility.  As the years went by, a council  of the organizations that made  up Harambee, and by now we're  into close to the year 2000  because in 1995-1996 we started  the planning process and moved  into a facility that was about  10 times larger than the  original facility which is the  site of the Villager Mall which  isn't much a of mall anymore  in a shopping sense but is a  community service facility.  In that period from 1995 to  2000, we now had a very dynamic  relationship between the  nonprofits, the private sector  supporters, and the government  agencies and involvement from  the consumers.  In fact, involvement from the  consumers had been a lynchpin in  this endeavor from the very  beginning.  And if you look at most of the  traditional impediments to  independence, health education,  quality childcare,  transportation, job training,  quality housing, we now had  participants in all of those  areas working together at this  facility.  Now I don't think that anything  is going to happen immediately.  There's going to be a lag time,  which may, in some way, account  for the fact that it took  several years before we found  any results that were  meaningful. 

 I want to point out that in the  last three to four years that  there have been some significant  problems in the operation of the  facility.  Tight budgetary problems have  resulted in a drop in community,  public support.  The commitments from the city  and the county are not as great  as they once were.  In addition, some of the  organizations have found in this  tight economy that their own  resources are dwindling, and  some of the organizations are  more focused on their own  central mission than they are on  the collaborative mission.  The last thing I want to note is  that there's a difference  between availability and  accessibility.  And that this is a question not  just in regards to healthcare  but into so many of these  services.  And, it's my own opinion, that  there are certain biases in our  society that affect outcomes of  the use of facilities.  And here's what I mean.  Something may be available.  That facility, for example,  exists on South Park Street. 

 This classroom is available.  But having access to it, having  knowledge about it, having the  economic resources to get there,  or just as important, having a  comfort level that you are  welcome there and that it is  your facility to use is a  different issue.  That's the distinction between  availability and accessibility.  One of the changes that may have  taken place during this period  of time is a belief that the  facility and its services were  not just available but also  accessible.  I'm not a PI, I'm not a  principal investigator, I'm not  even an unprincipled one, I'm  not in a position here to do any  of the research.  There are some wonderful people  connected here with the  University of Wisconsin that are  doing the research in  collaboration with the Madison  Dane County health department,  and perhaps we will have some  answers in the next couple of  years.  But in the meantime, this is a  rather interesting phenomenon.  I think that it is a result of  adapting certain principles  about how to operate  organizations which came out of  the private sector, came out of  the work of Deming, came out of  the work of John McKnight and  his notions of community  involvement and some very tough,  shall we say, negotiations that  went on to make it possible for  all these organizations to work  together.  So let me conclude with that,  and we're available for your  questions.  (applause)  >> Yasiri: And the students  know that I pass the mic to them  as they, of course, let me know  that they have questions and I  know that they all do. 

 Paul, since you're up there, and  I know Tom is going to be  joining you in just a second,  can you talk just a little bit  about the challenges in creating  a group like Harambee.  You said it was 1997, right?  >> Soglin: 1989.  >> Yasiri: 1989.  Okay, I was going say that 1997  felt like it was too soon or too  recently.  But I'm thinking about it also  in context with some of the work  that you've been doing working  with nonprofits, do you think  that groups are more compelled  to collaborate today given fewer  resources or not so?  >> Soglin: That's an interesting  question.  I don't think that, let's put it  this way, absence of money or  the need of funding is a  profound motivator for anyone.  I'm reminded of that cartoon or  that story in The Onion about a  year or two ago where Taco Bell  took in a roommate to cut down  its overhead, and an  undergraduate moved into the  Taco Bell so they could both  share expenses.  So you've got that as a  motivator, but I don't think  significant change is going to  come simply by economic pressure  on nonprofits or governmental  organizations.  I think the significant change  comes with a rethinking about  how do we fit in terms of  mission.  Again, going back to the notion  that the mission to provide the  finest family in healthcare  services for a community may not  be exactly the same as all of  these nonprofits, as wonderful  as they are, or these public  agencies. 

 And so that there may have to be  a larger umbrella mission for a  community to make this work.  >> My name is Derek.  And I just got a question about  some of your stats here.  Did you guys look at the  population differences in Dane  County itself compared to  Wisconsin?  Because I've been looking at  that line for Wisconsin is  pretty much the same and then  there's a huge drastic change in  Dane County.  So kind of like with crime, if  they focus on a certain area.  Crime might go down in one area  but they spread it across to  different areas of the location  they might be looking at.  So did you guys look at any kind  of population differences?  >> Schlenker: We're  beginning to.  What we chose as an approach was  to compare Madison and Dane  County with Racine for two  reasons.  One, we have the best infant  mortality rates in the state,  they have the worst.  And number two, the total  population of African Americans  in Racine is about the same as  it is for Madison. 

 So it seemed like a good study.  We have just recently acquired  the US census data for 1990 and  for the year 2000 and, as I  think everybody is aware, right  now the federal government is  collecting it for the year 2010,  but it's probably going to be a  couple years before we have  that.  So anyway we've got 1990 and  2000 which kind of brackets a  crucial period here.  So we now, to begin with, are  looking at data based on census  information to compare Madison  and Racine.  Things like income, housing,  family structure, education,  there's really a lot of stuff  there.  And we've just begun but I can  mention a couple things that are  interesting to me.  Some of you might know Racine,  others of you may not.  It's very different than Madison  in many, many different ways.  But it's not just enough to say,  oh, Racine, oh, Madison, they're  different.  That doesn't tell us anything. 

 What we want to know is what are  the key differences.  What are those differences that  are making a difference in  infant mortality.  So one of the things that I  think is not making a difference  is something as crude as  personal income.  Either individual per capita  income or family income.  Because what I can tell you is  that during this period where  infant mortality started to  plunge in Dane County, personal  income among African Americans  rose 70% during that decade from  1990 to the year 2000, it rose  70%.  Now your reaction to that might  be, well, there's your answer.  People's income rose, birth  outcomes improve.  But what if I told you in Racine  personal income among African  Americans over that same period  rose 80%.  And you know what happened to  their infant mortality?  It didn't go down, it went up.  So I think that is too crude a  measurement to tell us what's  going on. 

 Big differences that I do see  between Racine and Madison is,  of course, education, the number  of people that are high school  graduates, the number that  aren't, and also very  interestingly, if I recall  correctly, eight percent of  African Americans in Madison and  Dane County have bachelor or  graduate level degrees.  So these are PhDs and other  college graduates.  In Racine that is less than one  percent.  Now, there aren't enough PhDs  having babies to make a  statistical difference.  But what I'm thinking is, but  what if there's a PhD living  down the block from you and  you're just average person, is  there some kind of an effect, a  community effect, from having  people with a different  perspective on life that are  part of your community?  Could that actually affect your  health?  And that's the kind of thing I'm  thinking about.  >> Soglin: And David Rusk  has done work in this area  on the subject of education,  not health.  And basically what he concludes  is how well your child will do  in school is more determinate by  the income of the children  sitting around your child in the  classroom than anything you do.  >> How you guys doing?  My name is Dareon Cartman.  The statistics and all that  stuff, it looks nice, it's kind  of confusing me though.  But my question is more based on  the Milwaukee area. 

 I know there's a huge, like,  young women in high school get  pregnant in the Milwaukee area,  and that was based on something  like from a couple years ago.  So I may be off.  But do you think that's adding  to the fact that Wisconsin has  the highest infant mortality  rate, is underage kids?  Because in Milwaukee it's  actually one of the highest in  the nation of women being  pregnant, underage pregnancies  in high school.  Do you think that adds to the  number of infant mortality rates  and why Wisconsin is actually  the biggest or one of the  biggest for infant mortality  rates?  >> Schlenker: Yeah, my guess  is that it does.  But I wish we knew more about it  because what I can tell you is  that in Dane County over this  time period that you're looking  at, the teen birth rate among  African American women did not  change much.  And by teen I mean 19 and  younger.  But we looked at it a little bit  more closely, we divided it  between those young girls who  were 17 and under and those who  were 18 and 19.  We divided that.  And we found that, in fact,  among the girls who were 17 and  younger that that rate decreased  35% over this time period.  That those very, very young  girls that are still in high  school or should be in high  school were having babies that  much less than before. 

 But the 18 and 19 year olds kind  of drowned out that statistic.  So to turn around your question,  did that drop in very young  girls having babies contribute  to the infant mortality  improvement in Dane County?  It might have.  But it would be really important  to know what happened during  this same period in Milwaukee.  And you know what?  Nobody knows that.  And they don't know that because  they haven't looked yet.  But that's something that needs  to happen.  >> Hi, my name is Maria.  I was just wondering if you have  found any correlation between  the number of African American  nursing staff and accessibility  to prenatal care for African  Americans?  >> Schlenker: Have not.  Have not found that correlation.  And it probably would be  difficult to measure in such a  small community as ours. 

 But I think that would be very  important to look at in, say,  larger communities that have  larger and more diverse  populations than we do because  you would think there would be a  correlation.  But, on the other hand, maybe  not.  And it's important to establish  those kinds of links, if they  exist.  >> Soglin: Let me point out that  in the first four or five years  of the program that  the healthcare programs  of the individual institutions  did not change significantly.  In other words, the same  programs continued to be  offered.  But there is, evidently, a  difference in the way they were  offered.  And, again, that may be another  of the elements that contributes  in terms of moving from  availability to accessibility.  >> Can you explain that nuance  the way they were offered?  >> Soglin: Well, put it this  way, imagine that you're a  19-year-old pregnant  black woman.  Instead of going to one of the  hospitals, a formidable  institution where you may not  feel that you're welcome or even  if you are, remember perception  is critical here, as opposed to  going to a community-based  facility which now offers the  same health services, may make a  significant difference in the  perception, and then when the  patient gets there, again going  back to this notion of quality,  you're getting more services,  it's not just a checkup.  It's more of the involvement of  family, things of that sort. 

 >> Hi, my name is Beth Ludwig.  I was wondering what steps you  two, as individuals, are taking,  being leaders in this movement,  to inform both the population of  the successes in Dane County and  of the obvious ongoing issue of  the disparity between black and  white mortality rates.  >> Soglin: We've got a couple  groups going.  About a year ago when this data  first came out, there were a  number of us who were no longer  involved.  And we just started meeting.  People say, who are you?  And we say, we're the healthy  baby group.  And we've met sporadically on  and off for the last year or so.  One nice thing that we felt good  about is some UW researchers and  some others were working out at  Allied Drive, basically trying  to provide some health services  there.  And we found out about it, they  came and visited with us.  So some of these people who  helped set this up 20 years ago  exchanged some information. 

 We've been available to the  public health department.  Dr. Schlenker has been there.  His staff has been at some of    these meetings.  And then we've interfaced with  what you're doing.  >> Schlenker: Yeah,  and basically we have  tried everything we can think  of, and we will continue to try  everything we can think of.  We have been open in sharing  this.  I think more so than, say,  academic researchers would be  open about sharing the results  of their research because  they're so incredibly anal about  that.  That's not our job in public  health.  So we've talked about this far  and wide and, in fact, this has  already been covered by the New  York Times, by News Week, it's  had a lot of media play locally  and around the state, and we  look for every opportunity for  that.  And on the other side of that we  are now organizing a series of  neighborhood meetings where  we're going to black churches,  we're going to community centers  and any other grouping that we  can find where there are  interested people who we can  just have a conversation with. 

 Not just to inform them, but  even more important, to learn  from them to find out their  perspective.  I guess I really wasn't  surprised that when we first  started to talk to leaders in  the black community and just  regular moms and dads in the  black community that they had no  clue that anything like this had  happened.  And how could they?  Nobody did.  But we think it's essential that  we do that kind of grassroots  effort also.  >> Hi, I'm Logan.  And Jeanan had us read an  article that seemed to imply  that the Harambee Center  probably seemed to influence the  mortality rate change quite  significantly and that there is  another similar center in I  think it was Washington, DC,  that had the same effect.  So given the success of these  two centers, why is it that  they're not more prevalent in  metropolitan areas around the  country?  >> Schlenker: Good question.  >> Soglin: Why don't  we ask another question  to go with yours, which is, if  it did have success, then why  isn't there even more centers  like that right here in Madison  and Dane County?  And I'm afraid that the answer  is not going to be one that you  like.  For one thing, let me say this  in defense of people not doing  things, the revelation about  this information is relatively  new.  In the window of planning and  developing, it's a short window. 

 Secondly, from an academic and  scientific standpoint, we don't  have definitive proof that there  is a correlation.  That said, if you look at the  traffic that goes in and out of  Harambee on a daily basis, it is  quite obvious, I mean I look at  and I just kind of ask myself,  where would this community be if  we didn't have this facility?  Where would all these families  be receiving not just the health  services, but we've got the  expanded public library, we've  got all these other things going  on.  But I'm also a little fearful  when I look at the budget cuts  that we simply, get the slide  with the 34 infants, I mean look  at this.  This is so important in terms of  the financial impact, even for  those who don't like measuring  the value of services based on  the quality of human life.  At least understand the economic  impact of this.  And I wish I had a better answer  for your question.  >> Schlenker: I would  add that it's not necessarily  the quantity of services  and resources that are  available because we have a  wealth of resources available  here in Madison and Dane County  now.  And we did 10 years ago too.  What Mayor Soglin was talking  about and what many of us feel  is so important is not just kind  of the gross amount but the  collaboration.  And I'll tell you as someone  who's been in my share of  collaborative efforts, that's a  tricky thing. 

 To actually agree to  collaborate, in a sense you're  giving up power to somebody  else, and you may be giving up  turf to somebody else.  And if your primary goal is to  build your own empire, it's  going to be difficult to do  that.  >> Soglin: And that really gets  us to a very important point  in terms of entrepreneurship.  I come from what I call the Tom  Sawyer School of Management.  Does anybody know what I mean by  that?  >> Are you referring to the  story where Tom Sawyer was  supposed to paint the fence  and then he was able to get  everybody else to do it for him?  >> Soglin: Got it.  That's the kind of manager you  want to be.  Get out of doing all the work.  (laughter)  Make everyone convinced  that it's so much fun  and so enjoyable that they will  paint the fence for you.  Look at all the power you're  giving up and look at all the  fun that you're having.  >> Hi, my name is Kaylee. 

 I was just wondering as far as  educating women as far as  getting pregnant or not, like  education as far as prevention  or when they do get pregnant is  there education on how to  prevent all these other things  from happening besides just the  neonatal care?  Have programs been developed at  all?  >> Soglin: Well, there's an  interesting thing about the  collaboration here, and we've  still got some rough edges.  One of the big collaborators in  all of this was Planned  Parenthood.  And another one of the big  collaborators was  St. Mary's Hospital.  And to say that, on questions of  contraception, that they don't  get along is obviously an  understatement.  But one of the successes is that  both of them have been very  active and very good  participants in this effort.  >> Yasiri: Well, I think that  we're going to close  our questions with that.  And the students and I want to  thank both of you very, very  much for being here today.  Paul, we know you're a Badger,  but Tom's being here today makes  him a Badger as well so we thank  you with Badger mugs.  And please join me in thanking  Tom and Paul for being with us.  (applause)