Just Read: Bike sharing: review of evidence on impacts including health and equity

This is an evidence review of the impact of Bike sharing, which is now a generally-loved phenomenon in 800 cities with a fleet of over 900,000 bicycles, including our system in Washington, DC, Capital Bikeshare (@bikeshare). I think loved in DC both because of the application of technology to support a healthier society and availability of open data to the community to study the impacts.

From the perspective of health and equity, this is a worthwhile read. I’ve been a little bit of a student of these issues which I’ve blogged about previously: Photo Friday: What a difference open data plus 5 miles makes in understanding people’s health choices: Capital Bikeshare. It’s nice that some data is emerging.

Here are a few things I learned

  • Equity. Bike sharing is mostly utilized by white, male, affluent, more educated people. I wanted to dig into the gender differences because it is oft quoted that bike sharing is more likely to be used by women compared to bicycling. Part of this is geography in the placement of stations, part is financial hurdles to join and use systems. The equity issue is significant enough that there isn’t enough coverage in this article, just links to studies to learn more. So I’ll learn more (Thanks to Deborah Bey, PhD (@Geekyblkgirl) for providing me with lots of leads, most notably Better Bikeshare (@betterbikeshare).
  • Doesn’t replace car trips that much. From user surveys, bikeshare mostly replaces walking and public transportation. Car trip replacement was reported as 2% in London and 7% in Washington, DC. However, users surveyed about driving habits reported 29-50% less driving, based on the city. This data is from user surveys though, not direct measurement.
  • Environmental impact unclear. The vehicles used to balance bike stations throughout the day can increase motor vehicle usage. That combined with not-enough car trip replacement may increase carbon emissions.
  • Health. This is seemingly favorable, with a link to a good study which I’ll post on separately. There are higher injury rates for women which may make the health benefit less attractive. For older people, the benefits are greater because they are at higher risk for preventable illness. Unfortunately, they are the minority of bikeshare users.

Overall there is now a good basis to dig into deeper questions of (a) how good is bike sharing for communities and (b) is it good for everyone in communities as well as what changes could be made to make it a bigger win. My impression is that public perception is very favorable (who doesn’t want a bikeshare station in front of their place of work 🙂 ), and with promising analyses of health impacts for some, there is great potential.

Here’s another review of this study as well: Have You Heard About That Awesome New Bike-Share Diet? – Next City

Representing Kaiser Permanente’s Green Energy Program at the White House Summit on Climate Change and Health 6/23/15

Renewable Energy Infographic 52943Renewable Energy Infographic, source: Kaiser Permanente Share

As the title of the post says, I will be attending and speaking at the White House Summit on Climate Change and Health tomorrow: Your Health and Our Environment: How Can We Protect Both? | The White House

The event will be livestreamed at the link above.

I’m looking forward to sharing information about Kaiser Permanente’s commitment to green energy: Kaiser Permanente Share | Kaiser Permanente Makes Major Wind and Solar Energy Purchases

Details in the attached infographic. What I’ve learned being a Permanente physician is that there are things that can be done to protect our communities’ health. I’m passionate about this topic because I care about our health system’s ability to heal and not harm, for all humans. Climate change disproportionately affects vulnerable populations and is a powerful social determinant of health.

There’s a hashtag you can use to ask questions: #ActOnClimate. See you tomorrow maybe.

Just Read: S Street Rising: Crack, Murder, and Redemption in D.C.

Ironically, CBS-WUSA-Channel 9 new anchorman Bruce Johnson told me years later that a lot of the media professionals were going through the same issues that I was going through with drinks, drugs, alcohol and women. – Marion Barry, Mayor for Life

This is the story of one of those people, The Washington Post’s Ruben Castaneda (@RCastanedaWP), who was himself addicted to crack while he was covering the crack addiction of Washington, DC.

Drugs that consumed people, not the other way around

Ruben’s book, Barry’s book, and even Janet Mock’s book (see: Just Read: Redefining Realness: My Path to Womanhood – memoir of a young trans woman) portray the lives of 3 different people, in different parts of society, all touched by the cocaine and death epidemic in the late 20th Century. It’s hard to believe they didn’t know each other, they are so connected.

In Castaneda’s and Barry’s case, the very thing they were working to stop they were promoting at the same time. Is it lack of individual control, or is it greater social determinants and community conditions out of a person’s control? What happens when a community already without a strong foundation is flooded with an addictive substance? It didn’t seem to leave anyone untouched, including the President of the United States and the infamous Lafayette Park incident.

The Post had gone into overdrive after the Barry bust . Reporters were assigned to keep an eye on the disgraced mayor or his house around the clock. My colleagues downed coffee to make it through their late-night Barry watches, but when it was my turn, I took a couple of hits of crack . The irony of riding a crack high while conducting surveillance on a mayor who’d been busted for possessing the same substance was lost on me.

Castaneda, Ruben (2014-07-01). S Street Rising: Crack, Murder, and Redemption in D.C. (p. 4). Bloomsbury Publishing. Kindle Edition.

What caused the violence spiral to end? It’s unclear.

S Street slingers

Castaneda takes us through the S-Street Northwest of the 1990’s, destroyed once in the 1968 riots after the assassination of Martin Luther King, Jr., and again by drugs and murder. S Street and 7th is just 1.5 miles away from the White House and downtown Washington, DC. If you visited Washington, DC in your youth (the most common way people seem to experience it), you wouldn’t believe that just a 20 minute walk away from the majesty of our monuments are a people struggling to live. Actually, that’s still the case today, you just walk in a different direction.

The BBC did a great job putting together a show about Ruben’s work and Washington, DC, which is a good summary, as well as heartbreaking.

Since I am an afficionado of all things in the district, I took the time to visit some of the places mentioned in the book, including the most notorious open air drug markets in the city. Some of them are just blocks away from the current Kaiser Permanente Center for Total Health. One of them is adorned with a very large Kaiser Permanente billboard:

Compare the Hanover Place of today to 1984

How did it all end?

I can’t seem to find a good explanation as to how/why the drug wars as they are called ended. Was it because of increased law enforcement? Did the drugs consume enough people that the demand subsdided? Did economic development make a difference? There’s an interesting analysis here from 1999: Cracked up – Salon.com.

Really makes you think about social determinants of health.

The fact is that the murder rate in Washington, DC is down, but it is still significantly higher per capita than New York City, by a factor of 4 (Homicides remain steady in District, Prince George’s – The Washington Post), and we still live in something of a divided city (“New Maps of DC health data – Not yet one culture of health”).

I remember

Just as I once took a wrong turn into Janet Mock’s neighborhood in the early 90’s, I also did a student rotation in Washington, DC in 1995. It was true, walking even 2 feet east of 16th Street Northwest was like walking into a different world. It it is an interesting feeling to walk in the neighborhoods today that were the places that no one would dare go. It’s…. a feeling of respect and honor for our nation’s capital, which is hard to explain.

If you love Washington, DC, or need a reminder of where our cities came from, I highly recommend this book. There’s so many amazing stories about people brought together with little to no hope, in a place that should be overflowing with it.

Neighborhoods that are less comfortable places still exist; it is our challenge today to not wait until they are safe enough for us to spread health.

New Maps of DC health data – Not yet one culture of health

Catching up on social innovation I haven’t yet posted about…

I have complained previously about the fact that data purporting to show Washington, DC’s health status as a county is usually wrong (see: Do national numbers inaccurately represent Washington, DC’s obesity condition? | Ted Eytan, MD – Answer: YES) because DC has 8 wards within it that are not accounted for in the County Health Rankings’ of the world (@CHRankings). This makes these tools less useful in a place like our nation’s capital. What if you live here and love this city and want to make a difference?

Community Commons (@CommunityCommon) to the rescue. Earlier this year they so very nicely agreed to add Washington, DC ward boundaries to their most awesome mapping system , and some key health data points based on DC-level data. They even created a special hub “Center for Total Health” that’s invite only so I can bring community health activists to map their city, collaboratively.

Here’s the obesity map for Washington, DC:

Obesity by Ward, Washington, DC USA 51195

Here’s the smoking status map for Washington, DC by Ward:

Smoking Status by Ward, Washington, DC USA 51194

These are new; previously there was no way to understand DC’s health using an interactive system because all of the data is clumped at the county level. As you can tell from the above, if you see an obesity rate of 21 % for “Washington, DC” you’ll miss important distinctions.

Now, here’s the race / ethnicity map for Washington, DC, available by census tract:

Race/Ethnicity by Tract, US Census 2010, with Ward Boundaries  51203

Do you see a picture of different health status on the left side of the map vs the right side of the map?

Wanna play? Click on either map

The new capabilities provided by Community Commons allow us to map any sub-county level data over ward boundaries so we can understand our city better. I even created a few interactive ones that you can play with here. Just click through, you’ll need to create an account on communitycommons.org to make any changes. Up to you.

While I was at it, I also created a map using DC-data-whiz Michael Schade’s (@mvs202) interactive Google Places map, plotting presence of what Google labels “gyms” in a 4-metro station radius of Shaw/Howard University Station:

Heat Map - Gyms in Washington DC 51193

You can see that gym businesses in the Google places database encircle Dupont Circle (14.4 % obesity rate), with a lot less presence east of Shaw/Howard University Metro (17.4 % obesity rate heading into 35 % obesity rate). These distinctions are important – people who spend their time in the western half of the city may believe they own a culture of health, but it’s only they that do.

I mention Shaw/Howard, because I recently read the excellent book S Street Rising: Crack, Murder, and Redemption in D.C. by Ruben Castaneda (@RCastanedaWP) which has stimulated tons of thinking about how a city creates and loses health. More on that later…

Yesterday, I happened upon a ribbon cutting ceremony by our Mayor (@MayorVinceGray) (who has done incredible things for human rights) in that neighborhood. I asked a bystander if she was here during the riots that destroyed this part of the city in 1968. She said, she was, and it was a scary and sad time. I believe her.

Photos: S Street, 1968 and 2014 – next to Shaw/Howard Street Metro

She told me that her friends told her she should have taken photos of the before and after, because so much had changed. I responded that there were still plenty of photos to take – even though the buildings look new, there’s plenty of “before” to be found, the maps show it.

Thanks a ton, again, to Community Commons for being responsive/interested/supportive and no negative vibes meant to County Health Rankings – we are all friends and the two resources go together in the most useful way. Sometimes you have to go to the places that no one else goes to find and create innovation in health. That’s what social innovators do 🙂 .

If you’d like to do some DC mapping, drop me a line/comment/tweet and I’ll invite you to the hub on Community Commons.


Just Read: Redefining Realness: My Path to Womanhood – memoir of a young trans woman

There have been a lot of great reviews of this bestseller published, mine is a read from the perspective of a physician, trans* ally, supportive of equitable health care for all.

As the title says, this is a memoir of a young woman, Janet Mock (@JanetMock) formerly a staff editor at People.com, now (today) starting her own show at MSNBC – “Shift” (@ShiftMSNBC). I wanted to learn about the journey of a trans woman, and also to celebrate what we call “positive exemplars” – the people who change perception of what a ____ (name your population) is supposed to be. 

“Oh. This is a story of a woman growing up.”

That’s what I said to myself when I finished the book.

Clearly people are going to be interested in the portion of Janet’s life that is about transition, and she does a nice job throughout to convey important information about the social, medical, scientific millieu of being a transgender person. However, she tells the story of a young woman raised in challenging environments, in Honolulu, Dallas, and Oakland:

…plugging people into the “transition” narrative (which I have been subjected to) erases the nuance of experience, the murkiness of identity, and the undeniable influence of race, class, and gender. It’s no coincidence that the genre of memoir from trans people has been dominated by those with access, mainly white trans men and women, and these types of disparities greeted me head-on when I stepped forward publicly.

I was specifically taken by her description of growing up in Oakland, California, when the crack epidemic hit. It describes a drug that consumed people, not the other way around, and is so similar and impressive to a story told a continent away, in Ruben Castaneda’s (@RCastanedaWP) “S Street Rising,” about Washington, DC.

When we talk today about “social determinants of health” and individual behavior, there’s something here that seems a bit beyond what an individual family or person can control:

“How much you pay Charlie?” the man asked John. I had to stop everything inside of me from saying that Dad did not get paid to tend to John’s car. He was no one’s employee; he did it because he was John’s friend and he loved the Caddy as if it were his own. “He loves that car, man,” John said, calming my defenses. I knew he knew my father and appreciated his work. “But,” John continued , “I feel sorry for him, you know. He’s a crackhead. I give him twenty bucks here, another there.” I turned my head toward Dad, who was polishing away at a rim. Beads of sweat ran from his hairline to the lines of his forehead as he bobbed his head to a tune only he could hear. In one instant, Dad was . . . a crackhead.


I vividly remember the routine sight of a baby girl wearing a soiled diaper, playing with an equally dirty doll on her lawn. No parent or sibling in sight. She would just cry and cry and cry. No one asked, “Where’s her mama?” Her wailing became the background vocals to our double-Dutch anthems , kind of like the barely heard baby yelps in Aaliyah’s song “Are You That Somebody?” In addition to the baby girl, I saw stray dogs and crack vials on my way to school. But crack’s reach went beyond those vials we skipped over. When Maddy’s mom, who would beg the boys on the corner for “some stuff,” passed away of AIDS complications, I hugged my friend good-bye: Maddy and Aisha moved to San José to begin a better life with their mother’s sister.

I did a little research on the crack epidemic as part of this – it’s not clear exactly how it ended. Maybe through the actions of people like Janet’s father who moved away from Oakland, or Ruben Castaneda, who was hospitalized by his employer, the Washington Post, it just stopped tearing through people.

I think this woman’s (Janet’s) is important because it’s not about the loving middle class parents who recognize differences and from whence viral videos come from:

To be frank, these stories are best-case scenarios, situations I hope become the norm for every young trans person in our society. But race and class are not usually discussed in these positive media portraits…

Being a woman

There’s a helpful discussion about what it means to be a woman, a trans woman. I have seen people make comments that people who are trans somehow have a responsibility to identify themselves as such.

It is not a woman’s duty to disclose that she’s trans to every person she meets. This is not safe for a myriad of reasons. We must shift the burden of coming out from trans women, and accusing them of hiding or lying, and focus on why it is unsafe for women to be trans.

I agree. In the scope of human relations, why is it important to know someone’s sex at birth, or their sexual orientation before puberty for that matter (which is a different issue than gender, to be clear)? Why not appreciate people for what they are today? It’s hard enough for any person to do that for themselves, we don’t need to make it more difficult.

Getting Health Care

khun krap, Miss Janet,” he thanked me in Thai, reaching for my hands. “I want to thank you for trusting me to help you in this next step of your life. It’s a blessing that I get to make people like you more happy.

It’s amazing to think that an important part of the LGBT population needs to to go Thailand to be treated with compassion by the medical profession. It’s what they call in some circles “reverse innovation” – that the best ideas don’t start in the United States.

Considering the world she grew up in, she seems incredibly fortunate to have found an endocrinologist in Hawaii that listened and prescribed her hormones.

Not all trans people come of age in supportive middle- and upper-middle-class homes, where parents have resources and access to knowledgeable and affordable health care that can cover expensive hormone-blocking medications and necessary surgeries. These best-case scenarios are not the reality for most trans people, regardless of age.

The other thing this population is also forced into is sex work, not by choice, but by poverty, not just to pay for excluded medical care, but to manage a society that discriminates in employment. Janet openly discusses this part of her life. And then, at some point she transitions from a girl to a woman, with an academic degree, a profession, and the ability to achieve her life goals through optimal health. Just like every woman should.

A world away, except that it isn’t

We can read these stories and say to ourselves, “wow, so far away from my experience,” except this distance is based on choices we make.

I reflect on the fact that while Janet’s community was being devastated by crack cocaine, I was receiving an A+ education just a few miles away, at UC Berkeley, in Public Health. The Oakland freeways at the time were a little confusing to me, and a few times I took a wrong turn and probably drove through Janet’s neighborhood in a confused an anxious state, as I looked at the streets on either side of me. The same was true of my existence the following year in Washington, DC – just a few blocks away from neighborhoods spiraling out of control with deadly violence (I’ll post on that next week).

We can say that was a long time ago, except that those parallel worlds still exist today, wherever we are. We have a responsibility to know that they exist, and work to make them less hostile, or we’ll just say in another 20 years, “I had no idea that was going on a few miles away.”

From that perspective I’m grateful for the Janet Mock’s, the Ruby Corado’s (@CasaRubyDC) , and all the people I share a city and community with who are willing to teach so that the people who will come after them will have better lives. Because that’s what Janet says, it’s what Ruby says as well – “you know, I can take this, but the kids coming out deserve better.” They do. 

I was fortunate to see Janet Mock live when she was in Washington, DC when the book was published. She appeared at the Martin Luther King, Jr. Library, with an audience sitting under a mural of MLK’s legacy including the signs of people during the 1968 Memphis sanitation workers strike that said “I AM a Man.”

How appropriate for Janet Mock to be speaking to us about being a woman, then 🙂 . Photos from that event below. Thanks again for changing the way we think about women and providing a helpful resource for people to improve their compassion skills.

Health is more than about medicine, as taught to us by…ApplePay

My first transaction. Just a pair of vanilla cones, easily walked off / not to worry.

The day ApplePay was released to the world, I happened to be with a few close friends from the Innovation Learning Network (@HealthcareILN), in Charlotte, NC. Okay, I actually crashed their dinner – it was with people from Kaiser Permanente Colorado (@KPColorado), Robert Wood Johnson Foundation (@RWJF), HealthPartners (@HealthPartners), Nordstrom (@Nordstrom), and our world famous Innovation Consultancy (@KPInnovation) – who wouldn’t want to crash?

What they probably all remember is the drumbeat of my request to find an establishment where I could try ApplePay for the first time. My first transaction ultimately happened in Washington, DC a few days later, which is probably a better place for me to enjoy such a milestone anyway 🙂 .

I remember Tim Cook introducing ApplePay on September 9, 2014 – in my mind it was presented as mostly convenience and ease – the end of the wallet as we knew it – with a little bit of security added on. I wanted to try it just because of the cool factor, because at some level I am an innovator (shh, don’t tell, I try and portray myself as early majority).

What completely caught me off guard was what happened next.

When one, then two major retailers abruptly disabled support not just for ApplePay, but all contactless payment systems over the weekend, security took center stage. And in the process fairly large banks of good will began to experience significant withdrawals…

I have posted about the bank of good will concept previously: Using social media to build up the Bank of Good Will – Businessweek | Ted Eytan, MD, which is otherwise called “Using your peacetime wisely” to build a trusted following in advance of times of crisis.

In this case one of the companies has built a sizable amount of good will based on the decision to discontinue selling tobacco, and a nice rebrand (@CVSHealth @CVS_Extra). Now, watching the twittersphere light up shows what I’d call a significant erosion of that good will, and interestingly, around the issue of “health” in the broad sense.

If you do search of comments directed at @CVS_Extra today (click here to see a realtime search of tweets directed their way), you’ll see a slight reduction in the simmer, with tweets alternating between carved pumpkins and mild to moderate what I’d call “unhappiness” about the decision to shut off contactless payments for all people, even though they’ve been working in stores for several years now. Obviously turning something off that people once had is worse than never having it in the first place.

Looking at the unhappiness though, shows that people are discounting the health rebrand based on a perceived threat to the health of their financial transactions. In other words, they are making a link between their community’s physical health (improved by making tobacco less available) and their personal financial health (degraded, by making secure transactions less available). You can see it in the tweets, several of which I’ve favorited to demonstrate this.

Link to selected tweets connecting financial health and physical health in the era of ApplePay

As I look deeper there are actually people who appear to have joined Twitter just to make their opinion known. And people who don’t even own the required equipment (Apple iPhone 6) who are unhappy.

The issue of security, as explained by Tim Cook, is that the contactless mechanism of ApplePay keeps information held by the consumer, in the consumer’s hands (or their mobile device) and does not transmit it to the retailer – a one time token is created for the purpose of the purchase. The old-fashioned swipe-your-card method transmits a credit card number to the retailer with all the challenges that ensue from that approach (including free credit monitoring, which most Americans, including myself, now have as a result…).

I’m not going to get into the why the retailers made the decision they did and why a competing system is causing grief (plenty online about that), just thought it’s useful to point out this connection from a health perspective.

Health is about wellbeing and security in all forms, including physical, spiritual, financial, that allow people to achieve their life goals.

As I am fascinatedly watching through the lens of ApplePay and the theatre that is social media, consumers are making it known in 2014 that promoting health means promoting all of it. I assume I’m not the only person seeing this (because I’m not that smart and my ideas aren’t that unique) – let me know your observations in the comments…