Sharon Schmickle on MinnPost

Beyond DNA: Research has Minnesotans looking at how behavior and environment affect lifespans

Sharon Schmickle — Mon, 18 Sep 2017 13:29:25 +0000

Sharon Schmickle

Here’s a new measure of how long you might live: A Minneapolis-based insurance company is looking at saliva, but not for the usual DNA evidence. Instead, the company is looking beyond DNA to epigenetic markers.

The inquiry stems from a relatively new field of scientific research that is promising enough to have prompted major initiatives at the University of Minnesota, the Mayo Clinic and other prominent institutions worldwide.

Epigenetics also is bringing welcome relief to philosophers and theologians who’ve objected that the commonly understood dictates of DNA were far too rigid, that humans are more than mere hardwired products of their genes.

Epigenetics may not be a common word in your insurance office or health clinic. Not yet. But for the Minneapolis company GWG Life, it comes down to an innovative tool for gauging whether a person might beat his or her chronological age and live longer than the life-expectancy charts would suggest. Or, on the darker flip side, die earlier. The company, which buys life insurance policies from seniors, has begun collecting saliva samples and analyzing them for epigenetic markers that could provide indicators of overall health and life expectancy.

The approach is based on research done at University of California, Los Angeles (UCLA) by a biomathematician named Steve Horvath. A 2014 profile in the journal Nature said he has “discovered a strikingly accurate way to measure human ageing through epigenetic signatures.”

GWG Life obtained rights from UCLA for use of technology based on that discovery, and it is working to deploy it as a new tool for life insurance underwriting.

“It’s so novel,” Jon Sabes, GWG’s CEO, said. “We are bringing a real commercial application from a scientific discovery that I think will benefit consumers ... and that’s great. But boy, the underlying science behind epigenetics, how our environment impacts our biology ... it’s just so fascinating. For me that has been the big reward of this adventure.”

What is epigenetics?

Generations of students have drilled on the basics of DNA: Every cell in our bodies contains our master code, the full lineup of the genes we inherited to develop, grow and function for life. The codes in those genes are deployed to carry on the business of bodily life, and the underlying genes don’t change unless a mutation occurs.

Jon Sabes

That’s the simple picture. Now comes epigenetics. It turns out that lifestyle and environment can influence our genes more than was previously thought. Even while the DNA lineup remains hardwired, chemical compounds – often methyl groups — can attach to DNA or its key cellular companions and effectively switch the genes off or on.

University of Minnesota scientists are studying such epigenetic markers as they play into obesity, smoking, cancer, heart disease and other conditions. An overall goal of the various studies is to determine how behavior — such as smoking — and environmental factors — such as air pollution or even stress — can change the effective work of DNA.

Beyond shedding new understanding on the medical conditions, the research could lead to new treatments and medicines that can specifically target epigenetic markers.

New biology

The shift toward examining genes in their environmental context is applauded by many theologians and philosophers for whom biology had become too mechanistic, leaving little room for alternative interpretations of nature and its intricate systems – even, little room for mystery.

“None of this is absolutely new, but I think there has to be a shift that is going on and biology is now more open to a holistic perspective than it was a few decades ago,” said Fraser Watts, past president of the International Society for Science and Religion (ISSR) based in Cambridge, UK.

Fraser Watts

Watts made his remarks at a conference at Oxford University in July sponsored by the Oxford-based Ian Ramsey Centre for Science and Religion and the ISSR. Other speakers, primarily from the U.S. and the UK, expanded on the need to preserve morality, values, religion and meaning in a context where the basic biological elements of life are mapped down to the level of the genome.

Be wary, Watts said, of the deterministic view that human character and behavior are shaped by genes alone; that view distorts the reality of the living world. A more holistic view takes into account the complex relationship between parts and wholes.

“The idea that we have almost got nature sorted out excites some people more than the idea that nature is a mystery that we will never quite understand,” Watts said. “If you get excited by the idea that we’ve almost got nature sorted out, then you’re going to want to exaggerate the extent to which we have got it sorted out.”

Watts cited epigenetics as a prime example of a more complex perspective on the science of life. At its heart is the recognition that in real life DNA interacts with other factors that can effectively switch genes on and off. At least at this point of the research, epigenetics kindles a new awareness of the many secrets of life that are yet to be discovered.

Epigenetic clock

At GWG Life, much mystery remains about the epigenetics of longevity. The model the company is using does not necessarily identify epigenetic markers linked to specific diseases, said Sabes. Instead, it is built on a statistical framework incorporating data about longevity and epigenetic markers across broad population sets.

While many questions remain about the reasons this approach works, the model has withstood numerous challenges, and it has been replicated by other scientists, Nature reported.

GWG Life’s primary business is the secondary market where the company buys policies from seniors who no longer need them. While GWG is collecting and analyzing saliva samples, it doesn’t expect to factor the analysis into insurance policies until early 2018, Sabes said.

“Right now we are collecting and testing,” he said. “And we are working on developing our underwriting algorithm that’s derived from the longevity markers.”

Once the commercial model is ready, GWG’s target customers will be other insurance companies in the primary market, he said.

Ultimately, he said, the epigenetic model should “allow us to be more precise in our underwriting, and we think that’s a big deal, not so much for our business but more so for the primary life insurance industry.”

Reporting for the Oxford conference section of this story was supported in part by the International Society for Science and Religion.

Sabo's budget legacy challenges a key Kasich refrain

Sharon Schmickle — Tue, 15 Mar 2016 14:47:54 +0000

Sharon Schmickle

The many tributes to long-time Minnesota DFL Rep. Martin Olav Sabo, who died Sunday, challenge a recurring refrain from the current Republican presidential campaign.

Ohio Gov. John Kasich has claimed repeatedly that he “led the historic effort to balance the federal budget for the first time in a generation.”

But if history agrees with conventional analysis, it will show that Sabo, not Kasich, led the congressional drive to eliminate deficit spending in the 1990s. Indeed, Kasich actively fought the measures now credited with stopping the red ink.

“In Congress, Martin was reserved, but when he spoke the room went silent because everyone knew something worth hearing was about to be said,” Rep. Betty McCollum, D-Minnesota, said in a statement on Sunday.

Sabo’s chairmanship of the House Budget Committee in the 1990s, she continued, “set the country on a course that resulted in a federal budget surplus that was unfortunately squandered.”

Different styles

Both Sabo and Kasich hit the pinnacles of their congressional careers during the ‘90s when they served as leaders for their respective parties on the House Budget Committee. Covering Congress at the time, I watched them come to stand as icons of the titan clash between Republicans and Democrats over taxing and spending.

Their personal styles were as far apart as their ideological bases. Reflecting his Norwegian roots in the Upper Midwest, Sabo was forceful but restrained, careful not to overstate and unfailingly courteous. In contrast, Kasich bubbled over with loquacious enthusiasm and bold claims for his party’s goal of slashing the size of the federal government, taxes and deficit spending all at the same time.

Both men also could fairly claim the title “deficit hawk.” Who wasn’t one of those creatures at the time of national alarm over a deficit that stood at $290 billion in 1991 and was projected to top $350 billion before the end of the decade? Texas industrialist Ross Perot had spurred the sense of urgency with his independent presidential bid in 1992. (Much of the alarm faded away during the 2000s when deficits soared once again, but that’s another article.)

Where is credit due?

Kasich is correct in saying that the budget did come into balance while he chaired the House Budget Committee in 1997 and actually returned a surplus in 1998.

The debate begins over the question of what led to that achievement.

Most economists look back to three factors that came into play years before 1997, said analysis by the New York Times:

Amid a ferocious 1990 budget battle, then President George H.W. Bush reneged on his “read-my-lips” pledge and agreed to a package of tax increases and spending cuts to begin drawing down the deficit. Sabo voted in favor of that measure; Kasich voted against it. And voters severely punished Bush by denying him a second term.
In 1993, as House Budget Committee chairman, Sabo led a drive to pass then-President Bill Clinton’s budget package, also featuring some tax increases as well as spending cuts. Kasich voted against the bill along with every other Republican in Congress. The Capitol Hill newspaper Roll Call said that on July 28 that year, Kasich predicted, “This plan will not work. If it was to work, then I’d have to become a Democrat.” On August 5, he lectured Sabo and the other Democrats, “Do you know what? This is your package. We will come back here next year and try to help you when this puts the economy in the gutter.” Instead of falling into the gutter, the economy roared, and the deficit dropped.
The economy surged during the 1990s, fed in part by the dot-com bubble. In turn, government revenues also rose.

The backdrop to those three factors was constant sparring between Democrats and Republicans, between Sabo and Kasich, over budget priorities.

Kasich replaces Sabo

After Sabo’s victorious drive to pass the 1993 budget, his Democratic party took a beating in the 1994 mid-term elections, losing its majority hold on the House. Thus, Kasich replaced Sabo as Budget Committee chairman and pushed hard for the pledges set out by then-Rep. Newt Gingrich and other House GOP leaders in a document called the Contract With America. It called for sweeping tax cuts along with deficit reduction.

Martin Olav Sabo

Sabo was diminished in his rank on the Budget Committee, but not in his drive to keep the focus on the deficit reduction side of the equation. When other Democratic leaders decided not to put forth an alternative to the GOP tax cuts, Sabo split off from them and joined forces with a bipartisan effort to delay tax cuts until the budget was balanced. That surprising maneuver drew substantial media attention to his arguments.

At the same time, Sabo broke his pattern of low-key rhetoric to accuse Republicans of offering ideologically driven promises rather than serious efforts to shrink the deficit. Sabo publicly warned Kasich that he ultimately would be judged “by whether you have the capacity to move away from ideology to practical reform.”

Sabo also warned that the Republicans had pledged themselves into a position where they would be unable to pass a bill that Clinton could accept.

Train wreck, punishing pressure, final agreement

The upshot was a partial shutdown of the federal government in 1995, resulting in months of chaos.

Working relentlessly on several fronts, Sabo made a rare appearance on CNN’s Larry King show to needle the Republicans about their tax-cut plan, saying it was “rather strange” to try to balance the budget by going deeper in debt with a tax cut. Sabo also pushed the Clinton White House to back away from tax cuts until the deficit was erased.

Come 1997, when Kasich claims to have led the drive to balance the budget, Sabo kept up the punishing pressure. He led a group of House Democrats that tried to force floor action on the budget by mid-May, long before Kasich and the Republicans could agree on their strategy.

Truth be told, both sides at that point could see that the deficit was approaching zero.

Later in 1997, Kasich and Gingrich negotiated a balanced budget agreement with the Clinton White House.

“But little of it had actually kicked in when the government’s red ink had disappeared and surpluses swelled,” the New York Times said in its analysis.

Civil combatants

Throughout that fractious, prolonged battle, Sabo often attacked Kasich’s goals and tactics but never Kasich himself. And Kasich responded in kind, frequently expressing deep respect for the civility displayed by his foe from Minnesota.

Sabo, characteristically, began a House Budget Committee battle in 1995 by praising Kasich’s political skills.

On May 18 that year, just before the House voted on its preliminary plan, Kasich took the floor to say, “Martin Sabo is as class an act as we can find in public life. He is a wonderful human being. I love Martin because he has fought the good fight, and he's a man of conviction, and a man of courage and a man of principle. He will be a friend of mine forever."

Kasich’s remarks drew a 30-second standing ovation from both sides of the aisle.

Where chronic disease and hunger intersect, Minnesotans are innovating

Sharon Schmickle — Wed, 17 Dec 2014 14:41:00 +0000

Sharon Schmickle

Across Minnesota, thousands of people wait each day for nutritious meals and food-shelf goods to be delivered by car, van, pickup truck – even by snowmobile in remote settings.

Many of those Minnesotans need home or close-to-home food service because they are chronically ill, too sick to shop for groceries – and, sometimes, even too frail to cook for themselves.

And now, that intersection of disease and hunger is turning Minnesota’s food assistance efforts in new directions, particularly in rural areas where the distances between homes and grocery stores can be vast.

“The place where we have been taking aim and focusing our work is where food insecurity overlaps with some of the chronic diseases,” said Rob Zeaske, CEO of Second Harvest Heartland, a food charity serving 59 counties in central Minnesota and Western Wisconsin.

Where hunger meets disease

Among Minnesotans in that region who had been using food banks, 31 percent lived with diabetes in 2014, according to a survey by Second Harvest’s national partner, Feeding America. By comparison, 7 percent of Minnesota adults have been diagnosed with the disease.

Hypertension, another diet-related disease, also was disproportionately high among those seeking food assistance. Further, inadequate diet is a major risk factor in stroke, chronic kidney disease, heart ailments and a long list of other diseases.

The common maxim that good nutrition is basic to good health holds true and is highly relevant for people who already have such diseases, said Pamela Van Zyl York, a nutrition expert who coordinates the program for healthy aging at the Minnesota Department of Health.

Proper nutrition plays into the quality and length of life with a given disease. It is a factor in fending off complications. And it provides the energy the body needs to stay active and fight disease.

Good nutrition also can help prevent the piling of one disease on top of another. Those with diabetes, for example, are at high risk for heart disease, and a proper diet can help reduce that risk.

“If you have one or two or three chronic diseases, you still are at risk for some of the others,” York said. “If you are not getting good nutrition, you put yourself at risk for diseases across the board.”

'Radical change'

Inspired by the body of evidence that good nutrition also is good medicine, food delivery organizations are serving their clients with ever greater medical precision. Food shelves that once dispensed whatever canned goods hit their donation boxes now are finding the means to provide balanced and special diets, and also to distribute fresh produce, milk and quality protein.

Rob Zeaske

“For us, that’s included a radical change in our supply chain,” said Zeaske at Second Harvest Heartland.

“We are approaching this with the idea that food is absolutely medicine for people,” he said. “And when we have neighbors who can’t get healthy food – because they can’t afford it, or for whatever reason – we have a challenge.”

Hunger amid plenty

Ironically, many of those needing food service live in rural areas, close to the Minnesota farms that send an abundance of food across the state and nation – indeed, across the world.

Grocery stores are long gone in small towns where many Minnesotans still live, and the communities struggle to hold onto a last gas-station/convenience store where at least local residents can pick up fresh milk and a few other groceries, said Monica Douglas, a senior director in nutrition services at the Moorhead office of Lutheran Social Service of Minnesota.

The drive to grocery stores in regional centers is just too physically daunting or too expensive for thousands of rural residents, especially those who are battling diabetes, high blood pressure, cancer and other chronic diseases — those whose nutritional needs are the most complicated and the most urgent.

Lutheran Social Service distributes meals to some 20,000 Minnesota seniors living in 39 counties in the state’s western and central regions.

Douglas estimates that one fourth of those getting the meals are chronically ill. Lutheran Social Service works with discharge planners from local hospitals to determine where a low-sodium meal is needed, or food fit for a diabetic diet. Some diners request food that is pureed or softened in some other way. Recently, some have requested gluten-free food.

Closer to home

Thirty-six years ago, when Douglas joined the Lutheran Social Service program, three-fourths of the meals were served at congregate dining centers. But today, as the rural population ages and becomes more prone to chronic illness, the balance has tilted the other way and just over half the meals are delivered to homes.

“Our seniors are aging in place,” Douglas said.

Second Harvest Heartland also has seen a profound shift toward filling needs closer and closer to home rather than at a common location such as a food shelf, Zeaske said.

“Increasingly, we understand with seniors and also with other people who might not have transportation to a central location, we’ve got to figure out how to efficiently get food to them,” he said.

One innovation is mobile food pantries where the traditional food-shelf offerings travel on wheels to neighborhood locations. Another has been to make seasonal produce drops at multiple locations rather than one central site.

The meal must go through

Volunteers for Lutheran Social Service drive the food, usually in their own vehicles along rural roads that can be snow-packed and icy this time of year.

Some deliveries run more than 70 miles round trip, Douglas said. At one site near Lake of the Woods on Minnesota’s border with Canada, heavy snow clogged roads last year, so a volunteer made the delivery on a snowmobile.

“The need for volunteers in those areas is just crucial,” Douglas said.

The volunteers come from churches, local businesses, schools, police stations and senior citizens groups. Collectively, they form a stubborn last stand between their vulnerable neighbors and the hunger that can come with isolation.

“When you get into the rural areas, everybody knows everybody, and they take care of a good neighbor,” Douglas said. “That’s why we are so successful.”

Without the volunteers, Douglas said, the food service would have to be cut by at least a third.

While many of the seniors pay a suggested donation of $4 to $7 for their delivered meals, most of the funding comes from federal programs allocated through state agencies, she said. And budgets have been squeezed in recent years. LSS had to close about 10 percent of its sites a year ago, Douglas said.

“It was a very sad time,” she said.

Millions of meals

Under government programs statewide, providers delivered 1 million meals to seniors’ homes last year and served another 1.7 million at congregate dining sites, said Jean Wood, executive director of the Minnesota Board on Aging, which administers federally funded senior nutrition programs. That service is supplemented by other meal programs run by churches, non-profits and many other non-governmental organizations.

Typically, people use the home delivery service for about two months during transitional times, Wood said. They count on it after a health crisis, for example, or after discharge from a hospital. Medical care coordinators and hospitals often contact the providers to request food services for patients who need them.

As patients recover, “they find something that serves them better,” and transition off the home delivery program, Wood said. Some dining sites have been closed, she said, because they were serving too few people to operate efficiently. And some sites fall short on volunteers to make deliveries.

Other options available to those who need help include home delivery of multiple frozen meals. In cases where someone needs highly specialized meals, yet another option is to award a sum of money that can be used to hire a relative or a neighbor to do the cooking.

Channeling nutrition through health care

Now, organizations that help feed the chronically ill are seeking more direct partnerships with hospitals and clinics.

After all, that’s where many of their clients show up. Several studies have shown that inadequate nutrition goes hand in hand with the chronic conditions that require medical treatment. One study conducted in 2013 for Feeding America and the National Foundation to End Senior Hunger found that seniors lacking reliable adequate nutrition are:

53 percent more likely to report a heart attack
52 percent more likely to develop asthma
40 percent more likely to report an experience of congestive heart failure.

The findings were based on data from the National Health and Nutrition Examination Survey and food security research for the U.S. Department of Agriculture.

In other words, the hospitals and their satellite clinics work precisely at that target intersection where hunger and health come together.

Closing the hunger gap

Hunger in rural Minnesota?

Hunger is an often hidden problem that is affecting seniors, working families and children in rural as well as metro areas. Greater Minnesota makes up half of the population missing meals. Families who live in rural regions face a number of challenges making it difficult to put nutritious food on their tables: transportation obstacles, remote social service agencies and tight employment.

Source: Feeding America Map the Meal Gap 2012

Despite ambitious relief efforts, Minnesota still suffers a hunger gap of some 100 million meals a year, and the gap could be closed by 25 percent if the medical and hunger relief sectors worked together, according to analysis by the Boston Consulting Group for Hunger-Free Minnesota, a coalition that has been working to quantify the nature and extent of hunger in the state. The coalition includes community and food-relief organizations as well as large food processing companies such as Cargill, General Mills and Hormel Foods.

A pioneering effort in that direction took shape four years ago when Hennepin County Medical Center opened what it called a therapeutic food pharmacy, a food shelf in the hospital. The innovation has proved so successful that it has expanded into seven areas of the downtown hospital site and three satellite clinics. In addition to bags full of vegetables, fruit, dried milk and other wholesome foods, patrons get nutrition counseling.

Second Harvest Heartland is a primary supplier to the HCMC food shelf, and Zeaske said variations on that groundbreaking model are in the works. In one project, for example, another hospital is helping to develop a screening tool for food insecurity. Patients found to need assistance will be referred to Second Harvest, which is to triage them to available support programs.

By engaging with food providers, hospitals give their patients a bonus in that the patients can have a “one-stop sort of experience,” said York at the state health department. “They come to a site they are familiar with, and they only have to manage the transportation once,” she said.

Hospitals also can gain more effective and efficient use of dietitians and other nutrition professionals on their staffs. Moving in that direction, some clinics have begun staging farmers markets in their parking lots so that patients can get nutritious produce along with health care.

In general, though, York said, such change hasn’t been widely implemented.

“We haven’t found the system to make it work,” she said.

A dose of courage too

Yet another key benefit comes through engaging hospitals and clinics in the drive to ensure nutritious diets: Those respected institutions remove some of the stigma associated with a need for food assistance.

Much like a bottle of pills, a bag of food becomes something the doctor ordered.

“One of the biggest things that we hear from our neighbors is when they have fallen into challenging times how difficult it is and how much courage it takes to go in and either seek help from a local food shelf or pantry or to seek help from a nutrition program,” Zeaske said.

“We are very wired as Americans to believe that we’ve got to make it on our own,” he said. “We have to let them know that we as a community are there to support them during difficult times.”

MinnPost's late-in-life series is funded through a regrant by Allina Health from the Robina Foundation and is conducted with media partners Ampers and Twin Cities Public Television (tpt), whose documentaries are focusing on Minnesotans enrolled in a multiyear Allina study.

Late-in-life: Innovations focus on care coordination and tailored support

Sharon Schmickle — Mon, 17 Nov 2014 15:14:25 +0000

Sharon Schmickle

Carolyn Brown talks about her heart and meets with her doctor.

Carolyn Brown recalls a day when “doctors were seen as gods.”

“What they said went,” said Brown, of Hopkins, whose failing heart has driven her to see a host of doctors.

Under that traditional view, a medical pantheon presides over patients battling chronic illnesses. In Minnesota, chronically ill patients typically see nine or 10 different doctors a year.

Sure, they can be thankful for that specialized medicine. But too often, these sick and weak patients find themselves lost in logistical hassles and medical confusion as they shuttle from doctor to doctor, striving to make sense of instructions that don’t always connect – and, sometimes, actually conflict.

Now, though, health-care organizations in the Twin Cities and across the nation are testing innovative ideas for helping late-life patients coordinate their complex treatment regimens. At the same time, they are exploring patient-centered alternatives to the old doctor-knows-best model.

The innovators envision care that would include help with practical challenges such as transportation to medical appointments, paperwork and sorting through multiple diagnoses, prescriptions and follow-up instructions. Further, the care would reach beyond the practical to respect patients as individuals with their own life goals, fears and spiritual needs.

'We all need to be seen as people'

“When you tend to people’s real wishes, real goals, they make choices that work better for them and are less costly. They suffer less,” said Dr. Eric Anderson, a specialist in palliative care at Allina Health in the Twin Cities.

“As we age and become ill, we all need to be seen as people,” he said.

Dr. Eric Anderson

Anderson is the principal investigator for an Allina Health initiative called Robina LifeCourse. Launched in 2013, it is one of several efforts under way nationwide to test models for delivering more supportive, whole-person care to seriously ill patients and their families.

For Carolyn Brown, the benefits began with ample time to discuss the subtle signals and serious effects of heart disease with her doctors at an Abbott Northwestern Hospital clinic.

“We talk about anything and everything,” Brown said. “I try to write down what I want to talk about. We discuss that, and then we talk about other stuff.”

Brown has days when she doesn’t feel well enough to go to the clinic. It helps, she said, that LifeCourse sends people to her. She’s had home visits from a care coordinator, a chaplain, a pharmacist, nurses and others.

At age 79, Brown said, “I’m tired ... my body is just pooping out on me.”

When Brown’s energy has lagged, her support team has reached beyond her medical needs to help ease her stress over clearing out multiple storage lockers and disposing of craft supplies, a doll collection and “tons of books.” She’s had help writing a legacy letter to leave for her family and coping with the loss of friends who have died.

Perhaps most important, caregivers have listened to her.

“They are finding out that we have something to say,” Brown said.

The LifeCourse project calls for such teams to partner with more than 300 patients living with dementia, advanced stages of cancer or heart failure. The study is supported by a grant from the Minnesota-based Robina Foundation. In conjunction with this effort, TPT received a grant to make videos of LifeCourse patients and MinnPost received one for general reporting on the subject of late-life care.

Rather than treat patients episodically for different diseases, LifeCourse teams work with individual patients and their families through challenges they face both inside and outside the health-care system. At the center of each team is a nonclinical care guide. The team also works with doctors and other key players at Abbott Northwestern Hospital, Walker Methodist Health Center and Augustana Care.

Lessons in listening

While listening to patients like Brown was an original goal, LifeCourse teams have gained some deep insights about listening.

“Early on, when we started LifeCourse, we assumed that we would sit and get a story from the patient ... as if the story were something that we could put on a piece of paper,” Anderson said.

What they came to realize is that “the process of telling it is as important as the stories,” he said. Rather than pour out all at once, the stories unfold over time in ever new chapters, and the care guides “get a pretty deep understanding of what matters most to people, what thoughts and feelings drive their decisions and behaviors.”

One result is a better ability to help patients communicate their wishes and concerns to doctors, chemotherapy nurses and everyone else involved in their care.

“At the most dramatic end, what you gain is (the ability) to sit down with the patient and have just the right conversation,” Anderson said. “They are able to make the transition to the next level of care, for example, because of the groundwork that the care guide has been able to do.”

Help through a scary phase

When Margaret Stenger, of St. Louis Park, was recruited for LifeCourse, she already had a medical team in place: a trusted personal doctor, an oncologist and the professional networks they brought to treatment of her lung cancer.

LifeCourse added helpful structure by laying out important steps such as completing a medical directive, said Stenger, 58. Those steps can be overwhelming for patients and their families, especially at a time when they are all but paralyzed with fear of what is to come.

“This is scary,” Stenger said. “A lot of people just shut down because it is so scary.”

And the fear can mount unnecessarily for patients who are left on their own to comb the Internet for information about diseases. For Stenger, much of the information was off point because her cancer was not related to smoking but rather to changes in what’s known as the ALK gene.

Margaret Stenger encourages others to research their condition and reach out to others.

“The problem, at least with my type of cancer, is that so many strides have been made in the last three years that a lot of the information on the Internet is not right anymore,” she said. “When you go on these websites, you get some basic information. Some of it is good. Some of it is not.”

Every patient battling serious and chronic illnesses needs a “to get a team in place and work with it,” she said, whether that happens through an initiative like LifeCourse or independently.

But even with the best team, it also is important “that you advocate for yourself,” Stenger emphasized. “If you are not a good advocate for yourself, find one – sister, brother, uncles, aunts,” she said.

A guide for better care

LifeCourse plans call for researchers to measure patient and family reports on quality of life as well as experiences with care, utilization of palliative care and hospice. They also are to track care-team burnout. The results will be used to guide Allina’s continued transformation of its late-life care services and its partnerships with community providers of social services and long-term care.

The researchers expect to publish their findings. For now, Anderson said that “early results around quality of life are encouraging, and cost data are preliminary.”

While care teams spend more time with each patient, they also create opportunities to potentially curb costs – for example by assigning pharmacists to patients in order to reduce side effects from medicines and overlaps in different prescriptions.

Further, they can help patients evaluate aggressive last-ditch treatments. Care for people with chronic diseases accounts for more than 75 percent of national health-care spending, much of it coming near the end of life. In Minnesota, Medicare paid out an average of $36,000 during the last six months of life for each recipient who died in 2010.

Coordination, a high priority

Calls for innovation are coming not from patients alone but also from health-care professionals. They say the medical landscape is dominated by specialists and institutions operating within their own silos and too often failing to share information and coordinate treatments.

Dr. Matthew Press said his work as an internist often involves helping patients navigate that complex system. Press practices at New York-Presbyterian Hospital/Weill Cornell Medical Center. In an article for the New England Journal of Medicine, he provided an “instant replay” of one 70-year-old patient’s experience in treatment for a kidney stone and a mass on his liver.

Over 80 days the patient (identified only as Mr. K.) saw 11 different clinicians and had five procedures. Press communicated with other clinicians 40 times via 32 e-mails and eight phone calls and also communicated with Mr. K or his wife 12 times.

“Care coordination is now a high priority in health care and is the backbone of new models of care ... that aim to improve quality and reduce costs,” Press wrote. “But it remains an abstract concept to many people who are not on the front lines of clinical care, as well as to some on the front lines who lack (or don't want to have) the quarterback's view of the field.”

Press cited two main arguments for such coordination: First, patient safety is at risk because “patients can be harmed when the many moving parts of their care are out of sync.” Second, health care increasingly is delivered and financed across multiple clinical settings where the various players may never see each other.

A new model for coordination in Medicare

One of the biggest players on the late-life landscape is the federal government, through Medicare and Medicaid. Now, it too is testing new approaches to treating patients with multiple chronic conditions.

While Medicare has allowed some payments for care oversight, it has worked for the most part in a traditional system where doctors and various specialists are paid for face-to-face visits.

Under new rules proposed to take effect in January, the government would pay separate monthly fees to doctors who manage a comprehensive care package for Medicare patients with two or more significant chronic conditions. The doctors and/or their staffs are to draft a plan for each patient’s care, watch over medication management and communicate with other health providers who are treating the patients.

Approximately two out of every three Medicare beneficiaries have multiple chronic conditions, according to the U.S. Department of Health and Human Services.

The latest efforts to streamline chronic care management and make it more effective come on top of other innovation projects the federal government is sponsoring in Minnesota and other states.

Expanding ranks of caregivers

Across the country, many public and private organizations are testing other new ideas.

One national project proposes a “Caregiver Corp.” Inspired by the Peace Corps model, innovators at the Michigan-based Altarum Institute have linked with the Caregiver Action Network to push their idea all the way to Capitol Hill.

They call for a national network of locally based volunteers who would be screened and trained to supplement the nonmedical care provided by friends and families – from preparing meals to navigating computers to simply hanging out with patients who crave companionship.

In September, U.S. Sen. Bob Casey, D-Pennsylvania, introduced legislation that would create the Caregiver Corps. Under the bill, those 18 and older who consent to criminal background checks could serve as full-time or part-time volunteers for up to two years. They could directly assist people needing services and also assist informal caregivers, giving them respite from duties that often overwhelm relatives and friends.

Compensation could be provided in the form of stipends, tuition incentives or academic credit. Volunteer hours also could be banked for use against future needs for assistance.

Dr. Joanne Lynn, who directs Altarum’s Center for Elder Care and Advanced Illness, said ideas like the Caregiver Corps and initiatives like the Allina LifeCourse project “can help us figure out how to take a whole series of small steps that will get us where we need to be.”

This series is funded through a regrant by Allina Health from the Robina Foundation. It is conducted in conjunction with media partners Ampers and Twin Cities Public Television (tpt), whose documentaries are focusing on Minnesotans enrolled in the multiyear Allina study involving patients at this time of life.

Late-in-life: As U.S 'spends more and gets less,' the Dutch offer myriad health and social supports

Sharon Schmickle — Thu, 30 Oct 2014 13:11:00 +0000

Sharon Schmickle

This article is part of a yearlong occasional series on late-in-life health care — when chronic illness or a constellation of medical problems can cause a cascade of new needs, complications and worries. The series is funded through a regrant by Allina Health from the Robina Foundation and is conducted with media partners Ampers and Twin Cities Public Television (tpt), whose documentaries are focusing on Minnesotans enrolled in a multiyear Allina study. A new episode, “Meaning & Legacy,” the fourth of six, will premiere Thursday, Oct. 30, at 9:30 p.m. on tpt 2.1.

Courtesy of Jim and Johanna Christenson

Jim and Johanna Christenson are amazed at the level of
support provided to the elderly in the Netherlands.

Imagine these services for someone who wants to live at home while coping with life’s late stages: A neighborhood doctor makes frequent house calls – often by bicycle. The city installs a chair lift on a staircase. A professional team steps in to help with everything from lawn maintenance to house cleaning to grocery shopping.

This is not a fantasy system. It is the reality that Jim and Johanna Christenson of Pelican Rapids, Minnesota, found in the Netherlands where Johanna grew up. The Christensons have travelled frequently to visit her Dutch family and to help relatives who suffered late-life ailments including Alzheimer’s and heart diseases, cancer and the general decline that comes with old age.

Their European relatives routinely were surrounded by support that would be out of reach for American families unless they enjoyed the means to cobble it together on their own. It’s a level of care that is seen in other developed countries as a moral imperative — as the support that any well-to-do, civilized society should extend to the sickest and weakest of its members.

“Let me say I am impressed by Dutch health care,” said Jim Christenson, a U.S. citizen who retired last year and now travels to Europe for extended stays.

“This is the reason I prefer living in the Netherlands,” Christenson said. “The culture is mature and civilized. Nowhere does that shine brighter than in the way the Dutch treat one another.”

Spending more

When disease strikes, Americans benefit from the latest medical innovations — including life-saving devices, cancer drugs and state-of-the-art emergency-room treatments.

They pay for it too.

America spends far more on health care than other developed countries, according to a report by the Kaiser Family Foundation. Measured in sheer dollars, health spending in the United States — $7,598 per person in 2009 — was 48 percent higher than the next highest spending country (Switzerland), and about 90 percent higher than in many other countries that we would consider global competitors, Kaiser reported.

Source: Kaiser Family Foundation

America spends far more on health care than other developed countries.

It would be reasonable to expect that Americans also get better outcomes from their health care systems.

They do not, by several measures.

“Despite this relatively high level of spending, the United States does not appear to achieve substantially better health benchmarks compared to other developed countries,” said Kaiser’s report.

In health indicators, U.S. lags

In fact, the United States lags behind other developed countries in key health indicators. The United States ranks 42nd among countries in the CIA World Factbook’s latest estimates of life expectancy at birth, behind most European and many Asian countries. A baby born this year in Monaco (ranked No. 1) could be expected to live 89.57 years, compared with 84.46 in Japan (No. 3), 81.12 in the Netherlands (No. 22) and 79.56 in the United States.

Further, researchers at the New York-based Commonwealth Fund rank the United States last among 11 developed nations on a range of health-care performance measures. While the United States placed third in the effectiveness of the care that was delivered, it was scored as less efficient, accessible and equitable than the other countries. It also ranked last in healthy living as measured by factors of mortality and life expectancy. (For a deeper discussion of Commonwealth’s 2014 study, see Susan Perry’s report in MinnPost.)

Commonwealth Fund

According to the Commonwealth Fund, the United States ranks last among 11 developed nations on a range of health-care performance measures.

'Spend more, get less' paradox

Given those outcomes, experts in the United States are questioning the nation’s spending priorities. The country pours most of its health-care dollars into last-ditch efforts to save patients who are battling killer diseases. But patients and their caregivers are left largely on their own to struggle with the myriad of day-to-day practical needs posed by chronic illness and multiple medical problems.

In contrast, many other well-off countries place a high priority on providing comprehensive social support for patients and their caregivers as well as personal medical care.

For example, other countries in the Organisation for Economic Co-operation and Development (OECD) provide an average of $2 worth of supportive services for every dollar spent on health care. That is twice the amount the United States spends per health-care dollar, according to analysis of OECD data by Prof. Elizabeth Bradley of the Yale Global Health Leadership Institute.

Increasingly, health-care experts point to that disparity to explain the reasons that the United States lags behind other countries in life expectancy and other key health measures despite its enormous health-care investments.

Bradley and a colleague dubbed the problem America’s “spend more, get less” paradox in an article for the Yale Alumni Magazine in 2011.

“Safe housing, reasonable employment, and proper food supports may be more important for the population’s overall health than specific medical care,” they said.

That’s the reason most other developed countries tightly link health care with nonmedical support for frail individuals – transportation, food, help with chores, etc., said Dr. Joanne Lynn, who directs the Center for Elder Care and Advanced Illness at the Michigan-based Altarum Institute.

“Most countries start with being able to promise their citizens housing and food, but we start with promising costly drugs — and good luck on the housing and food,” Lynn said.

Netherlands: longevity and more

Take the Netherlands. The Yale Global Health study reported that in 2005 the country spent 21.4 percent of its GDP on social services and 12.2 percent on health services. Compare that with the United States, which spent 13.3 percent of GDP on social services and 16 percent on health services.

American writer Russell Shorto described life under the Dutch health and social support systems in an article for the New York Times Magazine in 2009.

Shorto lived in the Netherlands at the time when the country had just revamped its health-care system, coming up with a sophisticated model that is not at all a government-run, cradle-to-grave welfare system. Among other changes, the system was privatized, offering consumers a choice of insurers and plans. But it also was regulated – for example, making it illegal for an insurer to refuse to accept a client or to charge higher premiums based on age or health.

“I’ve found that many differences between the American and Dutch systems are more cultural than anything else,” Shorto said. “The Dutch system has a more old-fashioned, personal feel. Nearly all GPs in the country make house calls to infirm or elderly patients.”

Overall, Shorto said, the Dutch system reflects a state of mind that is different from American attitudes: “People have a matter-of-fact belief not in government — in my experience the Dutch complain about government as frequently as Americans do — but in society.”

Many say that the Dutch take a stronger we-are-all-in-this-together attitude toward life’s major challenges, and that attitude is rooted in the nation’s history of holding back the sea. A flood for one eventually would be a flood for all. So, they’ve had to cooperate over the centuries on maintaining systems of pumps and dikes. And the cooperative model took hold in other aspects of life as well.

Other European countries that stand out in the quality of their late-life care have their own reasons for strong social support systems. It is no coincidence that Sweden and Norway generally top the list, with value systems based on a culture of consensus and social cohesion.

A new 'participation society'

Even close-knit European societies are strained now, though, under the costs of caring for aging populations, especially given the economic turmoil of the past five years.

The Netherlands’ recently inaugurated King Willem-Alexander rocked Europe last year by using the occasion of his first annual appearance before the parliament to deliver a stern warning that the country could not sustain its social welfare system.

The classical welfare state “is slowly but surely evolving into a participation society,” the king said in a speech that was written by the government. He added that “Everyone who is able will be asked to take responsibility for their own lives and immediate surroundings.”

While emphasizing that the Dutch could work together to ensure that no one gets left behind, the king said his vision for a “participation society” was especially needed in the country’s systems of social security and long-term care.

“In those areas in particular, the classical post-war welfare state produced schemes that are unsustainable in their present form and which no longer meet people’s expectations,” he said.

Not surprisingly, the king’s words met strong pushback in the Netherlands and across Europe. It remains to be seen how far Europe’s social support network will shrink in the new mandate for austerity.

Eliminating or reducing services isn’t Europe’s only option. The Dutch king seemed to be calling for more community engagement — for families and neighbors to pitch in and help those in need.

Tough times, tough choices

The Christiansons see change coming in Europe.

But they also question the future for late-life relatives in the United States: Will home health care be available? How quickly would institutional care drain family coffers? Is individual long-term-care insurance worth the cost?

“I hear horror stories,” Jim said.

Even given Europe’s austerity drive, it is easier to trust the future under that system, he said.

“It’s a matter of social sensitivity, maturity and civility,” Jim said. “It seems to me that Europeans care more for their fellow citizens.”

Under the Dutch system, neighborhood doctors frequently made house calls while Johanna’s parents needed care at home. Thanks to a network of public and private programs, the family also was able to get a chair lift on the staircase of her parents’ home as well as a wheelchair and other devices. Warm meals were delivered to the home. Eventually, a support team provided home health care as well as help with household chores, grocery shopping – even, weeding the garden.

Relatives pitched in too. Now the Christiansons expect to do more of that under the Dutch concept of mantelzorg — meaning unpaid, informal care for one another.

“Where we will live when we need care, who will provide it and what it will cost remains to be seen,” Jim said. “Hopefully our Karma Account will be adequately funded.”

Journalists form collaborative international networks to better report world news

Sharon Schmickle — Tue, 02 Sep 2014 13:33:10 +0000

Sharon Schmickle

MinnPost photo by Sharon Schmickle

Tanzanian journalists cover farming issues in Zanzibar.

With a deadline looming, we had a major hole in our report about hunger in Africa.

The missing piece was in Zanzibar, 8,000 miles from my base in Minneapolis. And I was powerless to do anything but worry.

I had recruited five Tanzanian journalists to help cover the stories, and the Des Moines Register was ready to publish our comprehensive report. Everything had to be submitted before mid-October last year when experts from around the world would gather in Des Moines for a dialogue about feeding a growing global population.

But we were missing a video from Josephat Mwanzi, a senior Tanzanian journalist. I had known him for two years and had every reason to trust that he would deliver.

Still, where was the video?

Over coffee in Dar es Salaam in September, Josephat had shown me compelling footage telling the story of Zanzibar’s pathetic rice yields. Farmers, many of them women with children, worked small rice plots by hand only to lose their harvests to drought, worn-out soil and pests. Josephat’s video had captured the farmers’ frustration — their tired voices and worried faces.

Back in Minnesota, I edited other pieces from the Tanzanian journalists.

But where was that video?

Finally, an email from Josephat: “My apologies for my silence. I have been experiencing terrible internet challenges that caused me not to be able to attach and send back an edited copy of the documentary. Yesterday I spent almost the whole day trying to attach it but failed. Today I woke early morning, (and) it took 6 hours to attach successfully.”

Just one of many obstacles

Technical glitches are one of many obstacles hindering journalistic collaboration across national borders and time zones.

Still, global collaboration is more important than ever as news budgets for international reporting shrink at the same time that stories often spill across country lines. Readers, viewers and listeners stand to lose critically important context if journalists cannot find innovative strategies for following far-reaching news.

MinnPost photo by Sharon Schmickle

Students at a school in northern Tanzania have lunch.

In Minnesota, news from across the world quickly becomes local – as West African immigrants worry about the spread of Ebola in their homelands, as Ukrainian Americans rally in downtown Minneapolis against Russian aggression, and as conflict in the Middle East stirs mixed emotions in military families.

“Stories these days are increasingly global, and if you want to do the story properly, you can’t just stop at your own border,” said Gerard Ryle, director of the International Consortium of Investigative Journalists, which links 160 reporters in more than 60 countries.

“With fewer resources the major organizations are going to look to collaborate more – and, as you can prove that this will be successful, it will be repeated,” he predicted.

That is not to say it is easy to reach around the world for partners.

“It’s very, very difficult to do this kind of work, much more difficult than if you were to parachute an American reporter into a foreign country,” Ryle said.

In other words, the collaborative strategy may not be readily available to resource-strapped newsrooms that lack the capability to manage elaborate projects. Like ICIJ, though, organizations are working toward that end. They are experimenting with collaborative models and building international networks – with encouraging results.

Straight talk on ethics

My chance at collaboration came when I agreed last year to help the Pulitzer Center on Crisis Reporting cover food insecurity in Africa, beginning in Tanzania.

In addition to reporting, I was to recruit local journalists – not as fixers or stringers, but as professional partners. Each would contribute pieces adding up to a whole report that would be more ambitious than anything I could do alone.

MinnPost photo by Sharon Schmickle

Women do much of the farm work in Zanzibar.

I turned to journalists I already knew. Much as I respected them, I had to open our partnership on a sensitive note. Journalism ethics differ from country to country, in practice if not in theory. Pulitzer wanted assurances that our team would honor American standards.

In some countries, it is routine for journalists to accept money from sources, often called brown envelope journalism. The controversial practice persists because journalists in many parts of the world work for very low pay.

Nigerian reporter Ameto Akpe, who collaborated on a different Pulitzer project, said she ran a catering business to subsidize her journalism career. Later, as a Nieman Fellow at Harvard University, Akpe said one of her professional goals is to help “African journalists tell the stories they want to tell without worrying where their next meal would come from.”

Whatever the reason, our project could not compromise on ethics. Each of my partners pledged in phone meetings with Pulitzer and in follow-up correspondence to abide by a set of written standards.

They were good sports about it and also about my fact-checking of their finished stories.

The Tanzanian journalists had videotaped interviews, giving us a reference for checking quotes in their written stories. Most of the stories incorporated elements of agricultural research, and we were able to check our findings against scientific reports. I double-checked some points by contacting sources directly.

The key: trust

Establishing trust is crucial, said journalists on every side of collaborative deals.

At Round Earth Media in Minneapolis, Mary Stucky partners American journalists with others around the world. Their teams have produced major reports for top-tier news outlets — about women’s rights in Morocco, for example, for the New York Times, and about Mexico’s drug wars for NPR’s All Things Considered.

Stucky said she combs target countries for journalists who can be trusted to do the work and do it ethically. She looks for graduates of respected journalism schools and collaborators in other programs. She seeks recommendations from in-country editors and journalism professors.

MinnPost photo by Sharon Schmickle

A Tanzanian child has porridge to eat.

Recruits who pass that screening also work under the supervision of senior Round Earth editors before their pieces are submitted for publication or broadcast.

Round Earth’s recruits agreed that trust is a key challenge.

Professional reputations are at stake when reporters collaborate with strangers in other parts of the world, said Marlon Bishop, a New York-based freelancer who covers the arts in Latin America.

“If you are taking the other person’s word that they heard and saw something … that they are truthful and honest in their reporting, then you had better believe in that person 100 percent,” Bishop said.

Still, after collaborating for Round Earth with Mexican journalist Javier Risco, Bishop said, “I would jump at the chance to do it again.”

At ICIJ, editors fact-check stories and require transcripts of interviews as well as copies of documents uncovered in the reporting, Ryle said. The stories go through another round of editorial scrutiny at the media houses where they eventually are published or broadcast.

“Trust is actually the biggest challenge to overcome,” Ryle said.

Same story, different frame

One reward for the effort is the deeply informed perspective that local journalists bring to stories.

The Pulitzer Center set out in 2011 to investigate clean water shortages in West Africa. U.N. agencies and other organizations had spent billions to remedy the problems, yet filthy water continued to kill thousands of toddlers. Were aid organizations following through to maintain sanitation systems?

Pulitzer recruited reporters in five West African countries to look into that question in collaboration with American documentary producer Stephen Sapienza.

Akpe, the Nigerian reporter, welcomed the opportunity. But she looked through her local frame for reasons so many were drinking from dirty streams. Even in the modern capital, Abuja, officials had failed to plan for growth, and development projects had proceeded with no connection to clean-water grids.

“I pitched a story that focused more on corruption and the lack of transparency and planning,” Akpe said.

The African journalists were convincing, said Pulitzer’s Peter Sawyer who coordinated the project.

“They didn’t see western NGOs as the ones responsible for bringing water to their communities,” Sawyer said. “That led to a fundamental shift in the way we told the story.”

Goats, seeds and access

My Tanzanian partners also contributed essential local perspectives.

One of our reports focused on Maasai pastoralists whose grazing lands have been shrinking as development claims once-open savanna. It wasn’t a new story. CNN and others had covered it recently.

I turned to Lukas Kariongi Ole Sanango, a Maasai elder who worked as program director and journalist for ORS Community Radio on Tanzania’s northern plain.

I had visited the ORS newsroom two years earlier. It was a long, dusty drive from Arusha through rutted washouts and gangs of roaming baboons.

If anyone had a fresh angle, it should be Lukas. He didn’t disappoint. With Steve Martin Saning’o, another Maasai journalist, Lukas focused on acacia trees, a fixture on Tanzania’s savanna. Maasai families count on seeds from the trees to feed goats during droughts. Goats draw nourishment from the seeds and continue giving meat and milk to the Maasai.

MinnPost photo by Sharon Schmickle

This Maasai family worried that food would run short.

But private development increasingly blocked Maasai herders from the trees. Further, charcoal producers were cutting the trees.

Lukas and Steve pursued this story with access that no outsider could have gained, revealing in vivid detail the lives of the Maasai herders and capturing the cultural value of their animals.

Indeed, they had too much access for some tastes; one video shows Maasai men practicing the ritual drinking of blood from the carcass of a slaughtered goat. I gasped when I saw it.

What’s a vegetable?

The Tanzanian journalists were cooperative collaborators. But we struggled with language. Most journalists there speak Kiswahili or Maa in their daily dealings even while they are fluent in English.

I helped write video script and edit written pieces for U.S. versions of the stories.

When I edited the word “vegetable” into the Maasai story, Lukas and Steve objected.

“The Maasai don’t eat vegetables,” Lukas said.

I dug in: “I’ve seen them eat corn and beans.”

To them, though, the word “vegetable” meant something green like the spinach that is common in many African cuisines.

The word came out of the story.

Other collaborating journalists also encountered language barriers.

Akpe, of Nigeria, said one of her stories referred to “alligator pepper.” To her surprise, American editors had never heard of the prized African spice.

“Everyone in West Africa would know what it was,” she said.

Struggle to publish

More mismatches came in news judgment. Beyond our four-part series in the Des Moines Register, stories from my work in Tanzania were published in the Washington Post, in MinnPost.com, and on Pulitzer’s website.

We had planned for the Tanzanian journalists to publish locally too.

That strategy worked for Samson Kamalamo of Dar es Salaam, who covered attempts to thwart the weevils that routinely destroy half of Tanzania’s bean harvest. Samson published a Kiswahili-language version of his story in Changamoto, a newspaper where he was deputy managing editor.

Other journalists struggled, though, to find local outlets for their stories, as did other non-American journalists on collaborative teams.

“One of the biggest challenges was trying to get the Mexican media interested in the same stories we had planned for an international audience,” said Isabella Cota, who covers Central America and the Caribbean for Bloomberg News. She collaborated with American freelancer Annie Murphy on the Round Earth project covering effects of drug wars in Mexico.

It took months of pushing Mexican connections, Cota said.

In Nigeria, Akpe hit the same resistance to the clean water stories.

“Water and sanitation were not hot topics, so there was a challenge in getting your editor to give the OK,” Akpe said.

Worth the effort?

Still, the journalists said the experience was worth the struggle.

“There are a lot of journalists who want to collaborate on projects like these,” Cota said. “It’s just a matter of finding us. ... I hope this collaboration model takes off.”

For the model to take hold in a broad sense, though, newsrooms across the country would need ready access to networks of proven journalists akin to ICIJ’s network. Beyond sweeping investigative reports, ICIJ members use their network connections informally, Ryle said.

“You will find a reporter from Brazil picking up the phone or emailing someone in Sweden,” he said. “They are using the network for all kinds of smaller projects, not just for the big, cross-border stuff.”

Reports from the Tanzanian project can be seen at the Pulitzer Center's website. Tanzanian journalists who collaborated with the project are featured in the MinnPost videos embedded in this story.

Late-in-life health care: Initiatives aim to cut costs while increasing quality

Sharon Schmickle — Mon, 04 Aug 2014 13:10:00 +0000

Sharon Schmickle

A medical bill is a shocker, even for those with insurance coverage. An emergency-room visit with multiple tests can cost as much as a car. Major surgery? Think mortgage-sized sums.

The sobering reality that Americans could collectively go broke paying such bills for an aging nation has ignited challenges to traditional ways of financing health care.

Dr. Lee Newcomer

“You are going to see by the end of this decade a significant change,” said Dr. Lee Newcomer, senior vice president of oncology at Minnetonka-based UnitedHealthcare.

But the change will come gradually, he stressed: “You won’t see it next week.”

Few patients have a higher stake in the transformation than those who are late in life — when treatments for chronic conditions pile up, and so do associated costs. By far, these patients account for the greatest share of health care expenditures and also the most widespread need for quality care.

Visit the website of any institution involved with health care financing and you find ideas for revamping the system. Some ideas are controversial in medical circles; some may fail; some show promise.

Two recently reported initiatives help illustrate the nature of the drive for change:

A new cancer-care payment model erased incentives for oncologists to boost their incomes by prescribing drugs. The three-year study, conducted by UnitedHealthcare and five oncology groups, resulted in significant savings with no loss of quality in the care, researchers reported in the July issue of the Journal of Oncology Practice. Rather than collecting income from drug sales, doctors received a “bundled” payment based on the expected cost of a standard treatment regimen.
Minnesota saved $10.5 million during the past year in treatment costs for 100,000 low-income patients by partnering with hospitals and other providers to cut costs while preserving or improving quality of care. The state is one of the first in the nation to test the Integrated Health Partnerships initiative. Providers who met certain conditions during the first year were entitled to a share of the savings.

Unsustainable trajectory

U.S. health care spending has consumed an increasing share of the nation’s economic activity, according to the Kaiser Family Foundation. In 2010 the country spent $8,402 per person on health care for a total of $2.6 trillion, which was 17.9 percent of GDP. Back in 1960, it spent 5.2 percent of GDP on health care.

The rate of growth in national health spending has slowed in recent years. But experts inside and outside the health care system warn that aging baby boomers will push costs higher.

“Unfortunately the rising cost of health care in the United States is on an unsustainable trajectory,” Newcomer wrote in a commentary in the May Journal of Oncology Practice. He also co-authored the separate bundled-payment report.

“Payment models that reward cost-effective and high quality care are desperately needed,” Newcomer wrote.

Cancer therapy, in particular, accounts for about 11 percent of the total health care budget, and it is the most rapidly growing segment of health care. In Minnesota, cancer is the leading cause of death, followed by heart disease and stroke.

Overall care for people with such chronic diseases accounts for more than 75 percent of health-care spending, according to the Dartmouth Atlas of Health Care, which analyzes Medicare reimbursements. Americans with five or more chronic conditions represent a disproportionate share of that cost. In 2005, they represented 23 percent of Medicare beneficiaries and 68 percent of Medicare spending.

The costs rise dramatically as diseases progress toward death, the Dartmouth Atlas reports. In Minnesota, Medicare paid out an average of $70,000 during the last two years of life for people who died in 2010. More than half that payout, $36,000, came during the last six months of life when the typical patient was treated by nine different doctors.

Fee for (too much?) service

Under the traditional fee-for-service model, doctors, hospitals and other providers collect a fee for each visit, test, prescription and treatment.

That model is under critical review for several reasons:

It does not necessarily consider the quality of the care. Fees are charged regardless of the outcome.
As long as providers’ incomes depend on the fees, there is a financial incentive to pile on more services whether or not they are needed.
It does little to manage care across multiple providers and settings, leaving patients facing confusing arrays of doctors and choices.
Costs have skyrocketed, even after insurers and employers offering group coverage have tried managed care plans and other strategies.

Bundling payments

Now, alternatives to fee-for-service are rolling out on several fronts. Some build on bundled payment schemes in which doctors and other providers get lump sums for treating particular episodes such as a diagnosis of cancer. They come out ahead financially if they avoid unnecessary tests, hospitalizations, etc.

In the UnitedHealthcare study, oncologists got a single payment at initial visits with 810 patients who had been diagnosed with breast, colon or lung cancer. The payment was the same regardless of the drugs administered to the patients; in other words, the oncologists’ incomes were separated from drug sales. Other aspects of the care – patient visits, for example – were reimbursed under the usual fee-for-service arrangement.

Researchers, who used more than 60 measures of quality and cost to evaluate the results, reported that no quality of care was lost during the course of the treatment, which typically lasted six to 12 months.

More chemotherapy, fewer hospitalizations

What changed dramatically was the overall cost of the care. It dropped by 34 percent compared with a control group, the researchers reported. Unexpectedly, the savings did not come from chemotherapy drugs. That cost rose. Instead, money was saved primarily because the patients weren’t hospitalized as frequently and they received less radiation therapy.

The upshot was better treatment for patients, Newcomer said in an interview. The doctors spotted symptoms and side effects more quickly and treated those problems early enough to avoid the need for hospitalizations.

Another benefit for late-life patients whose cancer had returned and spread, he said, was that doctors had more incentives to work with the patients through a range of options, including the option to stop treatment.

“In fee-for-service, the only way that the oncologist is able to make any money taking care of those patients is to treat them,” Newcomer said.

In the study, doctors “had the opportunity to sit down and have that long discussion with the patient, to talk through the pros and cons (of various choices),” Newcomer said. “They were not penalized if they decided not to treat. And they were not penalized if they decided to treat.”

But what if doctors simply took the money and didn’t spend that extra time with the patients? The study was designed with numerous checks against that potential, he said, and the participating doctors had volunteered because they were motivated to “find a better way.”

Shared savings

Confronted with health and human service cost increases of 8.5 percent a year, Minnesota in early 2013 launched its version of a national initiative called Integrated Health Partnerships. State health officials partnered with six health care providers to test a new payment model featuring financial incentives for reducing the cost of care for Minnesotans on Medicaid.

Each year, the total expense would be compared to mutually-agreed-upon targets for cost and quality. If targets were met, any “shared savings” would be divided between providers and the state. In later years, providers and the state would share any losses as well if costs proved to be higher than projected.

The intent was to move away from a system that paid providers based on the volume of care they delivered rather than the quality of the care. The initiative is one of several state moves toward that goal since a health reform law was enacted in 2008. For example, the state implemented a “pay-for-performance” program that offers cash awards to doctors and nurses who achieve specified clinical results in treatment of diabetes and cardiovascular disease.

In this latest initiative, state officials estimated that the new payment system would save Minnesota’s Medicaid program some $90 million over three years while encouraging providers to innovate in care delivery and also to set realistic goals for improving the cost and quality of care.

“This new payment system will deliver better health care at a better price,” Gov. Mark Dayton said at the time. “By changing the way we pay health care providers we can incentivize reform, help Minnesotans live healthier lives, and slow the rising cost of health care in our state.”

The six health care providers initially participating were: Children’s Hospitals and Clinics of Minnesota, Essentia Health, CentraCare Health System, North Memorial Health Care, Federally Qualified Health Center Urban Health Network (FUHN), and Northwest Metro Alliance. Together, they served more than 100,000 Minnesotans enrolled in publicly funded programs.

In July this year, state officials announced that the program had yielded $10.5 million in savings during its first year. Three more providers also had signed up with more yet planning to join in 2015.

Innovations that helped realize the savings included:

High-risk patients served by North Memorial got home visits from paramedics who helped avoid emergency-room visits by providing care in coordination with doctors’ offices and clinics.
At Children’s Hospitals and Clinics, families with children who had complex, high-risk needs were matched with expert care coordinators. Children’s also extended evening hours at its St. Paul clinic, making it easier for families to get care but avoid the emergency room.
Northwest Metro Alliance, a partnership between Allina Health and HealthPartners, opened urgent-care sites with evening and weekend hours. Pharmacists follow up with patients who hadn’t picked up medications for chronic conditions. Obesity among children was addressed, and case-management services were established for hundreds of patients with complex conditions.

Still skeptical

Even while innovative payment models roll out, various players in the health care system remain skeptical.

Some worry that well-intentioned plans ultimately will fail. Doctors involved in high-profile studies may be eager to deliver quality care, but will the quality stand up over time and widespread practice?

Another worry is that patients’ individual wishes will be lost in large integrated financing schemes. As program managers set measurable standards for quality treatment, will they lead to care that patients actually want?

Yet another worry is that doctors and clinics pressed financially to meet outcome benchmarks will reject high-risk patients who could bring down their performance numbers. Will benchmarks be designed with enough sophistication to neutralize this scenario?

Meanwhile, many experts argue that health care institutions have a long way to go in other reforms that could curb costs and improve care – reforms such as efficiently sharing patients’ records and coordinating patients’ needs for social services in tandem with health care. (See the first article in this series.)

'We have to figure this out'

What isn’t disputed is the urgency of the need to contain costs before baby boomers reach late-in-life status.

“When we double the number of frail old people as all of us boomers grow old together, we have to figure this out,” said JoAnne Lynn, director of the Center for Elder Care and Advanced Illness at Altarum Institute. “Otherwise we will either so hobble the country that we can’t do other important things, or we will learn to walk away from real need in old age.”

This series is funded through a regrant by Allina Health from the Robina Foundation. It is conducted in conjunction with media partners Ampers andTwin Cities Public Television (tpt), whose documentaries (click on "Archive" on the linked web page) are focusing on Minnesotans enrolled in a multiyear Allina study involving patients at this time of life.

Minnesota's 'health care homes' aim to fill gaps in support for late-in-life patients

Sharon Schmickle — Wed, 19 Mar 2014 13:14:00 +0000

Sharon Schmickle

Lake Superior Community Health Center via Facebook

Minnesota's certified health care homes, like the Lake Superior Community Health Center in Duluth, aim to improve quality of life as well as health for patients with chronic and complex conditions.

This is the second article in an occasional series on late-in-life health care — when chronic illness or a constellation of medical problems can cause a cascade of new needs, complications and worries. This series is funded through a regrant by Allina Health from the Robina Foundation.

As the giant boomer cohort of Americans begins to reach senior status, neither individuals nor the disparate components of the U.S. medical system have fully prepared for a new reality: People can expect to live far longer than their forebears. And as they age, patients frequently will need years of coordinated care and support services before they enter the end stage of life. Yet disproportionate amounts of spending go for desperate treatments at the very end.

For example, for the average patient who died in Minnesota in 2010, more than half of the Medicare money paid out in the last two years of life was spent in the final six months.

In surveys, the vast majority of patients say they would prefer to avoid hospitalization and intensive care during the terminal phase of illness. But when doctors offer options, patients generally opt to pursue all chances for cures.

In a system where intensive medical interventions are the main options offered, it is human nature to grab for those lifelines, said Dr. Robert Kane, who directs the Center on Aging at the University of Minnesota.

“People — and Americans, particularly — are not very good at making wise decisions at the margin,” Kane said. “They tend to want whatever they can get. ... In America, if you can pay for it, you can have it.”

“In some cases you could say that’s bad social policy because we are doing a lot of stuff that doesn’t really make good sense,” Kane said. “But it may be bad personal policy as well because they are basically putting the rest of their life at risk to live in a miserable situation in order to gain very little.”

As a result, Kane said, “we spend a fair amount of effort in this country dealing with problems where the benefit does not necessarily outweigh the harm; we put people through very expensive and debilitating treatment that is not necessarily in their best interests.”

Burdens beyond treatment

Meanwhile, those patients — along with patients who suffer from multiple or chronic illnesses but are not terminal — face ever greater need for help with daily chores, errands, personal care and transportation. Ideally, they could turn to families for help. And many of them do just that.

But some patients have outlived their close relatives. That is especially true for elderly women. Almost half of women older than 75 years live alone.

Further, nearly 25 percent of Minnesotans over 50 who live alone have no one to care for them if they were to become sick or disabled, according to "Advancing Health Equity in Minnesota," a report compiled by the Minnesota Department of Health.

Even those who do have attentive relatives often find that their families can’t afford the time it takes to care for someone who needs multiple medical visits and help with daily activities as routine as remembering to take prescribed medicine.

The reality is that there simply aren’t enough younger workers to support an increasingly frail and aging population, let alone taking time off from work to provide hour-by-hour care.

The U.S. Census Bureau expresses the problem as a dependency ratio, or the number of people 65 and older to every 100 people of traditional working ages. The ratio is projected to climb rapidly, from 22 to every 100 workers in 2010 to 35 to every 100 in 2030.

Gaps in services

Minnesota has taken ambitious steps to fill the needs of patients late in life, creating an array of services for people in fragile conditions. Most counties provide home-delivered meals, hospice care for those nearing death, and other helpful services.

However, many services are lacking for Minnesotans who aren’t ready for hospice but are struggling to manage daily functions, according to a Gaps Analysis Survey for 2012, the most recent year surveyed.

A sizable majority of counties reported gaps in services that could help frail individuals remain independent despite chronic disease: companion service, transportation and chore service.

The gap that worries many health-care experts is the one between their own clinics and the government services.

Kane, the U of M expert on aging, said that communication is “extremely poor” between the social-service agencies and health care-workers.

“There is a big schism there,” Kane said.

Jean Wood, director of the Minnesota Board on Aging, agreed that the schism is worrisome. But she stressed that steps are being taken to do a better job of connecting patients with available services.

“I don’t think we have closed the gap perfectly at all,” Wood said. “But I think that there are these tools available, and we are getting better and better at using those tools and getting them out there.”

'Health care homes'

For example, Minnesota launched an initiative in 2008 to create “health care homes.”

Minnesota's health care homes

Source: Minnesota Department of Health

Minnesota's certified health care home locations, as of March 3, 2014. For the most up-to-date information on health care home locations, see the Department of Health.

The model offers a team approach to primary care in which providers, families, patients and others work together to improve quality of life as well as health for patients with chronic and complex conditions.

By late 2013, 43 percent of the state’s primary care clinics had been certified as health care homes, according to a report the state departments of health and human services sent to the Legislature.

The report acknowledges that “most healthcare systems do not partner effectively with community resources,” and says the lack of collaboration has led to “under-utilization of community services and fragmentation of care.”

Now clinics certified as health care homes will need to “identify and work with community-based organizations and public health resources such as disability and aging services, social services, transportation services, school-based services, and home health care services,” the report says.

A money-saver, too

Closing the service gap also could save money, according to related analysis by researchers at the University of Minnesota’s School of Public Health. By 2012, Medicaid enrollees served by health care homes had 9.2 percent lower costs than their counterparts at other clinics, the researchers reported.

Wood urged Minnesotans who aren’t getting the coordinated care they need from health care homes to seek services through free statewide information lines: the Senior LinkAge Line® at 1-800-333-2433 and the Disability Linkage Line at 1-866-333-2466.

In future installments, we'll look in detail at the multiple challenges faced by patients and new efforts to meet them, both in Minnesota and across the country. This yearlong examination of issues faced by late-in-life patients and their families is funded through a regrant by Allina Health from the Robina Foundation. It is conducted in conjunction with media partners Ampers and TPT, whose documentaries will focus on Minnesotans enrolled in a multiyear Allina study involving patients at this time of life.

A TPT documentary, "Late Life: Redefining Care," can be seen here.

Late-in-life care: fragmentation and complexity for the chronically ill

Sharon Schmickle — Tue, 18 Mar 2014 13:27:00 +0000

Sharon Schmickle

This is the first in an occasional series on late-in-life health care — when chronic illness or a constellation of medical problems can cause a cascade of new needs, complications and worries. This yearlong examination of issues faced by such patients and their families is funded through a regrant by Allina Health from the Robina Foundation. It is conducted in conjunction with media partners TPT and Ampers. A TPT documentary, "Late Life: Redefining Care," can be seen here.

If this day is typical, 106 Minnesotans will die before midnight. Of those passings, 16 will be unexpected. Most of the other 90, though, will represent the sad culmination of lingering diseases.

Given a choice, we would opt to live a long, healthy life and then be one of the 16 — dying suddenly. But those are the lucky few.

When the Grim Reaper makes a call in Minnesota, the odds are overwhelming that it will come in the guise of cancer, heart disease, diabetes and other ailments that sap life slowly. And whether those diseases strike a younger person or creep in with age, they almost always cause a period of frailty.

We deploy mighty medical arsenals to fight the specific diseases, spending billions every year. Much of that investment comes as last-ditch, life-saving attempts in patients who are near death.

A profoundly fragmented, confusing system

Meanwhile, fragile individuals who have months or years to live find themselves in a profoundly fragmented and confusing health-care system where they too often are treated as disease cases rather than individuals with personal wishes and practical needs.

“We have a health-care system that is great if you have a sudden heart attack or you come down with pneumonia,” said Dr. Diane Meier, who directs the Center to Advance Palliative Care at the Icahn School of Medicine at Mount Sinai in New York.

“But it’s completely useless during the 10 years that you are living with progressive chronic disease and you need help at home,” said Meier, who is also a national adviser to Allina Health's Robina LifeCourse Project, one of several efforts under way nationwide to test models for delivering more supportive, whole-person care to seriously ill patients and their families.

Where are the handymen, advocates and rides?

A weakened woman who fell down a flight of stairs could get thousands of dollars worth of emergency-room treatment. But could she get a handyman to install a hand rail on her stairway?

A man with multiple chronic diseases could see a dizzying array of specialists. But could he and his family get help navigating that system and advocating for their own wishes?

A doctor could prescribe drugs that cost more than a car. But could the patient get transportation to the clinic?

Too often, the health-care system has no answers to such questions. The system evolved to treat episodes of disease, not to provide comprehensive care during the years that patients are chronically ill, say advocates for the growing ranks of frail, late-in-life patients.

U.S. lags in spending on supportive services

While the United States spends more on health care than other developed countries, it spends far less on related social services.

Other countries in the Organisation for Economic Co-operation and Development (OECD) provide an average of $2 worth of supportive services for every dollar spent on health care. That is twice the amount the United States spends per health-care dollar, according to analysis of OECD data by Prof. Elizabeth Bradley of the Yale Global Health Leadership Institute.

Thus, while doctors pull out all the stops for individual medical interventions when life is threatened, ways of helping people deal with the myriad day-to-day needs posed by chronic illness or multiple medical problems are rarely built into the system.

A cascade of worries

Minnesotans Mary and Jessie Harris needed a lot more than doctors, hospitals and drugs when a barrage of diseases started pounding Jessie in 2012. On top of a weakened kidney and a pacemaker-dependent heart, he came down with multiple myeloma, then pneumonia, then a stroke.

Each condition complicated treatment for the others. Fortunately, Mary knew the health-care system. She had worked for years as a nurses’ aide, and she currently processes insurance authorizations for Health Partners.

“For a nonmedical person, it would have been really confusing,” Mary said.

The cascade of worries at home, though, was beyond confusing. Suddenly, Jessie could not work, drive, mow the lawn, walk the dogs, shovel snow and perform most of the other functions that had been routine.

Instead, he needed more personal care, more drives to doctors, more visits in hospitals. Worried that he couldn’t stay alone in their South Minneapolis bungalow, Mary toured assisted living facilities and cast about for home health care.

Gently, she broke the news to Jessie that the beloved dogs would need a new home.

That was too much. Somehow, they needed to stay put.

And even while working, Mary, 61, managed to cobble together enough help from neighbors, friends and a son who lives in Washington State.

“It was adrenaline,” Mary said. “I had more energy for some reason.”

It helps that his health has stabilized; he is also a patient in the LifeCourse initiative, which provides extra supports.

'I don't have time to get sick'

Still, Mary worries how she could handle another lapse in his health. Most of her sick leave at work is spent. And she doesn’t dare to think about her own rumbling stomach and sore knees.

“I don’t have time to get sick,” Mary said.

The adrenaline has run out for too many other caregivers. And now, the numbers of frail patients are set to skyrocket, threatening to overwhelm all capacity for providing both a high level of care and needed support services.

Explosive growth

Baby boomers are aging into the years when diseases pile up. Younger people also live with debilitating diseases and late-life decline. By far, though, people older than 65 are more likely to face that prospect.

Now their numbers are set for explosive growth.

By 2020, for the first time in Minnesota history, those 65 and older will outnumber school-age kids, according to the Minnesota state demographer. By 2030, one in four Minnesotans will be 60 or older.

Nationally, by 2030, 9 million Americans will be over age 85, when they are highly likely to suffer multiple chronic conditions, according to research by the Coalition to Transform Advanced Care. Their ranks will have more than doubled since the year 2000.

Even before the boomers advance into disease-prone old age, the Minnesota Department of Health ranks chronic disease as the state’s costliest health problem. Some $5 billion a year is spent treating chronic diseases in the state. And they are by far the leading causes of death. Cancer is the No. 1 cause, followed closely by heart disease, then stroke, respiratory illness, Alzheimer’s and diabetes.

One reason these diseases have become so prevalent is because we live longer than our grandparents and all the generations before them. In tandem with that trend, medicine has geared up remarkably to treat the diseases. A heart attack isn’t necessarily a death sentence anymore. It’s a mandate to rush to a hospital for stents, bypasses and drugs.

Many boomers aren't prepared

What we haven’t done nearly so well is prepare for the frailty that comes hand-in-hand with disease.

A sizable chunk of boomers in Minnesota appear ill-prepared to care for their own late-life needs, according to a survey conducted by the Minnesota Board on Aging and the state departments of health and human services. Nearly a third of the boomers surveyed said they were unsure how they would cover the costs should they need long-term care services. And 18 percent said they planned to fall back on a government program.

By their sheer numbers, those boomers will overwhelm the ability of family and friends to care independently for them. And they will tax the medical and public support systems to a degree that experts say is unsustainable.

In other words, change will come one way or another.

“If we do nothing, we will swamp the economy,” said Dr. Joanne Lynn at a recent media briefing organized by the Journal of the American Medical Association. Lynn directs the Center for Elder Care and Advanced Illness at the Michigan-based Altarum Institute.

“If we do nothing, we will either learn to walk out on old people or we will completely spend the output of the economy.”

Rather than “care” for the chronically ill, Lynn said the current system “provides disjointed specialty services, ignores the challenges of living with disabilities . . . disdains individual preferences, and provides little support for paid or volunteer caregivers.”

While that delivery service generates about half of the person’s lifetime cost for health care, “patients and families are left fearful and disoriented, with pain, discomfort and distress,” she said.

Massive costs at end of life

The upshot is a system in which massive medical costs pile up during the last few months of a patient’s life, often at a time when the patient has little chance of surviving.

Precise data characterizing fragile, late-life years is hard to find if you include privately insured younger people who struggle with chronic disease. For patients who qualify for Medicare, though, the Dartmouth Atlas of Health Care provides cost measures by analyzing Medicare reimbursements.

Care for people with chronic diseases accounts for more than 75 percent of health-care spending. Americans with five or more chronic conditions represent a disproportionate share of that cost. In 2005, they represented 23 percent of Medicare beneficiaries and 68 percent of Medicare spending.

Further, the costs rise dramatically as the diseases progresses toward death, the Dartmouth Atlas reports.

In Minnesota, Medicare paid out an average of $70,000 during the last two years of life for people who died in 2010. More than half that payout, $36,000, came during the last six months of life when the typical patient was treated by nine different doctors.

Wednesday: Minnesota's "health care homes."

Land O’ Lakes helps empower women in sub-Saharan Africa to develop business skills

Sharon Schmickle — Thu, 10 Oct 2013 12:58:29 +0000

Sharon Schmickle

Second of two articles.

MULALA VILLAGE, Tanzania — Women in sub-Saharan Africa have the highest labor force participation in the world, the vast majority of it working on farms. Yet, by almost every account, their productivity is low.

You wouldn’t know that worrisome reality by visiting Anna Pallangyo and her neighbors on the slopes of Mt. Meru.

Cow by cow and goat by goat, these women have built a small-scale dairy industry, with support from the International Development arm of Shoreview-based Land O’ Lakes Inc.

Wielding a machete to chop crop fodder for her herd, Pallangyo explained the slow cultural transformation that has made her an entrepreneur — known to tourists as Mama Anna, the cheese maker.

Traditionally, women in this part of Tanzania had limited rights to a family’s livestock, she explained. Men owned the animals, and they had first rights to sell the milk collected each morning. If women could squeeze more milk from the animals in the evening, that would go to feed the family. Only the leftovers — if there were any — were for the women to sell.

The upshot was that the women had very little income of their own and no real power over practices in the dairy farming that has been a tradition for generations in this northern region of Tanzania.

Pushing back

It would be reasonable to conclude that they also had no real incentive to improve the output from their farms which typically consist of two acres or less of land.

Not these women, though. They started pushing back in the 1980s for more authority to leverage their labor into more food and more income for their families. In 1999, they started working with Land O’Lakes which had just arrived in Tanzania, bringing technical know-how from dairy farms in America’s Midwest and financial backing from the U.S. Agency for International Development.

One strategy that came from the very roots of the Minnesota-based dairy cooperative was to band the women together in order to connect with processors, commercial buyers and consumers. As a group, they could establish collection points where milk could be kept fresh until it went to market. They could consult veterinarians, feed specialists and other experts. Eventually, they even could process their own milk.

Thrust to boost women farmers

This program doesn’t stand alone in Africa, by any means. African governments and a wide range of aid organizations also are working to empower women farmers.

Jon Halverson wasn’t with Land O’Lakes at the time of this program’s inception. But he was deeply involved in global agriculture and development, having worked many years for Cargill Inc. and then for the U.S. African Development Foundation. Now he heads the international development division at Land O’Lakes.

In northern Tanzania, women dairy farmers are demonstrating the potential Africa could unlock by empowering more women farmers.

Why the big thrust to boost women in agriculture, I asked him.

“Women are strategic because by and large they manage money well and they support one another, which is important in an African context,” he said. “They are industrious, innovative — and, they deserve an equal opportunity to succeed.”

There are many reasons why women farmers were structurally sidelined over the generations. Sometimes it was due to political power which rested largely with men. Sometimes their lowly status was based on tribal tradition, which could be innocent and destructive at the same time.

Sensitivity + income

Deep-seated prejudice doesn’t just go away. How could these women in Mulala village and others in clusters across Africa elevate their power and status?

“It takes a lot of sensitivity,” Halverson said. “You are not going to do that overnight.”

One powerful driver of change in poor families is extra income.

“A little bit of incremental income for women can be very transformational for the women, the family and the community,” he said. “African husbands will respect their wives more when they bring in that incremental income. They are much less likely to abuse them.”

Whatever the reason, many men in this part of Tanzania have come to accept the new order, and some even have joined the women’s groups where they’ve been welcomed.

Africa’s unrealized potential

What’s good for the women apparently is good for Africa, too. The continent could go a long way toward beating poverty and hunger if more women could follow the example of these Mulala farmers in terms of power and marketing savvy, according to the latest Africa Agriculture Status Report issued by The Alliance for a Green Revolution in Africa.

Women provide more than half the labor on farms across sub-Saharan Africa, yet they are five times less likely than men to own land. Their small-scale agriculture has enormous potential to reduce poverty and even contribute to economic development on the continent, the report said.

“Yet its potential has remained unrealized, largely because rural women who constitute the majority players in smallholder food production remain unrecognized and unsupported by agricultural policy and development interventions,” it said.

MinnPost photo by Sharon SchmickleWomen farmers are processing more of their milk, including into butter.

Not only do women lack land of their own. They also lack access to all-important factors such as credit, markets and improved seeds.

Reasons for the inequities go deep into village traditions and tribal cultures. Take agricultural extension services. Often it is offered by men. But in many traditions it is inappropriate for those men to talk with women who aren’t related to them. So the women farmers end up getting extension advice second-hand through their husbands.

A step further

Now, empowering rural women is seen as an urgent economic priority across sub-Saharan Africa. And other organizations, like Land O’Lakes, are investing money and expertise in that cause.

MinnPost photo by Sharon SchmickleRose Rita Kingamkono

Land O’Lakes has started taking the cause in a new direction with an initiative intended to nurture leadership in rural women, also with funding from USAID.

For too long, rural women have had little choice but to play passive roles in their families and villages, even while they worked as hard or harder than men, said Rose Rita Kingamkono, who heads the new initiative from offices in Dar es Salaam.

In many villages, men take the harvests their wives and daughters have extracted from the land, sell the goods and pocket the money for themselves. Because they have the money, men also make the decisions about what inputs to buy for the family farms.

“The women have no access to credit to buy anything that could make their jobs easier, no collateral,” she said. “Men own the land and the harvest. And when the husband dies, the property goes back to the man’s relatives. The woman is chased away.”

Objectives of the new initiative are to help women develop technology that could ease their labor and boost their yields, to promote leadership that could help women grow small businesses and to identify gaps in women’s legal rights.

Old gives way to new

Back in Mulala village, the scale of dairy farming is much smaller than modern-day operations in the American Midwest. Pallangyo has a large herd with two cows and four goats in her stables. Many of her neighbors tend just one cow and a calf.

Pallangyo also has branched out.

In her “Mama Anna” role, she tends bees and sells the honey to tourists. She makes cheese from some of her milk, also for sale to tourists. And she has lured the tourists by building a replica of a traditional dirt-floored stick house outfitted with antique tools of the type her ancestors used for generations.

But Pallangyo is moving far beyond the life she demonstrates for tourists. Just up the hill, she is building a cement-floored milk processing house with a modern cooling tank.

Sharon Schmickle's reporting from Tanzania was supported by a grant from the Pulitzer Center on Crisis Reporting.