Research Engine

Public health interventions at the speed of community

As the R.I. Health Public Health Institute scales up, ConvergenceRI sits down with Amy Nunn, its executive director

Photo by Richard Asinof

Amy Nunn, the executive director of the R.I. Public Health Institute, at its new location at 383 West Fountain St. in Providence.

By Richard Asinof
Posted 4/30/18
A conversation with Amy Nunn, the executive director of the R.I. Public Health Institute, captures the ways in which the startup institute plans to scale up its operations in Rhode Island.
How has the new commercial development on the former Route 195 land precipitated businesses and startups finding more fertile, affordable places to relocate in the neighborhoods of Olneyville, the West End and the South Side? What is the potential for the doubling of SNAP benefits program to be expanded to retail stores in Rhode Island, such as Walmart or Whole Foods? What kinds of new investments is Brown University willing to make in collaborative research with public health in changing the way that the medical community looks at chronic diseases and their relationship to environmental factors? Is the R.I. General Assembly willing to invest more money in public health to protect Rhode Islanders?
As much as there are numerous efforts and investments to expand the boundaries of primary care as the best way to improve community health and prevention and build up health equity in communities, a much under-reported story is how difficult it has become to find a new primary care provider in Rhode Island. And, as the demographics in the state change, with an increasing number of aging residents, the demand for primary care providers is going to keep growing.
Some smaller providers are closing up shop, one in North Kingstown, another in Barrington; some providers, such as the Women’s Medicine Collaborative, are allegedly not scheduling new patients for appointments for months, according to what ConvergenceRI has been told.
Other consumers have told ConvergenceRI that they have jumped across the border to Massachusetts to find a primary care provider.
One focus of public health research would be to track three things: the number of primary care providers in the state, both physicians and nurses; the comparative salaries for those professions with Massachusetts and Connecticut; and the average wait time to book a primary care appointment at primary care practices.

PROVIDENCE – The new digs for the Rhode Island Public Health Institute at 383 West Fountain St. are emblematic of the growth achieved by the start-up organization as it moves forward with its ambitious strategic plan over the next five years on public health initiatives that seek “to bridge and respond to social, structural and clinical determinants of health.”

These include public health issues that often reside on the outskirts of public conversation and political consciousness: to help eradicate HIV transmission in Rhode Island, to promote widespread Hepatitis C diagnosis and cure, to reduce food insecurity among children and older adults, and to reduce the burden of chronic diseases.

To accomplish these goals, the Rhode Island Public Health Institute brings to the table a strong emphasis on research, data and analytics to measure the results and produce evidence-based findings.

ConvergenceRI recently sat down to talk with Amy Nunn, the executive director of the Institute, at her new offices, which are located across Route 95 in a refurbished industrial building, reflective of the fact that many properties within what was once known as the former Jewelry District have skyrocketed in real estate values, making them unaffordable.

The remodeled co-working space behind the brick façade at 383 West Fountain St. is home to a number of new businesses, with a shared conference room and amenities.

As the new Wexford Innovation Complex moves toward completion, along with numerous new hotel properties under construction in downtown Providence, the move by the Rhode Island Public Health Institute from its former home at the School of Public Health at Brown University at 121 South Main St. reflects a growing trend: businesses and startups are finding themselves drawn to relocate in the communities and neighborhoods residing in the urban shadows of large-scale corporate development, in the places and neighborhoods where everyday collisions so critical to the success of the innovation ecosystem are now taking place – in the West End, in Olneyville and on the South Side.

One of the conundrums facing Rhode Island is that while the state has achieved success in becoming a healthy place to live, the spending for public health at the state level is poor, according to Nunn, despite what she called the “amazing” numbers in terms of health insurance coverage.

“Rhode Island is a pretty healthy state; I think we do pretty well, compared to Arkansas, where I’m from, which I think is the third least-healthy state in the nation,” Nunn said. “The areas where we fare poorly are addiction, Hep C, lead, ticks and some vector-borne diseases.”

Where Rhode Island has failed, Nunn continued, is that we have not appropriated sufficient funds for public health.

“The spending for public health at the state level is poor. The R.I. Department of Health is overwhelmingly underfunded. I think the legislature needs to appropriate more dollars for public health spending,” adding that she had recently testified before the R.I. General Assembly in support of the Department of Health’s spending bill.

Here is the ConvergenceRI interview with Amy Nunn, the executive director of the Rhode Island Public Health Institute, as it moves to scale up its operations from its new location at 383 West Fountain St.

ConvergenceRI: Why did you move?
In the last two calendar years, from 2016 to 2017, we doubled in size. From 2017-2018, we tripled in size, so we are growing at a really fast clip.

ConvergenceRI: When you say you doubled and tripled in size, are you talking about money coming in and personnel, or both?
In both personnel and financial resources, grants. We have now a body of work related to both chronic and infectious disease.

Our work [on food insecurity and Food on the Move] continues around a process of evaluating that program; it is a mammoth undertaking but definitely worthwhile. [See links to ConvergenceRI stories below.]

The work was based upon a few NIH grants. We haven’t fully evaluated [our efforts] as we transitioned from research to program [implementation], so now we are going to do a big evaluation, focusing on the impact of our SNAP “doubling” program, in particular.

[As part of the Food on The Move initiative, SNAP benefits are doubled when fresh fruits and vegetables are purchased by customers at the mobile markets set up at senior centers, neighborhood schools and community centers.]

I’m excited about that, because I think it will provide a new evidence base for what I think is really important: the implications for retail [stores] for the doubling of SNAP benefits program.

The Holy Grail is to convince grocers and the federal government to spend money on expanding the doubling of SNAP benefits and SNAP subsidies into that retail world.

In my dream world, Walmart, Kroegers, Hannaford, and Stop & Shop would be offering similar programs.

ConvergenceRI: How far away from dream to reality do you think that is?
I’m not sure. The federal Farm bill is up for appropriation this year, in the fall.

Right now, the SNAP doubling programs are really focused on grantees, like ourselves. But it is not a benefit that is offered to everyone who has SNAP. It isn’t currently being offered in retail settings.

ConvergenceRI: Can Rhode Island become a leader, a pioneer, in all this? Are there things that Rhode Island could be doing that would expand the doubling of SNAP benefits in retail stores? Could you create a pilot, for instance, in all Walmart stores located in Rhode Island?
That’s our vision. We are working with the Hunger Elimination Task Force and Sue Anderbois in a working group to try and figure out how to “operational-ize” this in retail. I know my limit. I’m a public health person; I’m not a businessperson.

ConvergenceRI: My guess is that you are probably good at the business angle, too.
I know when to ask for help. And, we definitely need help with being to make this operational from a business perspective. In retail settings, it’s definitely not our background, but we can offer a lot of important lessons.

ConvergenceRI: Have you ever sat down with Stefan Pryor, the secretary at CommerceRI, to make pitch?
No, I haven’t; let me write down that name.

ConvergenceRI: How has your relationship changed with the School of Public Health at Brown University with your move to a new location?
There were no bad feelings on either side. We just literally expanded. Brown played a fundamental role in kind of incubating us, by providing us free space and IT support. But we needed a larger space, because we now have 12 people working for us.

I still have my faculty appointment at Brown. I still have some research projects that are based at Brown, but now we have this new, independent space, which is exciting.

We’ve been working on our food insecurity project; we also have a big program focused eradicating HIV in the state of Rhode Island that’s funded by the R.I. Executive Office of Health and Human Services.

ConvergenceRI: How is that going? I know that there is a big push to have everyone get tested for HIV as part of their primary care check up.
I don’t think that that is happening. Of course, the U.S. Centers for Disease Control and Prevention have been recommending that that happen since 2006. I think that is super important.

We have really good surveillance in Rhode Island and across the country; we know exactly who is getting infected. Most of the individuals who are newly infected with HIV are men who have sex with men, who meet their partners online.

ConvergenceRI: Wasn’t there an effort to create an online advertising campaign on those sites?
We wanted to have an advertising campaign. So, we wrote an article in 2016…

ConvergenceRI: Yes, I reported on that.
What we found was that we were able to link those individual hook up sites with new infections, which was considered groundbreaking, scientifically. [See link to ConvergenceRI story below.]

Still, today, we are among the few [institutes], if not the only one, who have done that kind of research around the country.

The article provided evidence for what we wanted to do in terms of online advertising. The other thing that we found was that advertising on those sites can be prohibitively expensive.

And, I didn’t have the resources to fund a social marketing campaign, designed to advertise on those sites, and then move traffic to clinics. Now, with the support of R.I. EOHHS, we are able to do that.

We are in the middle of developing our social marketing campaign, which will hopefully be rolled out late summer. We are working with The Miriam Hospital.

Our ultimate goal is to open a new, express screening clinic.

We are focused now on driving traffic to AIDS Project RI and to The Miriam Hospital, which is our clinical partner. The current STD clinic at The Miriam is only open nine hours a week, Monday, Wednesday and Friday, 12 noon to 3 p.m. There’s a huge unmet need for screening,

[Nunn showed a video of a model of an express screening clinic in London that is now operating, which she said she plans to visit in May.]

ConvergenceRI: There is a community-led effort in Rhode Island to push for harm reduction strategies around drug use, including the distribution of fentanyl testing strips and safe injection sites. Have you talked with the folks at RICARES?
I haven’t yet, but I did chat with Brandon Marshall [at the School of Public Health] yesterday. He also has interest in doing work at community-based sites. I’m all for them; the data in support of the safe injection sites is so powerful.

I think, [the question is] finding the right venue for those, because no one wants them in their backyard.

ConvergenceRI: Isn’t it also getting law enforcement to buy into those strategies?
Yes. It requires a sea change, a culture shift.

ConvergenceRI: Because of the apparent effectiveness of PrEP in lowering the chances of being infected with HIV, there has been some pushback about whether such medications increase sexually risky behavior. In your research, have you found that to be true?
We have found among the patients that we serve, some 400 people, that people do not really change their behavior that much. If they were engaging in risky behavior before PrEP, they do that after [access] to PrEP.

I also think that whole conversation has a been a real distraction from the main issue, which is: if people need protection, then we ought to give it to them. If they’re taking the medication, it reduces transmission risk, it’s good for them, it’s good for the whole population.

ConvergenceRI: Jonathan Goyer said, in a recent conversation with U.S. Surgeon General when he visited Rhode Island in February: “The opposite of addiction is not sobriety, it’s connectedness.”
I love that. And, I agree with that. It is about people getting back to their networks and communities and re-engaging.

ConvergenceRI: Have you done any research about what defines an engaged community? And, how people view the boundaries about what a community or a neighborhood is today, not governed so much by the workplace, where you live or where you grew up, or who your parents are, but rather, where you belong?
Recovery is about social networks. Re-engaging back in normal life, in social bonds, and maybe in spending time with your family, your loved ones, or going to church.

ConvegenceRI: Is there good research being done on that topic?
I think there’s room for a lot more contribution. Someone from The Providence Center has been over here a couple of times, asking if we can evaluate their programs. I would love to, but first I want to understand: what are we measuring and how do we do that?

I believe we can make a scientific contribution [if we can document] that recovery is not the total lack of substances, but moving toward normalcy, resuming normal life patterns.

ConvergenceRI: Are you familiar with the research done by sociologist Shannon Monnat on the diseases of despair, tracking the mortality rates for alcohol, suicide and drugs? The recent data from Prevent Overdose Rhode Island on overdose deaths tends to support her research, looking at the demographics, even with the rise in fentanyl-related deaths, not just with heroin, but with cocaine.
I think we need to shut [fentanyl production] down in China. I think we need to slap trade sanctions on them. Because that is the bottom line. Stop stigmatizing those struggling with addiction; let’s make a structural response to shut down the fentanyl supply.


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