Transcription of Dr. Sam Zager for the show Books, Libraries and Health #166

Dr. Lisa:          As individuals who have been listening to the Love Maine Radio show for a while understand reading is one of my favorite activities. Today we have with us 2 individuals who understand the importance of reading, of literacy and health in libraries. We have with us Stephen Podgajny who is the executive director of the Portland Public Library and also Dr. Sam Zager who is a family physician at Martin’s point healthcare in Portland and a volunteer with the Portland Public Health Department. The two collaborated on a research project in which the aim was to document and clarify any associations between health and public libraries. What emerged was the health and libraries of public use retrospective study also called HeLPURS and some fascinating findings. Thanks so much for coming in today.

Male:              Our pleasure.

Male:              Thank you.

Dr. Lisa:          It’s an interesting thing for me to be in a room with people who have a mindset that’s similar to mine because that doesn’t always happen so I’m with you Steve, you’ve been working with the libraries for maybe your entire career or at least a pretty long portion of it.

Steve:             Yeah, the last 35 years, 36 years of working in public libraries, the last 33 or so directing them in Maine.

Dr. Lisa:          In Maine?

Steve:             Yeah.

Dr. Lisa:          I knew when you were up in Brunswick, I know you’re a longtime runner. As I was saying to you before we went on the air, I used to see your name up in the winners circle quite often at races. Then Sam, I’ve never met you but you went through the Maine Medical Center Family Practice residency program which is where I went through as a family practice resident and you trained with my father, Charlie Belisle.

Sam:               I did. It was a terrific honor. I was so grateful to have the opportunity to train here at Maine Medical Center and it’s given my wife, Tracy and me a chance to establish roots here. We are glad to be here in Maine.

Dr. Lisa:          It’s interesting work that you’ve been doing, Sam, Dr. Zager, but it’s work that started before you even got the Maine. this is something that you became interested in when you were living in Boston and you saw that there was some chance that public library branches in places that were less well-off than where you were living were in danger of being closed. This became important to you.

Sam:               It really did. As with a lot of things I think in life, you sort of stumble into it because you realize that something that’s happening around you matters. In 2010, I was indeed living in Boston and there was a proposal to cut costs by shutting down some branches in five neighborhoods in Boston. Initially, it seemed to make sense but when I found out more about it through an organization that opposed the closures called the People of Boston Branches, organized by a very energetic young psychologist named Brandon Abs, that these were branches in less educated and poor neighborhoods which just seems fundamentally wrong.

As I got more involved with the advocacy effort, I post the question well is it also unhealthy, is it also bad for the public health and for individual health to shut down access to all the things, not only circulation items but all the services that libraries provide as they’re embedded in their neighborhoods.

Dr. Lisa:          You ended up helping reverse that decision?

Sam:               I was one of many people but I think the role that I played was in really making the health argument. I dug into the literature in the medical journals and public health journals, social science journals and look for everything I could to see what we knew about the intersection between health and public libraries, not only reading but the libraries as entities in and of themselves.

I found a fair amount of indirect evidence through two main mechanisms. One is that libraries certainly are good for our education and literacy and both of those are very good for health. That connection is well documented in many spheres but in addition, it had something to do with social connections, the social bonds that people have are fundamental to health.

This has been shown in many organ systems, in many fields of medicine. People recover from strokes faster for instance they have good social connections. Libraries are very important neighborhood-based places where people can make connections with others. It’s not just about the text that can be transmitted over the Internet or saved in a thumb drive but there’s something about the institution that I thought was important. I wasn’t the only one. I found some co-signatories to this position paper that were eminent in their fields.

Among these 19 co-signatories, there was National Medal of Science recipient which is Congress’s highest scientific award. There was a Nobel Laureate so these were not people who just also started thinking about what makes people healthy and what makes communities healthy. They signed on. I presented this consensus statement as a expert opinion to the ways and means committee of the city Council in June of that year. Indeed by July 1, all of the libraries had received the funding even in these endangered neighborhoods which was terrifically gratifying.

It left me though with a little … I noticed that there was a gap in the research. This was predicated on expert opinion but as I think you know, that’s actually the lowest level of scientific evidence. It’s literally opinion, certainly qualified but I was looking for something that didn’t exist which was empiric, quantified evidence of a connection between libraries and health and that’s what HELPURS became.

Dr. Lisa:          Let me back up because I want to … I give you a lot of credit for doing this because it sounds like you’re actually doing this while you were simultaneously completing your medical education.

Sam:               I was. We have 2 daughters which …

Steve:             It’s a [crosstalk 00:32:48].

Sam:               Yeah, that’s right. Things don’t always happen when you plan on them. My wife, Tracy is an incredible partner and has made a lot of things possible and we try to do that for each other.

Dr. Lisa:          As I said, I give you a lot of credit. It’s really gratifying because I think we’re in a time where we all have to understand that health goes beyond the room in which a doctor and the patient interact. Steve, I know that for you, public libraries have been so important your entire career. It’s something that you really felt passionate about. I’m wondering though when you started this whole process, were libraries is important as they seem to have become now? What has the progression been?

Steve:             I was on sabbatical when Sam first brought this up. Someone said wait till I get back. I came back and I met Sam and he brought up this gap in the research. I remember we had a conversation. I think Sam said how do you know … How would you articulate that the library is good for community health because we have a health team so we have a series of what we call constituency or user teams. We identify literacies that we would love to promote in the community.

Some of them can be civility, science and technology, business and government, Portland history. One of them happens to be health. The point of this team is to do everything it can to contribute to a healthy Portland and healthy individuals. What I said to Sam was public libraries just assume they do quality work about developing collections. People take the things out or they buy databases, take them out and hopefully some good comes of it because it’s good stuff. But you never know whether there is this Association or whether someone’s behavior changes, whether they seek out a healthcare provider.

What triggers result from someone using library resources so I was terribly interested in this idea that Sam had about seeing if we could, if there was a relationship could be established, that could be demonstrated. I knew that it was something that didn’t exist or thought it didn’t exist in the public library world because I hadn’t seen it anywhere. Yet, it was terribly important area for us to investigate. After all, we were designating that it was an area of interest for us.

Dr. Lisa:          These areas of interest that you’re describing, when you first started work within the public library system, is this something that existed then?

Steve:             No. A lot of places use the team strategy. I suspect Martin’s point does and maybe even the magazine does. You have different things but public libraries have this unique ability to interpret their relationship or their mission any way they want programmatically. They all do similar things like they lend stuff. They have databases. They have a digital profile. They have a physical profile but the idea for us to make a statement that this was one of the areas that we wanted to focus on is actually very powerful statement.

You can build, refer to them as literacies again, about health knowledge, health education, living a full and productive life on many levels whether it’s civility or knowing things about science and technology for contributing to public debate but this idea of living a healthy life physically and emotionally, very, very important to us because it’s in the end, a public library is about people reaching their individual potential and for a community reaching its potential.

Sam:               One of the things that we discussed early on in this whole process was that we kind of see ourselves in the same business of helping people realize their full potential. As you know as a physician , if somebody’s not well, if they don’t feel well, if they’re not physically well, they can’t realize their full potential. That’s largely what libraries do. There was a tremendous kinship I think we had from the beginning.

Steve:             We’re essentially humanities-based institutions. People engage with the text through us often and there are other things that elucidate or expand to that engagement such as programming but whether it’s digital resources or print resources, that’s what people are doing with us primarily. There’s expertise on the staff level. There are other things but we have 650,000 people visit the Portland public library system. So largest engagement with the public cultural institution in the state of Maine.

The opportunity that we have to now particularly fired by the results of the study to potentially affect in a very positive way but now much more intentional way. I would argue that prior to this study, our benefits were coming, we thought we were doing the right things but this points … This study points for us a way forward. They can be a much more discreet and intentional investment of resources, whether it’s staff, types of space and individual collections that might reinforce some of the findings from the study.

Dr. Lisa:          I’m interested in this idea of space because the Portland Public Library just did a very large and beautiful renovation not too long ago and having cared for the same patients that I know Dr. Zager cared for up on Munjoy Hill as a family practice resident, I know that this library space really is … I have done home visits with the patients, some of the patients who live in the Portland area and not all of the people who go to Portland Public Library fall on this category but some of the patients, this is the more beautiful space. The Portland public library is far more beautiful than any space that they have the chance to inhabit a regular basis.

Steve:             Right and it’s very interesting the presence of art, the presence of furnishings and fixtures that are of a certain quality. All of these things as a public space are so important to well-being. Sam has a lot deeper thoughts on what these spaces might mean but clearly, folks are entering space that is aesthetically beautiful but there are also behaviors happening there that are healthy for the most part.

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Dr. Lisa:          This research study that you did, the Health and Libraries of Public Use Retrospective Study also called HELPURS which you have presented at the Maine Academy of Family Physicians meeting and won an award for. You’ve gone to the Society of Teachers of Family Medicine and presented there. This had some interesting studies specifically with regard to health, so tell me about to study and what did you find.

Sam:               HeLPURS was a retrospective study. We had 243 people consent to enroll. These are all adults who live in Portland. They’re all eligible for Portland public library cards and they understood to the consenting process that we would take discreet items from their medical record and connect that in a secure research database with any records that the public library may have about their quantity, recency and duration of their borrowing. We did not look at any titles.

The library doesn’t keep those data in their records and that was not interest of the study. We also did not even look at the types of materials that people borrow. In other words, if somebody borrowed something, whether it was a book, a DVD, a piece of sheet music, it all looked the same in this study. We consented these individuals and then went about the technical task of marrying this databases.

We looked at demographic information, age, gender, insurance type, socioeconomic status. We looked at health variables such as BMI or body mass index. We looked at blood pressure. We also looked at diagnoses in the so-called problem list. We wanted to know what problems their providers had identified and these individuals were working on for their own health and wellness. The library variables as I mentioned include essentially circulation information. What we found was that some really interesting things.

Indeed, the experts back in 2010 were onto something. There is a connection between health and public libraries. The improved clarity was that the connections centers largely in a mental health in particular depression anxiety disorders and especially substance abuse. There was some consistency in the findings for instance in smoking and drug abuse and mind you, this is not a survey. Do you smoke or … But this is very reliable medical chart information.

We found for instance that among those who had ever smoked, that’s more than … That’s about half the study populations had ever smoked in their life. Those who used the library at least a moderate amount had more than twice the odds, more than two times the odds of quitting smoking as those who didn’t use it at all or use it only a little bit which is fascinating to me. Kind of reminds me of home fitness equipment. It’s a good thing to have but it really needs to be used if you’re going to achieve what you want to achieve.

I think libraries perhaps fall into that category. It’s not only good to have a groundbreaking on a library in a community but to invest in the library so that it can be … It can yield good things for the health and wellness  of the community and for individuals. There was the finding about smoking which was fascinating to me that was also consistent with drug abuse, those who’ve been to the library in the last six months had statistically lower rates of drug abuse than those who had so-called remote usage or hadn’t been to the library for at least six months.

It’s not just having a card which is obviously an important first step but it’s using it and also using it with some regularity. It doesn’t require that much or at least we found that there was an association with just a little bit of usage like seven or eight items in a whole year borrowed, put somebody in that moderate usage category which was associated with smoking cessation, with not having a drug substance abuse problem, drug abuse. It also had associations with depression anxiety disorders which was interesting in its own way.

Dr. Lisa:          From this information, what do you think is going on? What do you think is happening? What is it about the libraries? Maybe is it the use of space? Is it the socialization? What is it that’s causing people to engage in healthier behaviors or have less anxiety, less depression?

Sam:               It’s a great question. We’ve been puzzling over this. I think that there’s potentially a number of things going on. There is a physician named Nicholas Christakis who has published out of … Published in the New England Journal, published in the British Medical Journal, has done work at Harvard and now more recently at Yale, who looks at the social connections, how the social bonds affect health outcomes.

This has been shown in smoking cessation, obesity, mood disorders etc. I think part of what could be happening and this is a hypothesis at this point, is that when you’re at the public library, you’re around other people who are nourishing their souls and that is a fundamentally healthy endeavor.

That can take many forms and one of the beauties of public libraries is that they can be whatever you need them to be. It can be a place where there’s performing arts done in community. It can be a place where people get voting or citizenship information. It can be a place where somebody literally learns to read, certainly take out any of the things and the holdings, the book mobile goes out into the community and brings the resources of the library to individuals who don’t necessarily have as much mobility or ability to get to a branch so there’s a number of things that libraries can do for people. It seems that being around other people who were doing something that is sort of life-affirming, that is healthy, that is forward-looking, is a healthy thing to do.

Steve:             I think the sort of confirming that some of the programs that we were doing have this effect in retrospect so things such as creative aging initiatives where we’re going out to various locations, housing and various things that encourage seniors to continue creative enterprise, aging in place initiatives, basic outreach things that were going out. Sam mentioned the book mobile so it is a lot about the space itself, the physical space but it’s also about the relationship building that happens with the public institution that again is not necessarily … Is interested in your growth, it’s not necessarily delivering a “service” or addressing a problem you have. It’s interested in a very positive kind of interaction and how you’re living your life.

Dr. Lisa:          I’m struck by a couple of things. One is that some have complained about the negative impact of technology upon human development relationships, health, that sort of thing but you’re a library and what you’ve just described to me is more than just books, it’s about digital access. It’s a very multi-platform thing that you’re offering the public, so you’re using technology in a very positive way through the library system. Also Sam, you never could have done this project if you did not have access to electronic medical records I suspect. Both the libraries electronic records and your records had to be available in order to even do the study in the first place so these are very positive uses of technology.

Steve:             Right. I mean I think people are … I think it’s our propensity as individuals to do either or. You have these people making broad assumptions that because there’s digital reading, there’s no longer print reading or because you can stay at home and search databases or you can search the catalog. A lot of times searching the catalog says I’ve identified something either at Portland Public Library or Bowden or Bates or the University of Maine or Bangor Public Library, please deliver it to our Burbank branch.

It’s a wonderful thing. It’s all about active minds and people reading potential. In the end, we need to [stow 00:50:43] it. The vehicles don’t matter but what does have to exist is a public infrastructure for public learning that does not require enrollment. It does not require a certain socio-economic class or membership and faith. It just needs to be there for people and Sam’s earlier comment was a really good one which is the public library can be for people whatever they want it to be almost and whatever area of inquiry or excitement is currently involved in their life.

Dr. Lisa:          I think that’s a really good point. I think what’s nice for me to hear is that we’ve  had people on the show who are educators and scientists and nonprofit leaders and for all of them, the sort of numbers availability in our culture right now is so high that everybody is being asked to prove value. In the healthcare system, you’re asked to prove that you can bring a person’s cholesterol levels down and that they’re going to live longer and stop smoking. Now, the libraries are able to start justifying in a more tangible way that we are going to also help with people’s health and education, cultural advancement, that sort of thing.

Steve:             I think the striking thing about the study, looking at it from the public library perspective, there was nothing embedded in it that was a reach. In other words, we didn’t do anything. The retrospective nature of it was very powerful because it was … We weren’t doing anything we don’t normally do.

If you look at it that way, it’s very, very powerful. We didn’t rig something that we suddenly are doing this other great program and we had an isolated population that addressed it and we got X result. The power of this is to go back and say you know what we do has real value but now pointing forward, some of these conclusions really inform how we could probably leverage some of those results to a higher efficacy or whatever you might say.

Sam:               I would add to that that there’s two main implications of the HELPURS. One is that I think it prompts us to recalculate our understanding of the return on public investment in public libraries. That’s sort of what Steve was just saying.  The second thing is that I think it prompts clinicians to think about what this does mean in a primary care practice. It wasn’t that long ago that reading itself wasn’t considered a medical intervention but now we have the Reach Out and Read Program.

It’s a very evidence-based thing that pediatricians and family docs do all the time to recommend reading. What HeLPURS, I think adds to that is that there’s this other facet, it’s maybe perhaps with future randomized studies, we can demonstrate that just recommending libraries, library exposure, library utilization, would be an evidence-based health intervention to do. I think in both in terms of what we do as a community but also what clinicians do with in that one on one doctor-patient relationship, I think HeLPURS adds in both spheres.

Dr. Lisa:          I would be remiss if I didn’t add in that Maine has its own version of Reach Out and Read which is Raising Readers, which has been in place for almost 15 years now I think. The final thing that is done with the five-year-old because children get books from birth to age 5 is to give them their library card. They’re supposed to go to their public library so it’s interesting that you … This is where I started my career. You’re coming in at this point and it’s really nice to be able to see that this thing that you’re talking about, the value is being proven. How can people find out more about the HELPURS study or the Portland Public Libraries?

Steve:             They can certainly visit our website at We just changed our URL so There’s information there under one of our research topics called health. We have some summary there of the study but they can certainly call us at 871-1700 extension 755. Depending on the nature of the questions, we would certainly refer them to Sam for some of the deeper, deeper conversations around this study.

Sam:               My co-authors which include Dr. Christina Holt and Amy Haskins who’s epidemiologist and Kathryn Malin who’s a [heart charging 00:55:45] medical student and I are preparing a manuscript that we hope will be out in the not-too-distant future. We see this as a conversation that we have started, not one that we have concluded.

Dr. Lisa:          Of course if they would like to reach you Dr. Zager, you are at Martin’s point here in Portland.

Sam:               Martin’s point here in Portland on Veranda Street.

Dr. Lisa:          Very good. I really appreciate the work you’re doing with libraries, the work that you’ve been doing a long time even the work that you’ve been doing little bit less long but still in a very important way. We have been speaking with Steven Podgajny, the executive director of the Portland public library and Dr. Sam Zager a family physician, volunteer at Portland Public Health and also researcher. We appreciate all the time that you spent trying to bring culture and reading and literacy and wellness to the world.

Sam:               Thank you very much.

Steve:             Thank you very much Dr. Lisa.

Dr. Lisa:          You have been listening to Love Maine Radio show number 166, Books, Libraries and Health. Our guests have included Doro Bush Koch, Becky Dyer, Steve Podgajny and Dr. Sam Zager. For more information on our guests and extended interviews, visit Love Maine Radio is downloadable for free on iTunes.

For a preview of each week’s show, sign up for our e-newsletter and like our Love Maine Radio and Facebook page. Follow me on Twitter and see my daily running photos as Bountiful One on Instagram. We’d love to hear from you so please let us know what you think of Love Maine Radio. We welcome your suggestions for future shows. Also let our sponsors know that you’ve heard about them here. We are privileged that they enable us to bring the Love Maine Radio show to you each week. This is Dr. Lisa Belisle. I hope that you have enjoyed our Books, Libraries and Health show. Thank you for allowing me to be part of your day. May you have a bountiful life.

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