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Demystifying Medicine One Week at a Time

Category: social determinants (page 1 of 3)

Public Libraries

Artist’s rendering of Central Library. It turned out as good as it looks.

In Tulsa the flagship downtown Central Library just re-opened after a three-year renovation.

It’s been spectacularly re-designed and updated with all of the latest library technology. It includes the nation’s only (to this point) embedded Starbucks Coffee–a plus or minus depending on your viewpoint. (Some academic libraries at universities already contain them.)

A recent newspaper article profiled another important feature of the Tulsa library: A full-time social worker.

As you may or may not know, depending on where you live and how much you use your public library, urban libraries are often visited by people in transition–those that are jobless, homeless, and who frequently have stable or unstable mental illness.

After all–libraries are free, have resources, generally have available computer time and tutorials, and kind librarians who can help with requests.

Many libraries now have social workers and other representatives of social service agencies that can help with issues like finding places to live, regular sources of food, and employment options.

I was glad to read about Deborah Hunter in Tulsa. Her story is all the more poignant because she’s driven by the fact that her own daughter was diagnosed with schizophrenia–a challenge that propelled her to get a professional degree.

I love our new library, and I’m glad that the library and Tulsa’s Family and Children’s Services are doing what they can to offer help to those in need.

Health is More than Health Care

When we think about achieving good health, it’s natural to think of visits to the doctor for “checkups” and age-appropriate interventions like vaccinations or cancer screening.

But here’s something you might not know: The “health care system” as we know it, an American industry on which we collectively spend $3 trillion annually, only accounts for one-fifth of our overall health.

Twenty percent? How can so much spending impact so relatively little of our well-being?

 

Well, it turns out other factors collectively have a much greater impact:

 

Genetics: To whom we are born impacts our health profoundly. If our parents are blessed with long, healthy lives, then we are much more likely to be, too.

 

Education: The better our education, individually and collectively, the more we can achieve in life. Education is tied to income (something we all know), but it also correlates directly to health outcomes in aggregate. Cutting investments in common and higher education is sabotaging our children’s future — not just in earning potential, but in real health: more suffering and earlier death.

 

Employment: The ability to earn a living wage means that people can be financially solvent and participate in the consumer economy. Given a choice, almost no one would choose handouts. People want meaningful work — work that employs our skills and engages our minds.

 

A diverse economy that grows new businesses means more job opportunities that not only pay the bills but allow us to invest in our families, homes, and communities.

 

Environment: It’s well known that those residing in certain Tulsa ZIP codes have life spans on average 11 years less than those in more affluent parts of the city (This difference has actually lessened from 14 years over the last decade.) Mayor G.T. Bynum has made reducing this disparity one of his administration’s central goals, as celebrated in a recent editorial in this newspaper.

 

We also know that when our neighborhoods are safer, we increase the likelihood that we will move our bodies more — which along with nutrition is the single greatest predictor of good health.

 

And of course: Nutrition! Access to healthy food and safe water is something that most of us take for granted. But many areas north, east and west of downtown Tulsa are literal food deserts — places with greater than two-mile gaps between locations where fresh fruits and vegetables can be purchased. And our Tulsa public transportation options barely ease this burden.

 

Nutrition and exercise are the two health determinants over which we have the most direct individual control. (How are you doing with those New Year’s resolutions so far?)

 

We can’t choose our parents, or therefore our genetics. But collectively, if we are in agreement that we want Tulsa to be a place of improving health, we do have a lot of say in how we manage our neighborhoods, our food supplies and our educational attainment.

 

At the University of Oklahoma-University of Tulsa School of Community Medicine the curriculum emphasizes study and advocacy of these so-called social determinants of health — beyond the “traditional” organ-based pathologies. We believe that interdisciplinary understanding of these factors — which can lead to exorbitant stress — will help to reduce the burden of ill health in our population as we age.

 

Tulsa has an opportunity to become a “Blue Zones” city like Shawnee and Fort Worth, Texas, recent cities that have contracted with Healthways to make structural changes to spur better health. The Blue Zones idea comes from the discovery of the five places in the world where citizens live the healthiest and longest lives because of exercise (walking most places), nutrition (more plant-based diets), and social connectedness.

 

We have the ingredients here in Tulsa to take on such a challenge, and working through the updated Community Health Improvement Plan that will soon be released by the Tulsa Health Department, we can all choose to live healthier lives — both individually and as a community.

 

Amazingly, we can do all of this regardless of our need to interact with our “health care system.”

 

Note: This essay appeared as an op-ed in today’s Tulsa World

Gleaning up after Thanksgiving

food-bank-frontWith the holiday season upon us, our thoughts often turn to those in need — of food, clothing and shelter.

I recently attended the Oklahoma Food Security Summit and was struck by a presentation about the practice known as gleaning, a term I’d never heard before.

The U.S. Department of Agriculture defines gleaning “as the act of collecting excess fresh foods from farms, gardens, farmers’ markets, grocers, restaurants….or any other sources, in order to provide it to those in need.”

In other words, getting food that would otherwise go to waste to those in need. This is how many food banks originated.

I interviewed Katie Plohocky, co-founder and director of Tulsa’s Healthy Community Store Initiative about one of its programs called “Hands 2 Harvest,” which is a gleaning effort for much of Tulsa.

In a nutshell Plohocky gathers volunteers to go to local farms and harvest crops that would otherwise be left to rot or plowed under because of minor blemishes or lack of farm labor. She then either sells this produce in her mobile grocery or distributes it to the Community Food Bank of Eastern Oklahoma or other local food pantries.

One of the things Katie and I discussed was how food distribution often is misaligned between food available and folks’ needs. Seems like there should be an app for that…

Also because of the season, the ever-reliable Oklahoma Policy Institute posted this video debunking myths about food insecurity. Great minds, as they say…

Caring Center is a Win-Win

Bama stacks wwwThe Bama Companies of Tulsa, Okla. made what I see as an historic announcement last month.

The company, a privately-owned global manufacturer of pies, biscuits (McDonald’s) and dough (Pizza Hut) has more than 1000 employees.

CEO Paula Marshall believes in second chances, making a practice of hiring parolees and those (particularly women) out of treatment for chemical dependency.

Marshall noted that there is a critical threshold, at 3-4 months of employment, where tardiness and absenteeism start to occur in many of these new hires — often resulting in termination or resignation.

Since it’s costly for the company to recruit and train new talent (Marshall puts the number at $5500 per employee), she figured it is wise to invest in helping employees surmount the challenges they face in maintaining employment — factors outside the workplace — like childcare, financial planning, transportation, and counseling.

[For decades the company has offered in-house medical services, which will continue with the new initiative.]

The company frames the decision to open it’s “Caring Center” as a business decision, but it’s clearly one with a heart.

To me, the plan reinforces the idea that it’s not strictly what happens within the walls of a medical setting that impacts people’s health. It’s the social determinants of health that have a bigger impact on health– education, environment, employment, access to adequate nutrition.

Opinions on the project vary. Some say Bama’s ‘Caring Center’ is nothing more than a glorified Employee Assistance Program (EAP). But in my view, EAPs are usually handled by 3rd party contractors, have limited uptake, and are focused more exclusively on mental health (important, to be sure, but not as broad as Bama’s effort).

Others ask, “Why not simply pay the employees more?” That is indeed a laudable goal. But arguably it’s the educational efforts and resource-matching that the Caring Center provides that will make more of a difference in employment sustainability. If an employee can keep his/her job, s/he will have more opportunity to climb the economic ladder. Bama, for example, like many companies, seeks to retain and grow talent from within.

Only time will tell if Bama’s Caring Center is impactful or not. Marshall has set the bar at what seems like an achieveable level: She hopes to lower the rate of employee loss from 8/10 to five or six out of ten to achieve financial success for the company. But if she succeeds, that’s many lives that will be impacted.

Will more companies choose to make these types of investments?

A New Hero

I have a new hero. Her name is Mona Hanna-Attisha, MD, MPH.

monahannaattishaDr. Hanna-Attisha is a pediatrician in Flint, Michigan. She grew up in a suburb of Detroit. She graduated from the University of Michigan before attending medical school at Michigan State University. During her clinical years (the 3rd and 4th years of medical school), she spent many months at Hurley Medical Center in Flint, which serves as a clinical training site for MSU medical students (far from the flagship campus — something I can relate to).

As you may know from recent news, Flint has had some problems — especially due to an overabundance of lead in its drinking water.

For cost-saving reasons, the city of Flint switched the source of its drinking water from the Detroit system to the Flint River in April 2014. Almost immediately residents of the town began noticing the water looked, smelled, and tasted different. It took nearly a year and half for both state and federal officials to acknowledge that there was too much lead in the Flint water — repeatedly questioning the evidence that it was so.

That’s where our new hero comes in.

Dr. Hanna-Attisha directs a pediatric residency training program at Hurley. There are 190 pediatric residency training programs in the United States, training in total about 2600 pediatricians every year.

I can relate to this part of her job — my most recent role was directing an Internal Medicine residency. Though the medical issues are different (kids vs. adults), residency program directors have three essential jobs: recruiting medical school graduates, charting the learning curriculum, and making sure the program stays accredited.

Program Directors become role models for trainees. We try to inspire and motivate residents, offering career and life advice during what is a demanding three year training curriclum.

On top of clearly being good at this role for her residents (7 per class for a total of 20 or so residents), Dr. Hanna-Attisha uses her MPH training to do science — in this particular case epidemiology.

She combed through records at her medical center and discovered that lead levels measured in children’s blood in Flint (as part of routine pediatric care) had on average nearly doubled since the time of the water source switch. Though her claims were at first disputed by state officials, Dr. Hanna-Attisha kept at it, talking to parents, hospital leadership, and advocating with state and federal officials.

In the end, the simple elegance of her team’s science got the message across. The story has now received national attention, including the declaration of a federally-recognized ‘State of Emergency’ in Flint over its water supply.

I was researching Dr. Hanna-Attisha, and came across this TED-like talk she gave at a Michigan State College of Medicine event in 2014. It predates the Flint water story, but it shows her to be a dedicated public servant — not only committed to her trainees and her patients, but beyond that to questioning the very core of what makes people unhealthy: the social determinants of health.

Take a look and let me know what you think.

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