Category Archives: Social determinants of health
This week, David Fleming, MD, MPH, stepped down as public health director of Seattle and King County in Washington State after seven years leading the public health agency. Over that period, among many other accomplishments, he led the department’s efforts to sign up more than 165,000 residents under the Affordable Care Act and oversaw a 17 percent drop in obesity rates in partnering schools.
NewPublicHealth spoke with Fleming about his views on the mission of public health.
NPH: How has public health changed since you began your career?
David Fleming: The mission of public health has not changed—and that's to prevent unnecessary illness and death—but what has been changing is what the nature of that prevention is. Increasingly, it is in chronic diseases, injuries and, importantly, the driving force of underlying social determinants of health. So public health has changed from being more of a direct service agency where we have frontline public health workers who are out there providing treatment to people and preventing infectious diseases, to really more of a collaborative kind of agency where we need to be working with a wide range of partners outside of the traditional domains of public health to help them implement the changes that need to happen. It's a fundamental shift, I think, in the business model of public health that we're in the process of witnessing today.
NPH: When you point to some of the achievements that you've had, whether they're specific changes in the state or specific models of examples that you've given to other states, what would you point to?
Fleming: First off, I think it's important to say that public health is a team sport, and so when I talk about accomplishments, I'm talking about accomplishments of the department in which I work on this and the staff that work here. I think that we have been successful at pivoting to that future that we were talking about a moment ago, at looking at how health departments can attack the underlying social determinants of health.
Increasingly, it is health disparities that are driving poor health in this country. We have been successful here in beginning to figure out how to partner with other sectors—the education sector to reduce obesity in our poorest school districts, for example. We’ve also worked with the community development sector to begin making investments in our poorest neighborhoods to increase the healthiness of our communities, so that people who live in them can be healthy, as well. At the end of the day, I think that we have been trying to lead this new path where public health is a partner in communities with all of the other entities that are capable of influencing health and figuring out how to make that happen.
In 2012, a new campus was constructed for the Buckingham K-5 public school in rural Dillwyn, Va., replacing the original middle and high school buildings that had stood since 1954 and 1962.
The Charlottesville, Va., architectural firm VMDO Inc., which constructed the campus, says the sites were transformed into a modern learning campus with the aim of addressing the growing concerns of student health and wellbeing. New facilities include a teaching kitchen; innovative food and nutritional displays; an open servery to promote demonstration cooking; a food lab; a small group learning lounge; scratch bakery; dehydrating food composter; ample natural daylight; flexible seating arrangements; and outdoor student gardens.
The firm took advantage of the school’s natural setting surrounding a pine and oak forest and wove them into the design and construction to showcase the “active landscape.” The school’s project committee and design team worked collaboratively to create a total learning environment in order to support learning both inside and outside the traditional classroom. Each grade level enjoys age-appropriate outdoor gardens and play terraces, which encourage children to re-connect and spend time in their natural surroundings. Inside the schools, in addition to core classrooms, each grade level has small group learning spaces that transform pathways into child-centric “learning streets” that have soft seating and fun colors that communicate both collaborative and shared learning experiences.
To study the impact of the healthy design features, VMDO teamed with Matthew Trowbridge, MD, MPH, an associate professor at the University of Virginia School of Medicine, with a special interest in the impact of the built environment on public health to study how health-promoting educational design strategies can support active communities and reduce incidence rates of childhood obesity.
NewPublicHealth recently spoke with Trowbridge about the project.
NewPublicHealth: How did the project come about?
Matthew Trowbridge: Through a collaboration between me and Terry Huang, who was a program officer at the National Institute of Child Health and Human Development and a leader in that institute’s childhood obesity research portfolio. [Editor’s note: He is now a Professor and Chair of the Department of Health Promotion, Social & Behavioral Health University of Nebraska Medical Center College of Public Health.] Back in 2007, Terry had been thinking about how architecture, and particularly school architecture, could be utilized as a tool for obesity prevention. The thinking behind that is that schools have always been a particularly interesting environment for child health very broadly, but also obesity prevention in particular, partly because children spend so much time at school and because the school day provides an important opportunity to help children develop healthy lifelong attitudes and behaviors.
One of the insights that Terry had was that while public health had done a lot to develop programming for school-based obesity prevention, the actual school building itself had really not been looked at in terms of opportunities to help make school-based obesity prevention programs work most effectively. In 2007, Terry actually wrote a journal article outlining ideas for ways in which architecture could be used to augment school-based childhood obesity prevention programs that was published in one of the top obesity journals. When I met Terry at NIH, we realized we both shared an interest in moving beyond studying the association between built environment and health toward real world translation. In other words, providing tangible tools and guidelines to foster collaboration between public health and the design community to bring these ideas into action.
Building a Culture of Health means building a society where getting healthy and staying healthy is a fundamental and guiding social value that helps define American culture...and it’s a mission that communities across the country are eagerly taking on. They include the six communities honored by this year’s Culture of Health prizes from the Robert Wood Johnson Foundation (RWJF), who are coming together today and tomorrow at RWJF’s Princeton, N.J. campus to celebrate their efforts and share the lessons learned. Picked from more than 250 submissions, these six communities are leading some of the nation’s most innovative public health efforts.
The RWJF Culture of Health Prize was launched to further the work of the County Healthy Rankings & Roadmaps program, which aims to educate the public and policy makers on the multiple factors that influence community health—such as education, economic conditions and the physical environment—and to provide solutions that will improve community health. The prizes honor communities that place a high priority on health and bring partners together to drive local change.
Health Beyond Health Care: RWJF-Sponsored Washington Post Live Event Sparks Conversation on Creating a Culture of Health
“Health Beyond Health Care” was the focus of a Robert Wood Johnson Foundation (RWJF)-sponsored Washington Post Live Forum today that looked at how creative minds in traditionally non-health fields—such as bankers, architects, designers and educators—are working together to build a Culture of Health in the United States.
“No matter where you live and how much money you have, you should have the opportunity to live a Culture of Health,” said RWJF President and CEO Risa Lavizzo-Mourey, MD, MBA.
>>View the full archived live stream of the forum.
Lavizzo-Mourey said RWJF began its work on the concept of a U.S. Culture of Health in 2009, when the foundation’s Commission to Build a Healthier America released a report recommending the concept. Last year, the Commission came together to see what progress had been made. Among the sites embracing the concept is Marvin Gaye Park in Washington, D.C. Once known as “Needle Park,” the community has transformed itself through lighting and landscaping. This was possible “because the community embraced the principles of a Culture of Health and demonstrated how, from the ground up, people partnering can change the nature of their community and make it healthier,” she said.
Pointing to the most recent Commission report, Lavizzo-Mourey said that looking at communities undergoing changes pushed the Commission to conclude that in order to improve health as a nation, we have to change communities—especially low-income communities—so that people can make healthy choices every day. That also means that health care has to connect with non-health care.
“Each of you,” she told the audience of thought leaders and policy makers, “is uniquely positioned to make changes that can get us to a nationwide Culture of Health.”
The day’s speakers spoke about innovations in their fields that are helping to create local changes in health, and which are often scalable for communities across the country.
“The most successful projects are those that start with bringing communities together to first assess the need, and then prioritize them and move forward with a particular project,” said Sister Susan Vickers, RSM, Vice President of Community Health, Dignity Health, who added that just about all the loans that Dignity Health has made to nonprofits in the community have been repaid.
Why a focus on health? “Health summarized all [of the other factors],” said David J. Erickson, PhD, Director, Center for Community Development Investments, Federal Reserve Bank of San Francisco. “The best predictor for future health for a third grader is whether they are reading on a grade level. Community development is big, but not big enough, and the medical system is not big enough either. We need to start aligning all of these sectors so we’re all working in the same direction to turn these neighborhoods around.” [Editor’s Note: Read a previous NewPublicHealth Q&A with Erickson.]
“We have to treat health as a national treasure—a natural resource—and put it up on the level of the seriousness of the economy,” said Rear Adm. Boris D. Lushniak, Acting U.S. Surgeon General. “The economy doesn’t do anything without a healthy people.”
Place Matters is a national initiative of the Joint Center for Political and Economic Studies, a non-profit organization based in Washington, D.C., whose mission it is to improve the lives of African Americans and other people of color through policy analysis and change. The Place Matters initiative was designed to build the capacity of local leaders around the country to identify and improve social, economic and environmental conditions that shape health. Nineteen teams are working in 27 jurisdictions.
NewPublicHealth recently spoke with seven Place Matters teams about their ongoing efforts. We will be showcasing their work in a series that begins today with a conversation with Brian Smedley, PHD, Vice President and Director of the Joint Center’s Health Policy Institute.
NPH: What are some initial steps that a community has to take when making changes in order to impact health?
Brian Smedley: Several things we believe are important, and these are principles that we employ in our Place Matters work. One is first and foremost to start with the very communities that are most affected by economic and political marginalization and that have suffered from disinvestment for years. These are often communities that have the leadership and sources of strength and resiliency to begin to tackle these problems. We believe that engaging with communities; identifying their key concerns; identifying the sources of strength and resiliency in the community; and finding out from the community what their vision is for a healthy and vibrant community are all important first steps for anyone engaged in this kind of work.
We also believe that there’s an important role for research to document the inequitable distribution of health risks and resources, and to show how that often correlates with patterns of residential segregation. We have worked with our Place Matters teams to produce what we call community health equity reports, where we document such issues as where people can buy healthy food; how close polluting industries are to neighborhoods and residential areas; sources of jobs; and neighborhoods that have high levels of poverty concentration.
“Of all the forms of inequality, injustice in health care is the most shocking and inhuman,” said the Rev. Dr. Martin Luther King Jr. in 1966 at the Convention of the Medical Committee for Human Rights, which was organized to support civil-rights activists during Mississippi's Freedom Summer. Those words are part of the Health is a Human Right: Race and Place in America exhibit on display at the David J. Sencer Centers for Disease Control and Prevention (CDC) Museum in Atlanta. The museum, located at the CDC’s Visitor Center, mounts several exhibits each year. The timing for the Health as a Human Right exhibit coincides with National Minority Health Month, observed each April to raise awareness of health disparities in the U.S. among ethnic and racial minorities.
The CDC exhibit, curated by museum director Louise Shaw, is organized by social determinants of health such as housing and transportation. Photographs, like those of teeming settlements in urban cities, are a key tool to show museum goers and online viewers the health disparities in U.S. history and present day.
Among the items in the exhibit:
- Mexican men sprayed with DDT on their arrival for a guest worker program in the 1950s.
- A corroded sanitation pipe and bottles of unsafe drinking water from the Community Water Center in the San Joaquin Valley, California.
- An inventive and cheap air sampler from New Orleans that people used to catalogue pollution levels and share with law makers.
- A Chinese version of the "Be Certain: Get Tested for Hepatitis B," campaign.
- A March of Dimes poster depicting an African American child with polio from the late 1950s. (For a long time after the polio epidemic began, many believed African Americans could not contract the virus. As a result, precaution campaigns were rare and late among that population.)
The exhibition is sponsored by CDC's Office of Minority Health and Health Equity, the CDC's Office of the Associate Director for Communication and the California Endowment.
NewPublicHealth spoke with Louise Shaw in Atlanta.
NewPublicHealth: What made you decide to mount and curate this exhibit?
Louise Shaw: Three years ago the CDC Museum was approached by CDC’s Office of Minority Health and Health Equity (OMHHE) to organize an exhibition to commemorate its 25th anniversary. As curator of the Museum, I was excited by the possibilities and conceived of a project that extended beyond just honoring OMHHE accomplishments. Dr. Leandris Liburd, OMHHE director, and her terrific staff, quickly jumped on board, and we all agreed to develop a historic exhibition framed by the social determinants of health.
NPH: What are some of the most striking issues you found in disparities between whites and minorities when it comes to social determinants of health?
Louise Shaw: Although we have made progress in many areas, we are still tackling similar issues in the 21st century that were debated 100 years ago. For instance, how we provide quality education to all children, regardless of race, ethnicity, or income status, was and is one of the greatest challenges facing our country. As the Robert Wood Johnson Foundation has documented, education and the optimum health outcomes are closely linked. Ultimately, education is the pathway to eliminating health disparities. Income equality/inequality is another complex issue that is being hotly debated today. One more specific example: although pre-term birth rates have greatly declined over the past century among all groups, the disparities of those rates between whites and minorities stubbornly remain, and are yet to be eliminated. We need to ask ourselves why that is so. Collectively, we have still not resolved what it means to live in a diverse, multicultural society.
NPH: Do you know of any outcomes that have come from the exhibit?
Louise Shaw: Internally at CDC, the exhibition has been an important touchstone for discussion and debate. I have received incredible feedback about the honesty of the exhibition, thanking me for connecting the dots visually among race, place, and health. By the time it closes on April 25th, over 30,000 people will have seen the show. I don’t think we have ever mounted an exhibition that has been visited by so many college and university students — some even virtually. A consortium of faculty members from the University of Connecticut, Emory University, and Georgia State University, have developed a formal evaluation tool. In addition, there is a local and national movement underfoot to figure out how the show can live on whether online or in another form.
The County Health Rankings and Roadmaps, a collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute, will celebrate its fifth anniversary next month. In the last few months, NewPublicHealth has been reporting on the work of programs grantees that are making changes in their communities to help improve population health.
Utah’s Salt Lake County ranks 20th out of 27 counties in social and economic factors. Its high school graduation rate is 72 percent, below the state rate of 76 percent. Approximately 19 percent of the county’s children live in poverty, compared with 16 percent state wide.
South Salt Lake, a city in Salt Lake County, has many resources and assets that make it a great place to live. However, the city’s residents also deal with challenges similar to those faced by individuals living in the elsewhere in the country. Nearly half of South Salt Lake’s residents live in homes with annual household incomes less than $35,000. Among similar-sized communities in Utah, South Salt Lake has some of the highest rates of obesity, chronic cigarette smoking, binge drinking, mental illness and prescription drug abuse. In previous years, South Salt Lake has had the highest rate of violent crime in Utah, but over the past three years the city has noticed a 76 percent decrease in gang-related juvenile crime and a drop in overall crime of 23 percent.
In spite of these challenges, the schools, community partners and the City of South Salt Lake share a common goal to ensure all of the city’s kids are performing on grade level, graduating high school and pursuing a post-secondary opportunity. To create a foundation to allow children to achieve these goals, United Way of Salt Lake, the City of South Salt Lake and numerous other partners have created the Early Learning Network, a comprehensive, integrated early learning system for children from birth to age five. The program is critical because research shows that evidence-based investments in children from birth to age five improve school readiness; lower rates of crime, teen pregnancy, substance abuse and obesity; are essential to academic achievement; and have a direct impact on people’s health and financial well-being.
The goal of the Early Learning Network is to make sure that by the time a child enters kindergarten, he or she will be ready to learn.
The Early Learning Network is a recipient of a County Health Rankings and Roadmaps community grant. Grantees are funded to work with diverse coalitions of policy-makers, business, education, health care, public health and community organizations to improve the education system in ways that also better the health of the community. Roadmaps to Health grants support more than two dozen projects across the United States that aim to create healthier places for individuals and families to thrive. The Roadmaps to Health Community Grants project is a critical component of the County Health Rankings & Roadmaps program.
NewPublicHealth recently spoke with Elizabeth Garbe and Chris Ellis of United Way of Salt Lake.
NewPublicHealth: Tell us about the Early Learning Network.
Chris Ellis: The Early Learning Network is a coalition of early childhood providers, basic needs groups, government agencies and health organizations. The primary goals of the group are to ensure that kids are demonstrating age-appropriate development and entering kindergarten ready to learn. The Early Learning Network is focused on a specific geography, the City of South Salt Lake. It is a great example of collective impact, as non-profits, businesses and government agencies are working together to determine the most effective way to support children ages 0-5 in this community.
The Network has discussed baseline measures to better understand what services are needed to support the community. Collecting data to set a baseline is essential in order to demonstrate whether we are making any progress on our two goals.
Many of the sessions at the National Association of Counties (NACo) Health Initiatives Forum meeting in San Diego this week have been moderated by Nick Macchione, director of San Diego’s Health and Human Services Agency and vice chair of the Healthy Counties Initiative Advisory Board. Macchione is a key architect of Live Well San Diego, a program voted in by the San Diego Board of Supervisors that is a long term, comprehensive and innovative strategy on wellness with a goal of helping all San Diego County residents become healthy, safe and thriving.
NewPublicHealth spoke with Nick Macchione ahead of the forum. Senior Policy Advisor Julie Howell and Dale Fleming, director of strategic planning and operational support, joined the conversation.
NewPublicHealth: The buzz about San Diego is that you’re working hard toward population health improvement.
Nick Macchione: I think the excitement about San Diego is that we have earned a reputation as a health innovation zone by having a collective impact on health and wellness. Our deeds demonstrate our words because over the past decade there have been five major broad-based population health improvements: reduction of heart disease and stroke; reduction of cancer rates; reduction of childhood obesity; reduction of infant mortality; and reduction of children in foster care. That reduction is extremely important to population health because we also look at the social determinants of health and not just pure health care.
We've taken an ecological approach to population health—working with partners across all sectors and coming together not just from traditional health care but beyond that to public health, social services, business, community, schools and the faith community.
And we’ve done that in the context of optimizing existing resources to improve outcomes. We’ve been blessed with a lot of competitive federal grants and philanthropy investments, but really the framework is how we leverage and optimize what we have first before we go and seek to augment with other resources. That has worked exceptionally well and that’s earned us that innovation zone reputation.
NPH: Tell us about Live Well San Diego.
Macchione: Live Well San Diego is a comprehensive public health initiative that involves widespread community partnerships to address the root causes of illness and rising health care costs. The tagline is healthy, safe and thriving. We think it’s a great template that communities can use, it’s transferable because San Diego has every imaginable bio-climate except a tropical rainforest. So we have desert towns, we have rural communities, we have mountain villages, we have beach towns and everything in between urban core. We also call it Project 1 Percent because 1 percent of San Diego represents the nation both in its diversity and its population. So, if we can achieve what we're achieving on advancing population based health in a broad scale it can be demonstrated throughout the country.
The U.S. Department of Housing and Urban Development (HUD) recently posted an interview with Teresa Bainton, director of the New York Multifamily HUB, which manages multifamily housing programs in the Northeast. Bainton’s job puts her in constant contact with families, veterans, seniors, developers, elected officials and building owners and managers. Bainton says the work, though so rewarding, is especially challenging in the Northeast, where housing prices are often higher than average costs for the rest of the United States.
>>Read the full interview.