Population Health Blog

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Addressing toxic stress among immigrant populations

By Dennis Archambault

The immigrant experience in America has never been comfortable. However, a recent analysis of current immigrants from Latino and Muslim backgrounds has shown high, persistent toxic stress, causing health providers to project long-term consequences. As we learn more about the correlation between oppressive stress and health, we’re challenged to identify solutions.

The Kaiser Family Foundation has published an issue brief on the topic, “Living in an Immigrant Family in America: How Feear and Toxic Stress are Affecting Daily Life, Well-being, & Health. (https://www.kff.org/disparities-policy/issue-brief/living-in-an-immigrant-family-in-america-how-fear-and-toxic-stress-are-affecting-daily-life-well-being-health/?utm_campaign=KFF-2017-December-Immigrant-Families-Lawfully-Undocumented&utm_medium=email&_hsenc=p2ANqtz-8xI-zjSyEnYAmzKe6jnP2CY_kFRn5345TQyL7bITQBtN1Fq5lSNAqyaVfwortyfzUUKjYRE2DWRV-8hLhc1s3dHMU2eg&_hsmi=59313422&utm_content=59313422&utm_source=hs_email&hsCtaTracking=1196ea7e-a1b6-40eb-a050-e5c7a95a7e6b%7C97ced1cb-5293-47c5-b9f0-10dca70ce629)  As one pediatrician noted in the document, “When you’re worried every day that your parents are going to be taken away or that your family will be split up, that really is a form of toxic stress…we know that it’s going to have long-term implications for heart disease, for health outcomes for these children in adulthood.”

As this issue gains greater exposure, mental health, public health, and integrated primary care providers will become more engaged in solutions. The problem is, most solutions require some funding. Whether it’s increasing access to community mental health services or community organizing around resilience, population health comes at a cost. Unfortunately, we’re more concerned about limiting access for immigrants, than creating a healthy environment for those who are here.

Immigrants have always helped define the future of America. If the current wave of immigrants is crippled by untreated toxic stress, the cost to society will be much greater than addressing issues today.

Dennis Archambault is vice president of Public Affairs for Authority Health. Authority Health will be hosting a population health forum on toxic stress and resilience in April 2018.

Anticipating an epidemic among socially isolated older adults

By Dennis Archambault

“I want to be alone.”

– Greta Garbo

There’s really nothing new in the recent New York Times headline, “How Loneliness Affects Our Health,” except a reference in the body of the article (https://www.nytimes.com/2017/12/11/well/mind/how-loneliness-affects-our-health.html?_r=0) that it is a “growing epidemic.”

Social isolation is a problem for anyone. It affects one’s ability to thrive in incremental ways, sometimes impacting mental health and overall wellness. For older adults, isolation from social engagement — work, society, family — not only contributes to depression, but has a biochemical impact, “raising the levels of stress hormones and inflammation, which in turn can increase the risk of heart disease, arthritis, Type 2 diabetes, dementia and even suicide attempts.”

It’s not that social isolation itself is the trigger for health issues. The article notes, “People can be socially isolated and not feel lonely; they simply prefer a more hermitic existing. Likewise, people can feel lonely even when surrounded by lots of people, especially if the relationships are not emotionally rewarding.”

We became acutely aware of this risk when the Griswold Building was converted from a HUD-underwritten low income senior apartment building to a market-rate apartment. One hundred and fifteen residents were evicted, most of them frail elderly. The trauma of the dislocation was profound. But the situation raised the question, how was the quality of the mental and physical health of these residents? Not being in a structured senior community, social isolation was likely to be profound. How do we address the well-being of this population as America ages. Virtual connectivity may help establishing linkages, but it doesn’t replace the mental and physical quality of real time human engagement.

While the researchers conclude that loneliness is not limited to the frail elderly, the disconnectedness of society is certain to increase and with it the challenge of maintaining the health of this population.

Dennis Archambault is vice president, Public Affairs, for Authority Health.

Kaiser: Time for health systems to help mitigate social determinants

By Dennis Archambault

The Patient Protection and Affordable Care Act (ACA) underscored the importance of health systems to identify and meet the health needs of the areas immediately adjacent to their hospitals, not just the market segments they wish to serve. This is one of the unsung qualities of the much publicized law. In meeting this requirement, hospitals have been identifying these needs and developing action plans for addressing the needs, leveraging community resources. However, this work is largely done in isolation.

An analysis of Baltimore, one of the cities with the worst asthma rates, has concluded that hospitals need to invest on the front end of the problem, not profit from the patient care required at the back end. A report published by the Kaiser Health News and University of Maryland Capital News Service (https://khn.org/news/hospitals-find-asthma-hot-spots-more-profitable-to-neglect-than-fix/?) notes, “The medical system knows how to help. But there’s no money in it.”

The article references a resident of the zip code with the worst asthma rate, 21223, where an abundance of houses are in disrepair or abandoned, rodents and bugs trigger the disease, and few community doctors are working to prevent asthma emergencies. “Like hospitals across the country, (Baltimore hospitals) have done little to address the root causes of asthma. The perverse incentives of the health care payment system have long made it far more lucrative to treat severe, dangerous asthma attacks than to prevent them.”

Ben Carson, a retired pediatric neurosurgeon and Secretary of Housing and Urban Development concurs: “The cost of not taking care of people is probably greater than the cost of taking care of them… It depends on whether you take the short-term view or the long-term view.”

The ACA requirement is significant not only in getting hospitals to assume responsibility for the geographic area where they are situated, but also in preventing the conditions they treat, and profit from. It’s a significant adjustment for hospital marketing processes, which have for years targeted services and populations that are most profitable. Now, to retain their tax-exempt status, they must become allies in population health management. It may, in the end, contribute to the downsizing of the health care industry. On the other hand, as the euphemism goes, it may “right size” the industry.

Dennis Archambault is vice president, Public Affairs, for Authority Health.

Where’s the political will to create low income housing?

By Dennis Archambault
With the domination of international, political, and sex scandal coverage in the news media (actual and “fake”), it’s difficult to get a reading on domestic U.S. human service policy. For example, what is the Department of Housing and Urban Development (HUD) up to?

HousingWire https://www.housingwire.com magazine offers a glimpse into what HUD Secretary Ben Carson may be up to with an interview in its current edition. Secretary Carson quantifies a problem that has been evident for some time – 11 million renter households in America are severely cost-burdened, spending more than 50 percent of their income on housing. There are nearly 500,000 homeless families and 40,000 homeless veterans. Carson noted that essentially, HUD’s response its Rental Assistance Demonstration https://www.hud.gov/RADprogram, which allows localities to leverage public and private funds to ensure that public housing units are maintained and improved. However, there doesn’t appear to be funding for new development.

There are 11.4 million extremely low income (ELI) renter households in the United States, about 26 percent of all U.S. renter households and nearly 10 percent of all households, according to a 2017 report by the National Low Income Housing Coalition http://nlihc.org/sites/default/files/Gap-Report_2017.pdf. The U.S. has a shortage of 7.4 million affordable and available rental homes for ELI renter households, resulting in 35 affordable and available units for every 100 ELI renter households.

Certainly, many of those households are in Detroit and scattered throughout Southeast Michigan. Yet there doesn’t appear to be any new housing units planned. With all the abandoned apartments in the city, and certainly the gaps in the built infrastructure of the city, there’s plenty of space to house folks. All we need is the political will to make it happen. That requires considerable hope.

Dennis Archambault is vice president, Public Affairs, for Authority Health.

Detroit fugitive dust management ordinance represents necessary tactic for environmental health

By Dennis Archambault

Critics of environmental health advocates will often point to the absence of  “sound science”  or “conclusive evidence.”  The problem is, most advocates don’t have time or money that industry has to evaluate claims.  And conclusive evidence is seldom available. Although the evidence for the human impact on climate change has met the scrutiny of several legitimate scientific authorities, still the critics express doubt and procrastinate as long as profit can be made.

The resistance to an ordinance drafted by Detroit City Council Member  Rachel Casteneda-Lopez to implement tougher regulations on the transportation and storage of carbonaceous materials, such as  “pet coke,” has featured similar complaints: lack of scientific basis, existing federal, state, and county regulations on managing fugitive dust, a lack of complaints, and the potential impact on jobs. The ordinance originated with the discovery of mounds of pet coke stored in the open along the Detroit River.

As one researcher pointed out recently, decisions to act in support of public health should not wait until there is 100 percent certainty of the validity of the risk and the source of the problem. In event of public health and safety, decisions are made with the best information and greatest likelihood they will protect life.

Industry complains that increased regulation is unnecessary, will contribute to reduced profits and/or increased product costs, and possible job loss. Regarding the latter, some residents may question whose jobs would be lost, given that relatively few Detroit residents work for these industries.

The environmental quality in Southwest Detroit/Downriver Delta communities is much better than it was decades ago, but remains bad, especially as it pertains to lung disease. Industry research and development is generally oriented to maximum efficiency of production systems and worker safety. However, it should also include environmental impact. Industry can afford it. Advocates can’t. Academic researchers may contribute with grant-funded research, but by the time permit requests and other environmental actions are posed, there isn’t sufficient time for research to be undertaken.

The action by Council Member Casteneda-Lopez and other Detroit City Council members who passed the ordinance on Oct. 29 takes another step toward protecting their constituents and improving environmental quality for the region. It may cost industry a little more to implement, but it’s the cost of doing business in a healthy community.

For an account of the proceedings, read this Detroit Free Press article: http://www.freep.com/story/news/local/michigan/detroit/2017/10/31/detroit-pet-coke-regulations/817246001/

Dennis Archambault is vice president, Public Affairs, Authority Health.

Suburban ‘pockets of poverty’ create new challenge for population health

By Dennis Archambault

Canton, Livonia, Dearborn — you might not think of these suburbs as having residents who are impoverished. It’s been well-known since the last major recession and the collapse of the manufacturing center that employment was slow to recover and many households are struggling nearly a decade later. That struggle translates into critical social determinants that erode access to health and health status overall.

Crain’s Detroit Business asked the question about the role of philanthropy in addressing “poverty quietly growing in the suburbs” (http://www.crainsdetroit.com/article/20171022/news/642721/suburban-poverty-on-the-rise-but-is-philanthropy-following). It might have asked the same about the public and private health system. Community needs assessments are noting these growing pockets of poverty, as are other initiatives like Healthy Dearborn, which has noted areas of food insecurity in that community, which has access to quality produce markets in almost ever sector of its geography.

Poverty is no longer geographically centered in urban centers like Detroit or its working class suburbs like Ecorse, River Rouge, and Inkster. In many cases its invisible, such as the homes of some refugee families that have no furniture. “Low-wage jobs, older housing stock that is less desirable and less expensive and drawing lower-income populations and the loss of jobs tied to the shift from a manufacturing economy are spurring the growth of poverty,” notes Alan Berube, senior fellow at the Brookings Institution.

There certainly is a role for philanthropy. But this is also a growing public health challenge that needs to integrate the resources of the private health system. The Crain’s article suggests that suburban poverty tends to grow, it doesn’t recede, but may be ignored. Health issues driven by the social determinants of poverty affect the neighbors of more affluent people as it does larger communities.

“Detroit is not an island,” notes Tonya Allen, CEO of the Skillman Foundation.

Dennis Archambault is vice president, Public Affairs for Authority Health.

Enduring the culture of crime: calling for resilience

By Dennis Archambault
It’s nothing new; certainly not for communities like Detroit that have been living with high crime rates for decades. You get by or get out. You cope.

The Detroit News is running a series of stories under the categorical heading of “coping with crime.” What is often misunderstood with the focus on statistics – whether or not they are accurate and whether or not Detroit is the number one crime city or somewhere near the top – is that there is a residual erosion of wellness in the community impacted by the knowledge of people who have been victimized and the fear that permeates the culture.
The city has an average of six killings a week, not to mention property crimes. The cumulative effect of knowing this through anecdotes that is near as a neighbor affects people. Even though thousands of Detroiters may not be affected by crime, they are affected by living in a culture of crime and the awareness that it’s happening and could happen to them. This makes you sick, mentally and physically. It diminishes the will to exercise outdoors. It encourages you to eat comfort food which is likely to be detrimental to your health.

Coleen Farm, also with Mothers of Murdered Children, said she’s had a tough time recovering after the fatal drive-by shooting of her son Don Adams Jr. on July 24, 2012.

“It was really overwhelming to deal with,” she said. “I had a major weight loss, sleepless nights. I was edgy — I would go from zero to 100 in two seconds. I would sleep all day. I didn’t want to be bothered with my other children, my family members. I was crying continuously.”

The resilience movement is designed to empower communities to get beyond enduring a crime-ridden culture to creating a community of caring. Impoverished areas enduring a culture of crime and violence can’t sleep well; can’t eat well; can’t learn. Sure, some will overcome and thrive. The social Darwinians would call them among the fittest; the others must fend for themselves. But the ethic of population health suggests that we have a social responsibility to lift all for the greater good.


Dennis Archambault is vice president, Public Affairs, for Authority Health

When it comes to treating chronic stress, it will take a village effort

By Dennis Archambault

I recently had an opportunity to discuss psychotherapy and analysis with a young psychiatrist with a successful practice. He was confident that proper therapeutic intervention really improves the well-being of his patients, many of whom suffer deeply from psychological distress. One of the modalities we discussed was psychoanalysis, an expensive process that has shown to help people recover from severe psychological problems. To be effective, psychoanalysis requires multiple sessions on a weekly basis, often for a long time.

I explained to the psychiatrist that I represent an organization that promotes population health among low income, vulnerable populations where there isn’t sufficient access to mental health services and a lack of financial resources to afford more involved therapies like psychoanalysis, not to mention access to transportation to reach a psychoanalysis. He acknowledged the cost issue, but went further to confirm that people living in the lower economic strata of society endure such depth and breadth of cumulative trauma, that individual psychotherapy wouldn’t be effective.
That message came out of a conference on “Building a Resilient Community,” sponsored by Starfish Family Services http://www.starfishfamilyservices.org/ earlier this year. One of the concepts discussed was a form of community psychology, “trauma-informed community building.” While individual counseling is helpful , care must come through the ongoing reinforcement of a healthy community – specifically family and neighbors.

The State of Michigan offers a good resource list on “Building Trauma Informed Communities” http://www.michigan.gov/mdhhs/0,5885,7-339-73971_4911_69588_80205—,00.html. One of the sources cited was a Robert Wood Johnson Foundation program in Washington, promoting the “self-healing” of the community, which promotes collaboration across sectors of resources, empowers local leadership to think systemically, use data to focus initiatives, and ultimately “instill a real sense of hope in communities that had given up on the prospect of a better world for their children.”

In the absence of a progressive health policy at the national level, local solutions like trauma informed communities and support networks are worth pursue. But, to reference a familiar adage, it will take a village.

Dennis Archambault is vice president, Public Affairs, for Authority Health

Healthy community design requires resilience in the face of chronic stress

By Dennis Archambault

Chronic stress is increasing throughout society, but is becoming an oppressive force among safety net populations. This has been a topic of discussion among mental health and public health professionals for some time. Authority Health’s population health program, this year, is focusing on chronic stress and the application of resilience as a public health strategy.

The Rockefeller Foundation is in the midst of a “resilient cities” initiative http://www.100resilientcities.org/, supporting the work of 100 cities worldwide to become more resilient to the physical, social, and economic challenges that are part of the new reality of the 21st century. The foundation defines building urban resilience as “the capacity of individuals, communities, institutions, businesses, and systems within a city to survive, adapt, and grow no matter what kinds  of chronic stresses and acute shocks they experience. Acute shock is defined as sudden, sharp events such as earthquakes, floods, disease outbreaks, and massive violent experiences. Chronic stress is cumulative, like high unemployment, poverty, violence, and persistent physical and natural environmental disasters.

Resilience thinking demands that cities look holistically at their capacities and their risks. Society is learning that individuals can adopt resilient strategies for surviving repeated onslaughts of pressure points, but perhaps the most challenging lesson — and one that is directly related to healthy community design — is developing collective impact from the cohesion of a resilient culture. That will take some work.

Dennis Archambault is vice president, Public Affairs, for Authority Health.

Hospital mobile van addresses disparities, but what about causes?

By Dennis Archambault

Norwegian American Hospital in Chicago, one of the awardees in the 2017 American Hospital Association Nova Awards program, was credited with helping reduce health disparities among children on Chicago’s Westside through a mobile clinic. While access to transportation may be one of the social determinants addressed through the project (it wasn’t mentioned in the award narrative), other social determinants such as environmental quality, interior household and school air quality, lead abatement programs, and school health and fitness programs were not addressed.

The first two paragraphs of the narrative are revealing:

“Norwegian American Hospital serves some of Chicago’s neediest zip codes. The average per capita income in its core service neighborhood is $13,391, while the unemployment rate stands at 12 percent.

“Those numbers translate into health problems, such as childhood asthma, elevated blood lead levels and high rates of childhood obesity and teen pregnancy. Because they lack regular medical care, many children in the community can’t meet the vaccine requirements for public school registration.”

Norwegian American Hospital certainly is contribution to the public health infrastructure of Chicago through the mobile clinic, but what if it had approached the health issues addressed in the first two paragraphs – asthma, related to internal and external air quality; elevated blood lead levels related to lead-based paint in old housing stock; and high rates of childhood obesity and teen pregnancy. These are social issues the hospital could partner with public health authorities in its community benefit investment. Depending on your source, household air quality is a major contributor to up to half of asthma cases. (Locally, one community development corporation notes that during the winter, houses with forced air push contaminated dust up into the breathing space of children, increasing their risk to lung ailments.)

The ultimate irony in this case is that the mobile clinic addresses a major social determinant – transportation. Providing a mobile clinic financed through philanthropy – an unsustainable funding model – has limited applications. However, funding an alternative transportation system that provides patients access to primary care medical homes might be more cost efficient.
Speaking of funding, it’s curious that the program is entirely funded through philanthropy: children’s Care Foundation, Northern Trust Co. Charitable Trust, the Col. Stanley McNeil Foundation, and the Illinois Association of Free and Charitable Clinics. There doesn’t appear to be an investment by the hospital itself.

A mobile clinic connected with schools in underserved communities is a good idea and could deliver much primary care than would otherwise be provided to this community. But what if Norwegian American Hospital and its competitors found common purpose in this or other health disparities and decided to improve the social systems that helps create the health disparity? Is that still a radical concept for hospitals?

Dennis Archambault is vice president, Public Affairs, for Authority Health.