Population Health Blog

Population Health Blog

Why It Matters

Is loneliness among the elderly a population health problem for our time?

By Dennis Archambault

It’s not customary to read philosophy. Or, at least, few people I know tell me about the latest philosophy book or article they read.  Philosophers are thinkers and often have some pretty interesting things to say.

Kwame Anthony Appiah, a  philosopher in Ghana, wrote about a cautionary tale, “What will future generations condemn us for?”  Climate change is perhaps the best example of how various groups speak of our responsibility to the future and how we may be judged for our environmental stewardship. Appliah examines that, our prison system, and “the institutionalized and isolated elderly.”

The philosopher raises the ethical dilemma: “When we see old people who , despite many living relatives, suffer growing isolation, we know something is wrong. We scarcely try to defend the situation; when we can, we put it out of our minds. Self-interest, if nothing else, should make us hope that our descendants have worked out a better way.

Former Surgeon General Vivek H. Murthy, M.D., wrote about the epidemic of loneliness in the Harvard Business Review recently: “During my years caring for patients, the most common pathology I saw was not heart disease or diabetes; it was loneliness.”

Drs. Sachin H. Hain and Craig Sammitt, in their article, “The growing imperative to address senior loneliness,” https://catalyst.nejm.org/growing-imperative-address-senior-loneliness/add, “The problem of loneliness and social isolation is increasingly well-recognized as a societal ill, but maddeningly difficult to address. What can we do to address a problem that has roots that are not just economic, but cultural in nature, and that has downstream implications that include an undeniable effect on health?”

Here we have a population health issue as articulated from various perspectives. We are observing it close up in the population of elderly residents in HUD-contracted senior apartments in Midtown and Downtown. What is the level of their food security? How are they accessing health and social services? How is loneliness affecting their health and well-being?

As we strive preserve low income senior housing, we need to take the next step to preserving health and well-being and addressing the “imperative” of senior loneliness.

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

What about a new Model T as a solution to Detroit’s inability to achieve consensus on mass transit?

By Dennis Archambault

It’s difficult coming from the privilege of employment and automotive transportation to understand what it is like to walk and bus five hours a day for work, much less two part-time jobs paying minimum wage and probably not very rewarding. Yet Detroiters like Ashley Williams need to do that every day (see article in Crain’s Detroit Business http://www.crainsdetroit.com/print/653251).

A few years ago, James Robertson (a.k.a. “Walking Man”) enjoyed his moment of fame after the Detroit Free Press documented his ordeal of walking and busing 21 miles daily from his home in Detroit to a factor job in the suburbs.

It’s a coincidence that both destinations are in Oakland County, a county that stubbornly refuses to help create a regional transportation system that help establish a more equitable system of mobility for lower income populations. These two cases help illustrate, in dramatic detail, the way that access to transportation impacts health.

The Free Press, in a recent update https://www.freep.com/story/news/local/michigan/detroit/2018/02/24/walking-james-robertson-transit-driving/357047002/ added an element to the transportation issue that, ironically, factors into Robertson’s story. While Oakland County won’t help him get to work through a transit system, a crowd-funding campaign raised money to buy him a new car. This raises another dilemma between the prerogatives of philanthropic solutions to social problems and societal solutions for the “greater good.” But that’s another issue.

Robertson’s story was repeated at a presentation in Dallas, Texas, titled, “The Road to Economic Mobility.” A solution raised at that presentation may not follow the narrative of those who have fought the good fight to bring regional transition to the Motor City: an affordable car for the masses.
The spirit of Henry Ford I must have been present for that discussion. Ford, of course, designed the Model T and produced it as an affordable vehicle that would given transit independence to average people; not those in deep poverty, but those who were suddenly part of the employment explosion fueled by mass production of automobiles. “The nation’s urban poor people need affordable passenger vehicles, in addition to mass transit, if they’re to share in the American dream,” noted a Free Press reporter summarizing the Dallas presentation by Rolf Pendalla, senior fellow of the Urban Institute.

“It’s easy to picture a rail line or a bus route. What’s harder is to analyze just how people get to their destinations on chains of transportation methods,” Pendalla said. In fact, even if a form of mass transit were to be approved in Southeast Michigan region, its sprawling, decentralized development will still require connections and lost time, not to mention inconvenience in foul weather. This sprawl was encouraged by automotive transportation and will likely require an automotive solution, unless traveling five hours by bus or some form of light rail/bus connector is created.

What about creating an affordable car, subsidized in some way through grants to auto companies, tax credits for consumers, low cost insurance rates, and low interest loans? Despite an era of reduced commitment to funding social programs, surely sufficient wealth and innovative thinking exists among urban planners and automotive industry executives.

Henry Ford did it, and he wasn’t a socialist.

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

The unintended consequences of Trump’s proposal to eliminate SNAP payments with food delivery?

By Dennis Archambault

The Trump Administration admitted that the proposal to eliminate SNAP benefits through a direct-to-home food box distribution idea was a trial balloon to raise the ire of those who support nutritious food access for low income people. The administration justified it as a cost-savings move that would have “the same level of food value” with products “grown by American farmers.” The administration released few details as to the nutritional value of the food, given that it would likely need to be processed. It would require employment and eliminate the $126 monthly SNAP allotment

For those of a certain age, the idea recalls the days when the federal government distributed surplus food to the poor, in the form of blocks of processed cheese and other products. Not appetizing, much less nutritious. Certainly, this is not community supported agriculture https://www.localharvest.org/csa/, regardless what the administration says about “grown by American farmers.”

Why not? Is this really a bad idea – as a supplement to SNAP, not as a replacement? The administration references “Blue Apron” https://www.blueapron.com/pages/sample-recipes as the inspiration for the proposal. If the federal government really wants to provide food “grown by American farmers,” how about providing food grown by “local” American farmers and nutritious processed food through a CSA program?, complete with recipes? When you think about food insecurity, transportation issues, and other barriers to accessing and consuming fresh, nutritious food, direct delivery has merit. Think Amazon, should that company be looking for an opportunity to demonstrate social responsibility.

What if the government used innovation to create a more effective supplemental food system along with an accessible home delivery program? Certainly, there are plenty of challenges to this idea, but maybe there’s a kernel here that’s not so bad after all.

All it takes is the will.

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

‘It’s poverty, stupid!…’

By Dennis Archambault
In our attention to the social determinants of health, it’s important to reconsider the root cause – poverty. By fighting for scarce funds allocated to help low income populations — housing, food security, education, transportation, health promotion and disease prevention — we lose sight of the cause. American poor are getting poorer; in fact, our poor are now being compared with other developing countries. Those who say that the poor in the United States are not really poor, as compared with the poor in developing countries, need to read an analysis by Angus Deaton in the New York Times https://www.nytimes.com/2018/01/24/opinion/poverty-united-states.html.

According to the World Bank, 769 million people lived on less than $1.90 a day in 2013 – of these, 3.2 million live in the United States. It’s even worse if you factor in the advantages, Deaton argues, of poor villagers who don’t have to deal with housing, transportation, heat and other infrastructure costs. In that case 5.3 million Americans are “absolutely poor.” And this number is growing, as it is throughout the world, as the disparity between the rich and the poor grow.

For population health, in a society where there is little commitment to improving the social infrastructure, that’s a deadly sign.

Just as political consultant James Carville once advised presidential candidate Bill Clinton, “it’s the economy, stupid!” Indeed, it’s poverty. As long as poverty prevails, and the income disparity between the rich and the poor widens, and there is a social climate adverse to equity, then we’re going to have hustle that much harder. And hustle we will.

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

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.