Population Health Blog

Population Health Blog

Why It Matters

Create Health

By Dennis Archambault

It more than rhymes with wealth; it is wealth. Like a smart investor, you use it wisely to protect and enhance your personal safety. It’s not an end-all, but an essential component of holistic well-being.

From a negative perspective, to be without health is costly, if only through modest co-payments on insurance. But they may be considerable, draining your discretionary income. From a social equity perspective, an unhealthy start in life puts a child at great disadvantage for developing their mind and body; their learning capacity is lessened, and ultimately their earning ability leaves them socially disadvantaged.

If you are physically unhealthy, you are limited in your movement, literally and figuratively. This does not impact your will, of course, and much can be overcome. When you live in a life-threatening, or life-limiting disease state, you may be enriched by the experience and motivated by the challenge to overcome it, but you still are placed at an economically and socially disadvantaged state.

Yet, we value money far more. With it, we may feel empowered, mobile, comfortable. Without it, we may feel impoverished, desiring. We may need to sacrifice quality of life to “earn a living,” or we may choose to do so to maximize our “quality of life.” We will deny our health on all levels — nutrition, exercise, safety — in the pursuit of wealth. It’s about the money, they say. Yet we wonder where the money goes when more than 17 percent of the gross national product is spent on health care, yet the American society ranks lower than many developed nations in health and quality of life.

Life is unfair, yet an enlightened society finds ways to achieve social justice. That is the work of population health. It’s more than an individual’s responsibility — or misfortune. It is a social responsibility, if only to contain the massive, often misdirected fiscal expenditures and drain on productivity. It is also an individual responsibility to make the most of what they have and to use the power of human will to overcome barriers.

If we agree that health is wealth, how does one create wealth? Create Health, an alternative, interdisciplinary approach to enhancing well-being, defines health as “to bring into existence something not previously seen or experienced or is significant different from the past.” http://createhealth.info/what_is_health.htm. Most views of creating health involve restoring health from a disease or injury state. There is another perspective that assumes the absence of infirmity and the creative ability of human beings to marshal the will to enhance their well-being. And in the case of population health, the ability of an enlightened society to create an environment that allows this to occur.

Others are a little less esoteric in how they define creating health: it’s about creating an environment steeped in values, culture, sensible eating, leisure exercise, constructive socialization, and relaxation http://www.sparkpe.org/blog/how-to-create-well-rounded-healthy-family/. This is hardly new. Advice columns and popular magazines have been advocating this for years in the name of “lifestyle.”

Also well-covered in the popular media is the mind/body/spirit equation. Deficiencies in one can impact the other component, but enhancing all — individually and through an integrated approach — is a method of creating health. For example, working on self-discovery, physical development, and spiritual exploration often results in enhanced well-being.

Much has been communicated about what informed and motivated individuals can and should do to enhance their health and well-being. Less covered, however, is the role that population health plays in creating environments that foster health. Just as the public sector is called on to create conditions favorable to individual and business economic development, the same is true with public health.

The World Health Organization http://www.who.int/management/working_paper_9_en_opt.pdf and the World Bank http://documents.worldbank.org/curated/en/2007/01/8348853/healthy-development-world-bank-strategy-health-nutrition-population-results articulate visions for how health systems — not the hospital systems known by the same term in the United States — can contribute to improved population health.

Economic development, especially in desperate urban areas of the United States, looks first and foremost at the potential of business development for job creation and related wealth for communities through taxing and consumerism. However, communities should be looking at the importance that a healthy, productive population creates wealth. The negative is well-known: an unhealthy population is unproductive and a drain on societal resources.

So why does society allow expenditures for public health programs to be cut continuously instead of “investing” in the health infrastructure the way society invests in roads and sewer systems? Why is prosperity defined only in terms of business and why isn’t health defined as prosperity?

To draw from the late comedian Rodney Dangerfield, health doesn’t get much respect in this society.

Dennis Archambault is director of Public Affairs for the Detroit Wayne County Health Authority.

Wayne State law clinic advocates against pet coke piles in River Rouge

Students in Wayne State University Law School’s Transnational Environmental Law Clinic (http://law.wayne.edu/clinics/environmental.php) have been at the forefront of research and action into concerns about storing mountains of petroleum coke near local rivers and residential areas. Pet coke – a byproduct of oil refining from tar sands – began being stored in four-story mounds along the Detroit riverfront near the Ambassador Bridge in fall 2012. The mounds drew public concern from business owners, community activists, environmental experts, politicians and residents in spring 2013, when photos taken from the Canadian side of the Detroit River showed clouds of dust blowing off the piles. Residents complained about breathing the dust and of it getting into their homes, and environmentalists worried that runoff from the piles would further pollute the river.

In August 2013, after months of controversy, then-Detroit Mayor Dave Bing ordered the pet coke piles removed, citing violations of city regulations. The mounds were transported elsewhere, including to Ohio. The company that owns the pet coke sought to store it in River Rouge, eight miles south of its earlier location, but State officials have denied a permit to store it there. Michigan Department of Environmental Quality denied the permit request because of the “fugitive dust” issue, according to the Detroit News.

State environmental officials have said the mounds pose no significant health risk. Wayne Law Assistant (Clinical) Professor Nick Schroeck, director of the clinic and executive director of the nonprofit Great Lakes Environmental Law Center, has spoken out against the pet coke storage piles. The environmental law clinic, which began in 2009, works with the Great Lakes Environmental Law Center (http://www.glelc.org/files/schroeck-glelc-press-release.pdf) In 2011, the clinic joined forces with University of Windsor (Ontario) Law School to become the nation’s first Transnational Environmental Law Clinic.

Clinic students, including third-year law student Benjamin McCoy of Ann Arbor, were active in the 2013 community efforts to get the Detroit pet coke piles removed from an area near the Ambassador Bridge and continued their advocacy on the issue for the proposed piles in River Rouge. Second-year law student Paul Stewart of Ann Arbor got involved with state agencies over the Detroit pet coke issue on behalf of the clinic. He drafted a Freedom of Information Act request to state agencies involved with the policies, analyzed the information received from the request and gained a better understanding of the legal issues involved in the piles.

For the proposed pet coke storage piles in River Rouge, third-year law student Patrick Tully of Boston represented the Law Center at an April 9 public hearing. Also April 9, U.S. Rep. Gary Peters, D-Bloomfield Hills, and other legislators called on the U.S. Environmental Protection Agency to investigate pet coke’s potential effects on public health and the environment, as well as the best methods for storing and transporting the piles, which are exported to other countries to be burned with coal for energy, a polluting process not permitted by U.S. law.

Schroeck, with others from Wayne State, is seeking funding to study health impacts from pet coke and industrial pollution in Detroit and legal solutions to address the concerns. The ensuing study will involve clinic students.

Source: Wayne State University Law School. For information on the Transnational Environmental Law Clinic, contact Shawn Starkey, shawn.starkey@wayne.edu.

Detroit’s evolving food system has historical roots

Today’s urban agriculture is rooted in Southeast Michigan’s rich history. The Kickapoo Sauk and Fox people of Southeastern Michigan, historically the first well-known cultures to live here, were mainly farmers who grew corn, beans, squash, and tobacco.

During the late 1800s and early 1900s, mission pear trees were known as a striking feature of the local landscape as the French had planted them on their “ribbon farms” lining the Detroit River. Farmland dwindled as industry grew in Southeast Michigan, but it seems that every tough economic time hailed a return to growing food. During the depression of 1893, Mayor Hazen S. Pingree encouraged poor residents to grow food on 430 acres of public land – including the city hall lawn, parks, and other vacant areas.

The Depression Gardens of the 1930s represented another effort by people to feed themselves during tough economic times – work-relief gardens supplied work for the unemployed, and food for hospitals and charities. There were also War Gardens during World War I and World War II as part of an effort to get households to grow more of their own food so that produce from farms could be sent overseas. In 1944, victory gardens supplied 42 percent of the nation’s vegetable supply. However, gardening slacked off during the postwar economic boom.

In the 1970s, Mayor Coleman Young started the Farm-A-Lot program as an answer to the many vacant lots in the city. Some citizens took up the challenge and in the 1980s the Gardening Angles was formed. It was steered by Gerald Hairston and other elders with southern roots. In 1992, Detroit Summer, a project initiated at Detroit’s Boggs Center, involved young people with the Gardening Angels in planting community gardens. Farm-A-Lot ended in the early 2000s.

What eventually became the Greening of Detroit’s Detroit Agriculture Network replaced it with gardening development and support programs, garden resources, adult and youth education, market programs and soil testing services underpinning the development of a new organic Detroit food system. It now involves more than 1,350 community gardens tended by an ever-more sophisticated group of growers using better techniques and practices for developing this home-grown industry.

Detroit agriculture is flourishing, from family, community, school gardens, to market plots and mini-farms – thousands of sites that together report tons of fruits and vegetables produced each year. There is also a thriving beekeeping community, and some agriculturalists have gone so far as to raise chickens, rabbits, and even goats.

The capacity for large-scale production is here with 20 square miles (12,800 acres) of vacant space in Detroit. Researchers at Michigan State University have reported that Detroit land has the capacity to fulfill most of the produce needs of Detroit’s population – finding that nearly 76 percent of vegetables and 42 percent of fruits consumed in the city could be supplied from as little as 2,086 acres of land. The food production capacity is here. However, in order for this to become a fully-functioning food system, it needs to be legal to farm in Detroit. That requires state legislation to amend the Right to Farm Act of 1981 city land use policy to equitably regulate the results of a movement that has grown organically throughout our neighborhoods.

In late 2012, the City Planning Commission voted to recommend the adoption of Urban Agriculture ordinances to the Detroit City Council, which is expected to approve them in early 2013.

This article was excerpted from the Council’s Detroit Food System report –  http://detroitfoodpolicycouncil.net/knowledge-center/reports. Cheryl Simon, Coordinator of the Detroit Food Policy Council, is a member of the Population Health Council. 

Making a Healthy Sense of Place

By Chris Allen

In the foreword to The Economics of Place: The Value of Building Communities Around People, published by the Michigan Municipal League, author Peter Kageyama writes,“Place shapes us. Place defines us. Place is what forms our identities, our attitudes, and our relationships. … No longer is it sufficient to build places that are merely functional and safe. Our place making aspirations must be as high and as grand as our economic goals because they are bound together.”

Many of us were introduced to the term “place matters” in the PBS landmark documentary, Unnatural Causes. Where you live often reflects how well you live. Social determinants that are beyond your control, such as unsafe communities and environmental pollution, create conditions that affect public health.

“Place matters” and “place making” sound similar, but there is a subtle difference: One focuses on the impact of the built and natural environment, among other social determinants, on the well-being of people. The other seeks to design environments that are attractive and promote urban vitality. Both are concerned with creating a healthy sense of place. What’s missing in the latter is people.

The Michigan Municipal League identifies eight essential assets that make communities vibrant places in the 21st century:

Physical Design and Walk ability

Green Initiatives

Cultural Economic Development

Entrepreneurship

Multiculturalism

Messaging and Technology

Transit

Education

I would argue that one of the greatest assets of any place is healthy, productive people. The eight essential assets identified by the Michigan Municipal League are essential to an economically vital community and the health of the population. Health, and the innovative ways of creating health — a timeless measure of wealth — is the ninth element.

Few would disagree that an attractive, “livable” urban region is desirable to those who live and work there and those who may be considering relocating there. But would a community be considered “livable” if a significant portion of its population suffered from chronic disease, that it’s infants died at a rate comparable to some developing countries, that its elderly live lives of quiet desperation?

Safe, well-designed streetscapes; clean air and water, parks, green initiatives and accessible public spaces, diversity, literacy, job creation — it’s all part of the broad definition of healthy communities, because it encourages exercise, reduces health and injury risk, reduces stress, and promotes social connection.

Rather than place making in the absence of community health, let’s look at the economic impact  of a healthier community: High maternal and child health results in better educational performance and reduced inclination to pursue crime. Reduced chronic disease and substance abuse improves job readiness and performance. Healthier elderly people, who are more mobile and remain contributing to our society longer, would not only be more humane but it would reduce health costs in a big way.

We must have economic development, and we must create more aesthetically pleasing places to live, work, and recreate, in order retain our best and brightest and recruit new talent. But economic development alone will not create a vital, healthy community for all. In fact, economic development may create unintended consequences, such as air, water, and noise pollution. That’s why we advocate for introducing a “health lens” in reviewing economic development projects.

Health is often the missing element in the place making conversation. Place matters for all of us. Place making, in the context of promoting health and well-being, should not create just an aesthetically pleasing feeling. It should create a place that develops healthy people and represent all segments of the population in order for the community to truly emerge with a healthy sense of place.

 Chris Allen is the CEO of Detroit Wayne County Health Authority. This blog is drawn from a speech delivered to the Downriver Delta Legislative Briefing in Ecorse, Michigan, May 16, 2014.

Building resiliency among pregnant women in vulnerable circumstances through holistic midwifery

Katie Moriarty, PhD, CNM, RN, CAFCI

“To the young it seems no door is closed and as if all hearts are open. Everything is possible. Love comes so easily. I loved my work and the freedom that it brought me. I loved the teeming streets, the families I encountered, and I thought the joy would last forever.”

Personal crisis, inner strength and resilience are amazing qualities that we see in the characters from Episode 4 of Call the Midwife. Shelagh struggles with seeing a way forward from her pain of infertility and works through this by reigniting the community choir. We witness a young woman that bravely faces her labor and with patience and perseverance gives birth to her gorgeous daughter. Sister Winifred moves from being unsteady without joy in her new role of midwifery to a position of inner calm, confidence, and a true sense of purpose and happiness. Mrs. Reuben survived the horror of the holocaust but then had to face an inner prison with her fear of leaving the safety of her home for 12 long years. She commented that being a midwife is truly a wonderful thing—bringing life into the world and seeing everything made new. The midwives and nuns noted her problems when they did their home visitation and connected her with help and provided psychological and emotional support. They truly addressed her mind, body, and her spirit. Mrs. Reuben witnessed the birth of her granddaughter. As her daughter, Leah, walked through a door to motherhood — Mrs. Reuben figuratively and literally walked through her personal pain and out her front door back into the community. Lastly, Jenny’s experienced intense emotional pain after the tragic accident and death of her boyfriend – Alec.

Early in the show Dr. Turner states –“It isn’t the end of the world. It is just the end of a road.” That comment made me think of challenges and the quality of human resilience. As modern day midwifes, we witness the same challenges, struggles and tragedies that we saw in this episode. We see poverty, fear, infertility, losses, and abuse. But we also get to assist women and families to face these challenges and move forward.

We can help build resilience by helping women make connections and having a loving support system; developing goals and then breaking them into achievable steps. This fosters that feeling of success and can lead you to the next step. Visualizing the positive goals—and realizing each day is a new opportunity for us to change. Change is part of life and you can work on the goals that are attainable. Having open communication really assists to determine where someone is and where they want to go. Then you can work on problem-solving skills. Each small success can lead to a more positive view of yourself and your abilities. Helping women get involved in community groups for more social support can help. Addressing our care in a holistic sense—the mind, the body, and the spirit. Strategies can take many forms: keeping a journal, meditating, yoga, exercise, spiritual practices. Connecting women to the resources that are needed! Each mother and each family are different — that is the excitement of being a nurse and being a midwife. The key is to identify the individual and aid them in their personal strategies to foster resilience.

As a nurse-midwife, we work to improve the health of our mothers, babies, families—and ultimately our communities. David Olds, founder of the Nurse-Family Partnership, stated: “There is a magic window during pregnancy…it’s a time when the desire to be a good mother and raise a healthy, happy child creates motivation to overcome incredible obstacles including poverty, instability or abuse with the help of a well-trained nurse.” In Call the Midwife, and with modern day midwives and nurses, women, families, and communities can be empowered with knowledge and resources, helping them reach their short and long term goals.

“You will feel better. Maybe not yet- but you will. …..You just keep living- living until you are alive again.”

Katie Moriarty, PhD, CNM, RN, CAFCI, is director of the Nurse-Family Partnership at the Detroit Wayne County Health Authority. She maintains a midwifery practice and blogs in response to the PBS series Call The Midwife.

The Salt Crisis: It Will Take More Than Self-Control

By Dennis Archambault

The medical direction is often simply stated: lower your salt intake. Easier said than done, when your eating habits take you to various fast food restaurants routinely. Self-discipline at home is one way of changing your taste for salt in meals, but when your diet is heavily influenced by fast food, it may be a losing battle.

If hypertension is the “silent killer,” salt is the covert agent, conducting clandestine operations across all types of eating practices. According to Thomas A. Farley, a physician and fellow in public policy at Hunter College, “The reason that nearly everyone eats way too much sodium is that our food is loaded with it, and often where we don’t taste or expect it.” In a commentary published recently in The New York Times http://www.nytimes.com/2014/04/21/opinion/the-public-health-crisis-hiding-in-our-food.html?_r=0, Farley says it’ not the usual suspects. Blueberry muffins, for example, can have more than double the salt of a serving of potato chips. And how about wholesome whole wheat bread? That can have nearly 400 milligrams of sodium, he says.

As a physician, he says traditional medical advice to adopt a low salt diet is “virtually impossible” because nearly 80 percent of the sodium consumed by Americans comes in packaged and restaurant food — no matter where you go or what you eat. It’s not just fast food or processed food products.

Farley cites a 2010 Institute of Medicine recommendation for mandatory federal standards for sodium in food http://www.iom.edu/Reports/2010/Strategies-to-Reduce-Sodium-Intake-in-the-United-States/Report-Recommendations-Strategies-to-Reduce-Sodium-Intake.aspx. But, of course, it’s more complicated than establishing new regulations. The good news, he says, is that 21 companies have pledged to reduce sodium. The bad news is that far more are ignoring the recommendation.

Farley’s commentary is worth noting as community health advocates grapple with how to deal with salt and reduce the incidence of hypertension in society.

Dennis Archambault is director of Public Affairs for the Detroit Wayne County Health Authority.

Supporting the Health and Well-Being of Older Detroiters: Forced Relocation in an Urban Context

By Tam Perry, Ph.D., M.S.S.W., M.A.

As Detroit gentrifies, some current low-income apartment tenants may be required to find new residences as these buildings change ownership.  The impact of these decisions affects many seniors. This policy brief highlights relevant concerns around moving experiences in order to frame recommendations for policy and practice surrounding the involuntary relocation of older adults.  Our coalition recommends increasing awareness of the needs of older adults and/or other vulnerable populations in the moving process, advocating that private interests consider and prepare for the costs, financial and other, of the necessary assistance for involuntary movers, and urging policy officials to require the provision of recommended assistance to relocating residents.

As Detroit’s urban core redevelops, it is expected that private ventures will have heightened interest in acquiring real estate in the city.  We must ask how older adults are both part of its past, and part of its repopulating and rebuilding. By examining the health-related, emotional, financial, and logistical supports needed for urban seniors making a housing transition, this research raises awareness of the issues to policy makers creating revitalization incentives in order to create urban contexts for all ages.

In Detroit, it is critical to examine relocation in an urban context and its relationship to health and well-being.  Relocation in older adulthood can be fraught with future concerns of autonomy, frailty, and mortality.  While predictive factors of relocation, such as health of a spouse, have been established, limited attention has been paid to understanding the diversity of experiences in the process of moving in older adulthood.  While moving at any age can be challenging, relocation in later life is an experience that often involves reconciling one’s past and possessions, and planning for one’s future needs.

In recent months, the Hannan Foundation convened a group of providers serving older adults in Detroit, and formed a coalition to address the needs of vulnerable seniors in Midtown and Downtown Detroit who face possible relocation.  The group originally formed to help better understand the impact of forced relocation.  In a collaborative effort, this coalition has come together to examine the issues and recommend ways to support older adults.

In order to ensure that older adult involuntary movers will receive specific, needed services and to make the involuntary moving process as successful and low-risk as possible, the coalition has identified two policy needs:

1. Increase awareness of the needs of older adults and/or other vulnerable populations in the moving process: physical health, mental health, emotional health, financial capacity, logistical needs, and the older adult’s network.

2. Policy officials need to require that those acquiring buildings resulting in seniors and other vulnerable populations relocating provide these recommended services: subsidize relocation costs for existing tenants, subsidize voluntary mental health/clinical assessments and services, and assure inter-agency coordination so older adults will have an identifiable point of contact, as well as monitoring the status of the individual for at least one year following relocation.

In examining the health-related, emotional, financial, and logistical supports needed for urban seniors making a housing transition, this issue brief identifies critical considerations in the relocation of seniors, and their implications for social policy. We realize that vigilance is required to facilitate accessibility to and understanding of information as well as ease of transition for older adults who relocate.

This post was excerpted from an issue brief written by Tam E. Perry, Ph.D., M.S.S.W., M.A., assistant professor in the School of Social Work, Wayne State University and principal investor on the MCUAAAR-funded project, “Leaving Home in Late Life: A post-move study of African American Elders and their kin in Detroit. She can be contacted at teperry@wayne.edu. Her work is supported by the National Institutes of Health.