Population Health Blog

Population Health Blog

Why It Matters

‘Health in All Policies’ comes to Michigan

By Dennis Archambault

It’s evident to those working in the population health field that health, or well-being, is impacted by everything. Health impact assessments are applied to specific circumstances, often after an initiative is conceived and even implemented. The “Healthy Community Framework” was developed by the California Health in All Policies Task Force in 2011, based on discussion with community, government, and public health leaders responding to the question, ‘What is a healthy community.”

On June 26, following  a  1 ½ day Power to Thrive gathering in Lansing, Ingham County launched a statewide effort to enact “Health in all policies” resolutions in every Michigan county. The Health Authority is supportive of this process.

According to the American Public Health Association, “The environments in which people live, work, learn, and play have a tremendous impact on their health. Responsibility for the social determinants of health falls to many non-traditional health partners, such as housing, transportation, education, air quality, parks, criminal justice, energy, and employment agencies. Public health agencies and organizations will need to work with those who are best positioned to create policies and practices that promote healthy communities and environments and secure the many co-benefits that can be attained through healthy public policy.” To download Health in All Policies: A Guide for State and Local Governments,” visit www.apha.org/hiap.

Features of the Ingham County resolution include:

  • 42% of Mid-Michigan residents die prematurely (before age 75);
  • In 2013 Americans had an average life expectancy of 78.1 years (below the international average of 80.1) despite the U.S. leading the world in medical research and medical care spending;
  • The U.S. health care system is changing to ensure everyone can afford to see a doctor when they’re sick, and to build preventative care like screening for cancer and heart disease into every health care plan;
  • Americans are expanding their thinking of “health” to encompass not only personal choices and medical care, but also the conditions of our homes, schools, workplaces, playgrounds and parks; the quality of the air we breathe and the water we drink; and our ability to get a good job and healthy food and housing, and to manage the stress surrounding us;
  • Health equity is a fair, just distribution of the social resources and social opportunities needed to achieve well-being;
  • Health in All Polices encourage and support the creation of healthier communities by modifying and aligning existing health- and “non-health”- centered operations of an organization toward a vision for health;
  • Health in All Policies provide a framework for organizational decision-making in ways that promote health and prevent harm;
  • Health in All Policies create conditions that allow and encourage people to make the best individual choices for their health and well-being;
  • The Land Use and Health Resource Team (LUHRT) was formed in 2003, and later became a coalition of the Power of We Consortium, comprised of persons from Michigan State University (MSU) Extension, the Ingham and Clinton County Public Health Departments, Tri-County Regional Planning Commission, MSU researchers, planning agencies, environmental organizations, pedestrian/bicycle advocates, and developers, for the purpose improving understanding of and integrating health and local land use planning;
  • In 2004 Meridian Township Planners began using a Health Impact Assessment Checklist to determine ways to promote health and prevent harm in the course of siting and permitting buildings, by offering suggestions and recommendations to developers, and LUHRT partners have in 2014 made the checklist a publicly available, interactive, online Health Impact Assessment Tool;
  • Health in All Policies can include or lead to commitments to the use of Health Impact Assessments in one-time decision-making (i.e. a new building/construction, rezoning, variance, incentive); creation of inter-branch or inter-departmental health and equity teams; Health Equity and Social Justice workshops for employees and elected and appointed decision-makers; improvement of community engagement practices; internal translation orders for publications; procurement reform for transparency and ease of use; equity mapping projects; and other alignments toward healthy physical and social environments;
  • Health and “non-health” partners in Mid-Michigan formed in 2014 a Health in All Policy Workgroup to provide technical assistance on Health in All Policies, as part of the Mid-Michigan Health In All Project;
  • The 2011 National Prevention Strategy was developed to guide our nation in the most effective and achievable means for improving health and well-being by prioritizing prevention and integrating recommendations and actions across multiple settings to improve health and save lives;
  • Elected and appointed local government decision-makers in Mid-Michigan can lead the creation of Health in All Policies in local governments in Michigan and in the Midwest overall.

Dennis Archambault is director of Public Affairs for the Detroit Wayne County Health Authority and represents the Health Authority in the Power to Thrive process. For more information on the Ingham County resolution contact Doak Bloss at dbloss@ingham.org.

Using a Public Health Lens to Understand and Address the Foreclosure Crisis

This is the final installment in a three-part series on foreclosure and health.

Communities are taking on the foreclosure crisis

Focusing on the health implications of the foreclosure crisis can be overwhelming. However, communities and organizations across the country are fighting back, from boosting tenant protections, to using eminent domain to keep families in their homes, to filing a lawsuit against Morgan Stanley that alleges the company violated the Fair Housing Act by targeting low-income African-American neighborhoods in Detroit with sub-prime loans. Detroit communities are defending against evictions and fighting for jobs, pensions, and services. While many efforts are led by grassroots community organizations and sectors outside of public health, there have been successful partnerships between community-based organizations and public health agencies that have helped reshape the debate, reframe the issue, identify measurable indicators of impact, and bring in new sectors and allies that can help build a broader base for not just addressing the foreclosure crisis, but for building a fair and inclusive society where everyone has the opportunity to be healthy.

How can public health be part of the solution?

In addition to research on foreclosure and health, public health organizations, such as local health departments, are becoming engaged in multiple ways, from targeting physical and mental health services to those going through foreclosure to engaging in policy change. In looking specifically at policy change, a public health lens can help:

1. Reframe the policy debate: Haas Institute for a Fair and Inclusive Society Director john powell recently spoke at the Beyond Bankruptcy: Building Power and Resilience conference in Detroit. He used three questions from PolicyLink’s Founder and CEO, Angela Glover Blackwell as a framework for looking at Detroit’s bankruptcy: 1) Who decides? 2) Who pays? and 3) Who benefits?

Bringing a public health lens to these questions can help reframe the policy debate from a focus on political battles and short-term economic issues to looking at long-term health outcomes. A public health lens shows the economic and health costs of the foreclosure crisis are borne by low-income communities of color and the benefits are reaped by a small percentage of people who profited from the crisis, and who have also had undue influence over political decisions. Public health data and stories of how foreclosure affects health can help highlight the injustices of the current system that mean shorter, sicker lives for many.

2. Change the narrative: Professor powell also mentions that while we must address technical issues, such as municipal bankruptcy and foreclosure, we must also change the narrative. Many of the Beyond Bankruptcy conference speakers described how our country’s racialized past has led to the crises we experience today. powell described how our country’s deep and profound anxiety around issues related to race prevents us from finding the solutions we need to have a fair, inclusive, and healthy society. While this is not something public health can tackle alone, the central, underlying values of public health, such as interconnectedness, fairness, and social justice can be used to change the discourse to emphasize how investing in people, communities, and public structures is critical for our health and prosperity.

3. Connect to residents: Health departments are already connected to many residents through partnerships, services, and policy work around specific health issues. A growing number of health departments are expanding this work to also include addressing social factors that affect health, such as housing, and they are doing this in partnership with residents and grassroots organizations. Public health organizations can also support efforts to ensure that those most negatively affected are at the forefront of “who decides” and “who benefits” from policy decisions. This can also be a way to change the narrative—as community members drive efforts to address issues like the foreclosure crisis, they can also focus the discourse on community assets and resiliency, rather than solely focusing on challenges.

Why public health must become engaged in the foreclosure crisis

The Institute of Medicine defines public health “as what society does collectively to assure the conditions for people to be healthy.” While engaging in the foreclosure crisis will be challenging for the public health field, the reality is that the foreclosure crisis and municipal bankruptcy are conditions that gravely affect the health of our communities. A growing number of researchers and organizations are beginning to address foreclosure and municipal bankruptcy as public health issues. Communities and resident-driven community-based organizations are already taking a lead on changing these conditions—public health researchers and practitioners from around the country must join in if we are committed to ensuring that everyone has the opportunity to be healthy.

Here’s a list of housing, foreclosure, and food resources in Detroit. If you have other resources to share, please add them to the comments. Do you have ideas about how public health can help address the foreclosure crisis? Let us know in the comments.

Katherine Schaff, MPH, is a Doctor of Public Health candidate at University of California –  Berkeley and is studying how local health departments are engaging in and communicating about the foreclosure crisis. She can be reached at kschaff@berkeley.edu

Using a Public Health Lens to Understand and Address the Foreclosure Crisis

By Katherine Schaff, MPH

 This is the second in a three-part series on foreclosure and health.

 The previous blog focused on how foreclosure directly affects individual and community health. However, there’s another way that foreclosures affect health—as people lose their homes and drain their assets trying to save them or as renters cope with added expenses and displacement as landlords face foreclosure, the loss of wealth also affects health, as well as growing inequities in wealth across the country.

What’s the connection between foreclosure, wealth, and health?

Public health research clearly shows that wealth is correlated with positive health outcomes. Throughout the history of the United States, wealth has always been inequitably distributed based on race, class, and place, and the foreclosure crisis has only increased barriers to a more equitable society. It’s important to note that the origins of the foreclosure crisis are not recent—multiple sources, including a report from the Kirwan Institute for the Study of Race and Ethnicity and a recent presentation from Haas Institute for a Fair and Inclusive Society Director john powell at the Beyond Bankruptcy convening in Detroit discuss how the crisis must be viewed in its historical context, including how New Deal legislation in the 1930s opened up home ownership, but mostly for whites in suburban areas. The Kirwan report states as “these racially discriminatory federal guidelines were then absorbed into private market practices,” communities of color were isolated from mainstream banking institutions and faced an influx of high-cost credit institutions. The report continues:

Present-day sub-prime mortgage brokers targeted these communities not out of personal racial animosity, but because these neighborhoods were starved of prime credit entirely, or because families were “equity rich but cash poor,” with paid-off homes but unmet credit needs (such as college tuition or medical expenses) – a condition that drove sub-prime refinancing growth. Termed “reverse redlining,” the targeting of credit-starved neighborhoods is and was possible because prior redlining had isolated these communities from mainstream banking and lending.

Home ownership is the main source of wealth for many people, which means that as the foreclosure crisis intensifies already deeply ingrained wealth inequities in the U.S., especially along racial lines, negative health impacts will follow. By 2007, non-conventional mortgage securitization generated $3.8 trillion of assets for financial institutions, while people of color experienced a loss in wealth of an estimated 164 to 213 billion dollars from 2000 to 2008 – the greatest loss of wealth to communities of color in modern U.S. history. Through focused predatory lending in segregated communities, people of color, especially African-Americans and Latinos, have been particularly affected by the crisis and are at increased risk of adverse health outcomes given the links between housing, foreclosure, wealth, and health (for more research on this, click here, here, and here). Wealth inequity is also generally linked with poorer health for the whole population, with more unequal societies experiencing worse health outcomes on average than more egalitarian societies. As both wealth and inequities in wealth are passed on through generations, this massive redistribution of wealth foreshadows not only poorer health for the current generation, but for future generations.

Additionally, as the foreclosure crisis has been described as a modern re-redlining of neighborhoods, it may also impact health outcomes through maintaining and increasing segregation. Williams and Collins describe residential segregation as a fundamental cause of racial inequities in health through numerous pathways, such as creating differential access to transportation, quality education, neighborhoods with low crime rates, environmental hazards, quality housing, purchasing power for nearby goods and services, exposure to tobacco and alcohol advertising, and access to medical care. They examine how this contributes to higher rates of chronic diseases, such as hypertension and heart diseases; infectious diseases such as tuberculosis due to overcrowded housing; and injuries related to violence, including homicide.

What’s public health’s role in addressing the foreclosure crisis?  

Make sure to read tomorrow’s follow-up blog, which focuses why public health can play an important role in addressing the foreclosure crisis and creating solutions that improve access to housing and health.

 Katherine Schaff, MPH, is a Doctor of Public Health candidate at University of California – Berkeley and is studying how local health departments are engaging in and communicating about the foreclosure crisis. She can be reached at kschaff@berkeley.edu.



Using a Public Health Lens to Understand and Address the Foreclosure Crisis

By Katherine Schaff, MPH

This is the first of a three-part series on foreclosure and health.

In 2006, the number of foreclosures began to rapidly increase across the United States, disproportionately affecting African-American and Latino communities. The effects of the crisis continue to reverberate across the nation. With over 13 million homes foreclosed on between 2008 and 2013, communities face blighted properties and a smaller tax base while speculators scoop up properties, contributing to gentrification and displacement. The origins of the sub-prime mortgage crisis, and resulting waves of foreclosures, are complex, as are the solutions. However, across the country, public health workers, researchers, and community-based organizations are becoming involved in using a public health lens to both understand the crisis and develop solutions, as well as organize for change across neighborhoods and sectors.

Many people facing a foreclosure drain their retirement and savings in an attempt to save their home and face profound grief, material hardships, and health problems. A growing body of research utilizing diverse methods show how foreclosures affect both individual and community health. A 2010 Causa Justa::Just Cause and Alameda County Public Health Department report on foreclosure and health summarizes much of this literature and provides an insightful diagram (see page 6) of the multiple pathways from foreclosure to health, supported by literature and local data.

How does foreclosure affect the health of individuals?

At the individual level, a homeowner going through foreclosure or a renter whose landlord undergoes foreclosure can face housing, work, and school instability, increased financial pressure, and a disruption of social networks. This can increase depression and stress; decrease housing options; increase the likelihood of moving to substandard housing; decrease the amount individuals are able to pay for food, medical care, and transportation; decrease individual and family wealth; and potentially lead to homelessness. These factors are, in turn, associated with statistically significant increases in: hypertension, heart disease, psychiatric conditions, renal disease, visits to the emergency room, cost-related healthcare non-adherence, and cost-related prescription non-adherence. A recent study suggests the foreclosure crisis may be partly responsible for a rise in suicides. In another study, 60% of respondents in the process of foreclosure had skipped or delayed meals because they couldn’t afford food and 48% had skipped filling a prescription. Residents in Oakland, CA experiencing foreclosure were 1.6 times more likely to report their physical health had become worse and two times more likely to report their mental and emotional health had worsened over the past two years than those not undergoing foreclosure.

How does foreclosure affect the health of communities?

Foreclosures affect more than the individuals that lose their homes. They impact communities. As foreclosure rates rise, negative health impacts are seen throughout the neighborhood. At the community level, foreclosures: decrease property values and tax revenue, which in turn, affects local governmental funding for services that affect health; degrade the social and physical infrastructure of neighborhoods; increase home vacancies and property abandonment, which is associated with a rise in crime and vector-borne illnesses, like West Nile; and affect community health for both those undergoing foreclosure and those who live nearby but are not undergoing foreclosure. Greenberg and Schneider studied the connection between abandoned sites, such as factories, warehouses, and project housing, and violent death. While they did not include foreclosed properties in their analysis, they did show a connection between abandoned sites and higher rates of violent death for neighborhood residents, including homicide, suicide, poisoning/drug abuse, falls, and fires. Recent research shows that residents in neighborhoods with higher rates of foreclosure are also more likely to have higher blood pressure and higher rates of obesity than in neighborhoods with lower rates of foreclosure, potentially due to heightened stress residents face in knowing that their neighbors and neighborhood are facing financial and housing crises.

What does this mean for public health practitioners and researchers?

Across the country, public health researchers and practitioners are becoming engaged in addressing the foreclosure crisis. Before focusing on solutions in the third blog of this series, tomorrow’s follow-up blog will summarize the link between foreclosure, wealth, and health.

Katherine Schaff, MPH, is a Doctor of Public Health candidate at UC Berkeley and is studying how local health departments are engaging in and communicating about the foreclosure crisis. She can be reached at kschaff@berkeley.edu.



Population health past and present: Five reasons why the future is about segmentation

By David Goldbaum

Population health in health systems is not new, but like the concept of “continuity-of-care” it is evolving.  Health care providers have always attempted to identify patient sub-groups (populations) that are costly to treat and difficult to manage.  The environment is different today for five main reasons:

  1. In the past, insurers paid providers largely based on how much they spent to treat patients.  Today they are increasingly paid on how much they should spend.  That spending is based on data reflecting what the cost of care should be based on best practices.  Providers that fall in the lower quartile on performance (cost and quality) are increasingly finding themselves punished financially.  Providers and insurers must effectively identify and manage spending incurred to treat their most expensive patients within narrow sub-populations.
  1. In the past, insurers were held primarily accountable for the cost and quality of care.  Today, that accountability, driven by regulations under the Affordable Care Act, is quickly being shifted to the direct providers of care.  In the past, if the cost of care grew, insurers passed those higher costs onto employers or governments that were paying the bills.  Led by Medicare, the shift in accountability means there are fewer channels through which providers can pass along the cost of care delivery. More than ever they must identify and manage care delivered to pockets of high cost beneficiaries.
  1. In the past, there was little data readily accessible to providers of care to manage the day-to-day care of patients at the point-of-service.   Today, so much data is available that analyzing and understanding that data has become a key tool in identifying and managing the care and quality of high cost patients, including vulnerable populations.  Medicaid and Medicare administrative claims data nationwide are being made available to research and provider organizational collaboratives to identify the utilization patterns of population segments, develop population specific benchmarks and track the progress of their populations.  Most large health systems and physician group practices have electronic medical records and point-of-service data available virtually in real time.
  1. In the past, analytical technologies used to understand health care data were cumbersome to deploy and use.   New analytical technologies, developed by commercial companies like Google and Yahoo, now exist for use by any organization.  These technologies are being used by the most advanced health systems to quickly analyze huge volumes of current data.  Unlike past technologies, these methods and tools combine the skills of traditional hospital information technology staff, statisticians, health services researchers and hospital quality management staff. They automate the process of distinguishing the characterteristics of patients that incur high healthcare costs from those that have lower costs; those that are that are likely to follow a prescription drug regimen and those that are not likely to; those that can most effectively be discharged to a nursing facility from those that should be discharged to another setting; and those that are most likely to get post-surgical infection from those that are not.
  1. In the past, providers were responsible for services rendered to their patients within their institutions.   Today, providers are increasingly being held accountable for the cost of their assigned patients regardless of the institutions in which they are treated.    Performance is increasingly being measured in terms of the cost and quality of care delivered.  Hospital inpatient systems are not working well when patients are re-admitted within 30 days of discharge. Patients that inappropriately seek services from a hospital emergency department for primary care suggests that outpatient systems are not being effective in reaching those patients. The total cost/patient/month of care across provider settings is the actual cost of care that counts – more than the cost to a particular provider.

In the past, process improvement initiatives based on 6-Sigma, Lean, and Toyota have made big contributions to improving performance across all populations.  Today, the right people, labor force and technology seem to offer the greatest potential for managing the health of populations.

David Goldbaum is a health economist and Executive in Residence at Detroit Wayne County Health Authority.

Psychiatrists focus on the impact of chronic social stress

By Dennis Archambault

The City of Detroit, and arguably much of the region, has endured psychological stress through several bouts of social and economic shock in the past 50 years, most recently being the foreclosure crisis and municipal bankruptcy. It’s fitting that the American Psychiatric Association (APA) selected Detroit for its Division of Diversity and Health Equity 2014 Leadership Summit.

The APA notes that “the current state of Detroit’s economy continues to be an enormous stressor for local citizens and communities. It can affect every aspect of people’s lives by creating stress at home, in the workplace and communities-at-large. Ongoing financial stress can lead to a variety of physical and mental health issues including anxiety and depression, sleep disorders, alcoholism and other substance abuse disorders.”

The summit was also designed to examine mental health disparities and social determinants that affect mental health, including the effects of the recent “economic disaster.”

In 2010, the American Psychological Association warned that stress may become a public health crisis. Its “Stress in America” survey http://www.apa.org/news/press/releases/stress/index.aspx confirmed the concerns of many that long-term chronic stress could have a significant impact on physical and emotional health. The survey noted that Americans appear to be caught in a vicious cycle in which they manage stress in unhealthy ways. The lack of willpower and acute time/energy constraints impede the ability of people to make lifestyle or behavioral changes – especially true among those in fair or poor health.

The impact of chronic social stress has been a topic of members on the Health Authority’s Population Health Council. Most recently, the impact of municipal bankruptcy and household foreclosures on health and social justice was discussed at a conference on bankruptcy at the Wayne State University Damon Keith Center for Civil Rights.

Psychologist Elissa Epel, who has studied the impact of stress, from its effect on DNA to its relationship to overeating, says it is easy to ignore stress because it’s invisible and pervasive. “Most of us have gotten so used to living in a matrix of stress – time pressure, demands, rushed social interactions, rushed eating – that we don’t even notice it.” What about those in vulnerable populations, enduring the intense stress of violence, hunger, homelessness, and poverty? “There are many active ingredients in the milieu of low socioeconomic status that can cause wear and tear. Interestingly, though, perception can play a large role here. We have measured this by giving people a picture of a ladder and asking them to place themselves on a rung (the bottom rung being the lowest status). Rating oneself as low, regardless of actual income or education, relates to poor adaptation to stress. Specifically, when given the same task to do in the lab, people low on the ladder reacted hotly each time, as if it were new, instead of habituating to it. There is also the built environment of low socioeconomic status, which doesn’t leave opportunities for buying healthy food and places for exercise or safe walking. And the built environment can feed back and affect how people feel.”

Dr. Rosalind Wright, a physician and epidemiologist at the Harvard School of Public Health, made this observation: “When the stress is chronic and the stressors are out of our control, we experience it as a threat, rather than a challenge. This type of stress can have negative, lasting effects on key system in the body. It’s like having the fight or flight response turned on all the time.”

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

Financial security determines diabetes care in Detroit-area women

A study recently published by a University of Michigan Social Work researcher has confirmed a social determinant influencing the health status of many Americans: financial security. If you have it, you’re more likely to be well or manage your health problems. Without it, you’re more likely to be ill and be less able to care for your illness.

Emily Nicklett, in the current issue of Qualitative Social Work (http://bit.ly/RqSzSq), notes that changes imposed by a diabetes regimen are considered unmanageable by financially insecure women. Study participants who were raised with fewer resources were more likely to have family members who were diabetic and have fewer treatment options available to them. However, more affluent women were more capable of managing the disease. Financially secure women have greater access to self-treatment options and a more optimistic outlook than women who don’t have the same financial security, the study found.

Research participants recalled experiencing fear, depression or denial after being diagnosed with the disease. Those with a more favorable financial situation tended to be more optimistic about their diagnosis. Knowledge and experience about diabetes prior to diagnosis could be partially responsible for this difference, according to the study.

Nicklett published the research with Sara Kuzminski Damiano, of the University of Southern California. “It became apparent that having previous knowledge about diabetes and the regimen, as well as having previous experiences viewing complications unfold among loved ones, shaped the experience of diagnosis and attitudes toward diabetes,” according to Nicklett, a U-M assistant professor of Social Work. The authors interviewed women with Type 2 diabetes in the Detroit area.

Emily Nicklett can be reached at enicklet@umich.edu.