Population Health Blog

Population Health Blog

Why It Matters

UCBerkley Haas Center blog targets Detroit water shutoffs and equity issue

The world is watching Detroit. The debate over the Detroit Water & Sewage Department’s action to discontinue water service for Detroit customers that are behind in bill payments has aroused the passions of people throughout the country, as well as human rights advocates within the United Nations. Most recently, Rasheed Shabazz, a Haas Institute for a Fair and Inclusive Society Fellow, published a post in the institute’s blog, “Detroit’s Water Crisis: The Flood of Inequality.” John powell, executive director of the Haas Institute, is also co-chair of the Health Authority’s Population Health Council.

“Detroit’s water crisis’s origins go beyond bankruptcy and municipal finance, and its solutions will require empowering city residents, developing dense networks dedicated to identifying and implementing complex solutions and forward thinking that’s deeper than the Great Lakes,” Shabazz writes. “This will all require unthinking the current narrative of the water shutoffs, Detroit’s bankruptcy and how Motown got to where it is today.”

Shabazz says the discussion should involve the connection between the “status of distressed cities and the housing crisis, the culpability of investment actors, and the associated consequences on municipal budgets, metropolitan regions’s concentrated poverty and racial dynamics.”

To read his entire blog post, visit http://diversity.berkeley.edu/detroit%E2%80%99s-water-crisis-flood-inequality.


U-M Researchers Look At Transgenerational Stress

Stress is an underlying condition that plagues many in the health care safety net, and psychological trauma is a significant contributor to the malaise. The University of Michigan recently announced a study that demonstrates transference of psychological stress from mother to baby. Dr. Jacek Debiec, a U-M psychiatrist and author of the study, is quoted by the Detroit Free Press as terming this condition “transgenerational trauma.” Like other forms of psychological trauma, it can trigger nightmares, flashbacks, and physiological reactions among children, even though they never experienced the trauma.

Dr. Debiec says, “You take care of the mother, you take care of the baby… and the sooner you take care, the better.” This  suggests that maternal caregivers should assess the emotional health of pregnant women and offer counseling support. The problem is creating an accessible supply of mental health providers in the safety net.

For information on the study, check out this link: http://www.freep.com/article/20140728/FEATURES08/307280167/rats-inherit-fear-in-U-M-study

Alytia Levandosky, professor of Psychiatry at the University of Michigan, has also conducted studies on whether stress — specifically, domestic violence — in pregnancy affects the physical and emotional health of the child. http://psychology.msu.edu/Faculty/FacultyMember.aspx?netid=levendo1

Is it time for a cultural revolution when it comes to health behavior?

“Culture: the beliefs, customs of a particular society, group, place, or time…a way of thinking, behaving, or working that exists in a place or organization.”

By Dennis Archambault

We considered labeling a population health proposal, “Creating a Culture of Health in Detroit.” To some, it seemed like a “me too” concept. After all, Risa Lavizzo-Mourey, MD, CEO of the Robert Wood Johnson Foundation, coined the phrase last year; not quite a cliché, but it’s certainly getting a lot of use. Yet, isn’t repetition part of the rhetorical process leading to acceptance?

I kept thinking about our county, Wayne County, the sickest county in the state, at least as far as the RWJ County Health Rankings go. I’m sick of looking at the indicators. Yes, we’re sick for many reasons, including the social determinants that have such a heavy influence on health. But it’s more than something in the water. To a large extent, we permit, even encourage sick behavior. It’s part of our way of thinking, behaving, working.

We’ve learned through the extensive smoking campaign, traffic safety, and drinking/driving campaigns that it’s not until we can motivate peer influence, and social engineering, that positive change occurs on a major scale. We have learned to work smarter, more safely, and not accept workplace injuries as a natural part of doing business. Why can’t we take that next big step and creating an American manifesto: We will be well…?

Of course, there is plenty of cold reality to deal with beginning with an economic system that still rewards sick care, while primary care and prevention services struggle to be heard in budget deliberations. Investments for programs that create or promote health are even less prominent in budget debates.

We can keep working at the poor health indicators incrementally, struggling for grant funding for programs. But until we have collectively decided that we will have a healthy society we won’t achieve the massive change that’s needed in health status. Just as the three martini lunch is no longer acceptable in our culture, we need to become intolerant of other behaviors that contribute to an erosion of health and the need for health care services.

Of course, in our society we struggle between the societal imposed public health standards and the “right” of individuals to live as they choose. But American society evolves and despite our political polarization we manage to establish norms.

Dr. Lavizzo-Mourey’s description for creating a culture of health is less prescriptive and more visionary: “It means a society in which each person has the opportunity to lead a healthy life, with adequate housing, educational opportunities, safety from violence, healthy food options, exercise, and of course, affordable, quality health care. A desire for a culture of health is already emerging across the nation.”

Imagine if one of the questions we ask each other routinely is “Did you get your exercise in today?” And if not, you respond with regret. “No, not enough time or energy, but definitely tomorrow.” Or neighborhood conversation about the meal you’re cooking or planning to eat at a restaurant? Or looking forward to your next physical exam as an opportunity for improving your life, rather than a dreaded appointment your provider to evaluate BMI, cholesterol, and other disease indicators.

The point here is that we accept the fact that we live in a culture of sick and harmful reinforcement. We may laugh about skipping meals and grabbing junk food at the gas station, rushing through to the end of the day. We may willfully drive haphazardly in order to get there. Why don’t we have enough personal and social discipline to say, “This is crazy?!”

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

Maternal Mortality Becomes An Issue For Population Health

By Katie Moriarty, PhD, CNMF, CAFCI, RN

The Detroit News article on maternal mortality (“Detroit’s Maternal Death Rate Triples the Nation” July 10) highlights the disturbing statistics regarding maternal mortality in Michigan, particularly the City of Detroit.  The article states that experts attribute the increased maternal death rates to uncontrolled chronic health conditions and issues surrounding poverty and access to care.

While the United States spends much more on health care, its performance lags far behind other developed nations on quality indicators.  Research documents that care of childbearing women and their newborns is by far the most common reason for hospitalization and its care is the most costly hospital conditions for both Medicaid and private insurers.  The overuse of many interventions puts women and babies at risk and increases cost.  We are doing more and paying more and yet we are accomplishing less – it is termed the “Perinatal Paradox”.  Wide variations exist within health care practice across different providers, hospitals, and even geographic areas. There is an evidence-practice gap in our maternity care in the United States.  In order to close that gap it will entail active roles from policy makers, health systems, clinicians, payers, consumers and the media.  We need to address the overuse of harmful interventions and increase the use of many underused maternity practices which have been shown to be effective, such as in-home nurse counseling.  We need to ensure that all mothers and babies receive evidence-based care that is safe, effective, and satisfying.

The Coalition for Evidence-Based Policy, a non-profit, non-partisan organization, identifies the Nurse-Family Partnership (NFP) as the only prenatal or early childhood program that meets its “Top Tier” evidence standard, which is used by the U.S. Congress and the executive branch to distinguish research-proven programs.   The Detroit Wayne County Health Authority implements the NFP program in Detroit.

NFP is a home visiting program for low-income women having their first time babies.  Each woman is paired with a bachelors-prepared nurse who provides clients with home visits throughout their pregnancy, until the child’s second birthday.  The program has three main goals to improve pregnancy outcomes:

  • Help women engage in good preventive health practices, including thorough prenatal care from their healthcare providers, improving their diets, and reducing their use of cigarettes, alcohol and illegal substances.
  • Improve child health and development by helping parents provide responsible and competent care.
  • Improve the economic self-sufficiency of the family by helping parents develop a vision for their own future, plan future pregnancies, continue their education and find work.

NFP evaluates the client’s health status on their intake into the program and continues the evaluation throughout the program. The program addresses personal health, environmental health, needs for health and human services, relationships with family and friends along with their maternal role, and life course development.

As an evidence-based, community health program, NFP helps transform the lives of vulnerable first time mothers with over 37 years of research from a series of randomized, clinical trials of the NFP program, including research published in the June 2014 edition of the Journal of American Medical Association – Pediatrics.

NFP is client centered meaning that it is adapted to be relevant and valued by the woman and the family.  The program is based on adult learning and behavior change theory—and the belief that changes are most successful when building on your own knowledge, strengths and successes.  The program is multidimensional with a holistic view to different and varied aspects of their lives.   With approximately 2,400 first-time mothers enrolled in the Healthy Michigan and traditional Medicaid health plans in Detroit, and the startling mortality statistics that were noted in the Detroit News article, we need to make evidence-based programs like NFP more accessible.

Katie Moriarty, PhD, CNM, CAFCI, RN, is a certified nurse midwife and director of the Nurse-Family Partnership in Detroit. She can be reached at kmoriarty-nfp@dwcha.org.

Water shutoffs raises prospect of public health crisis, draws international concern

By Dennis Archambault

As access to water becomes more prominent as a global issue, thousands of Detroit households with water bills more than $150 and 60 days late are facing shut-offs. According to the Detroit Water and Sewerage Department, around 150,000 residential accounts are delinquent. The department confirmed that 46,000 shut-off notices were sent out in May. Of those, 4,531 customers had their water service shut off. However, 60 percent of the affected customers paid their accounts and 17,000 Detroit customers are enrolled in a payment plan. The Heat and Warmth Fund (THAW) is developing an assistance program for low income home owners similar to one it has in place for heat, but it wasn’t operational by July 1.

The prospect of mass water shut-offs has raised the potential of a public health crisis impacting personal health and social hygiene. The issue has caused considerable alarm among community health advocates. It has even drawn international attention.

The United Nations (U.N.) recently announced plans to intervene in the situation, suggesting that the shut-offs may violate U.N. human rights to safe drinking water and sanitation mandates. The U.N. High Commission on Human Rights Special Rapporteur on safe water and sanitation, Catarina de Albuquerque, can make recommendations and lend “moral weight,” but has no authority, according to the Associated Press. Another U.N. official, Leilana Farha, U.S. special rapporteur on extreme poverty and human rights, has expressed concern that children are being removed from their families and homes because, without access to water, their housing is no longer considered adequate. “If these water disconnections disproportionately affect African Americans they may be discriminatory and in violation of treaties the United States has ratified.”

As with the foreclosure crisis, lack of payment of utilities stems from a social equity issue as much as personal negligence. The Nonprofit Quarterly notes, “Indebtedness isn’t always treated equally in our society. Some people get dunned incessantly by debt collectors while others seem able to run up thousands or even millions in debt but are given the latitude to extend their indebtedness until their income and assets catch up. Differences in treatment – or indifference to some of the human costs – seem to be the case with Detroit water bills.”

The Detroit Free Press and Detroit News have assumed opposite editorial perspectives. The Free Press calls it “a fiasco, an outrage, a budding humanitarian crisis, a community health risk, shortsighted, atrocious public policy.” The editorial notes that 38 percent of Detroiters live in poverty and per capita income for city residents is $14,861, with unemployment rate at 14.5 percent. Of further concern, the Free Press adds, is “that the water department’s shutoff policy is uncompromising, making no exceptions for households with infant children, elderly or disabled residents.”

The News, on the other hand, took “scofflaws” to task for not paying their bills, while agreeing that there should be programs to assist the needy. The News editorial charges, “This is not the wholesale humanitarian crisis that a United Nation’s expert claimed last week. Rather, it is one more step to demonstrate that things have changed in a city that for too long did not enforce its own laws.” The editorial adds that the city does offer assistance plans. “The narrative being pushed by community activists is that water is a right and no one should be cut off for non-payment. But even in the days of community wells and aqueducts, citizens came together and taxed themselves to pay for obtaining and delivering water. … Customers who are struggling financially have a responsibility to alert the water department to their need.”

The Unitarian Universalist Service Committee in Cambridge, Massachusetts, has initiated a petition (http://actnow.uusc.org/site/PageNavigator/Detroit_Water_Shutoffs_Petition.html) drive to discontinue the water shut-offs. The petition reads, in part:

“Water is not a luxury good. It is a basic human right due to all people, including low income individuals and families.

“As a person of conscience, I oppose water shutoffs that affect people who cannot afford to pay and whose family integrity and health are at great risk. It is morally wrong to shut off water to individuals and families, including infants, children, people living with disabilities, people who are chronically ill, and the elderly.”

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

NPR confirms prevailing wisdom: Where you live has a big effect on your health status

Public health professionals have known for some time that where you live has much to do with your health status. This message has gotten beyond public health circles primarily due to the PBS program Unnatural Causes and related community engagement http://www.unnaturalcauses.org/resources.php?topic_id=6&page=3.

Dr. Anthony Iton made the correlation between zip code and longevity . “Place Matters” programs throughout the country, including Wayne County, are focused on social determinants of health in specific geographic areas.

On June 23, National Public Radio added to the conversation with “Are Life Spans Getting Longer? It Depends On How Wealthy You Are” http://health.wusf.usf.edu/post/are-life-spans-getting-longer-it-depends-how-wealthy-you-are. NPR reporter Kelly McEvers interviewed two women from different economic background. Her report provides a very detailed account of the health inequity of the two women.

McEvers concludes her report by saying, “Policymakers say this growing disparity between women…raises all kinds of questions. Should we raise the Social Security age if some people aren’t living longer? Will (the) Affordable Care Act help? What about increasing minimum wage? One thing researchers can agree on — the trend is not slowing anytime soon. The life expectancy gap between rich and poor is only getting wider.”

No Kid Hungry This Summer

By Sara Gold

“Summer vacation” conjures up powerful images in our collective consciousness. I see daylight that lasts well into the evening and hear the ice cream truck winding up and down the grid of neighborhood streets. Screened windows and doors are open and the air is fresh, warm, and alive with the buzz of summer. School is out. Time to play. All is well.

And yet, for many kids in the Detroit area, the reality of a stress-free summer vacation filled with these experiences is not possible. This is evidenced as well as anywhere by the number of children that are “food insecure,” meaning that the household struggled to access adequate nutritious food during some point in the year. For families that rely on free and reduced-price school meals during the school year, the summer months can strain the family food budget, and the risk of food insecurity is elevated.

In 2012, Feeding America’s Map the Meal Gap study found that 22.3 percent of children in Wayne County were food insecure. Although food insecurity is a measure of access to nutritious food, it is also a proxy for a biological state indelibly linked to health: hunger. The connections between hunger and health are well documented. Children and adults who are hungry face increased mental and physical health challenges, many of which follow children into adulthood.

These statistics make me sad and angry, and they used to make me feel helpless. Where to start? When it comes to childhood hunger during the summer months, the United Way for Southeastern Michigan, through the work of Michigan No Kid Hungry, is supporting real solutions.

Michigan No Kid Hungry, a statewide public/private partnership, is increasing access to and participation in federal child nutrition programs including the summer meals program, which is known as “Meet Up and Eat Up.” By maximizing participation in these programs, we can help eliminate childhood hunger with tools we have at our disposal today. Over the last two years, we’ve gathered stakeholders to form the Detroit Chapter of Michigan No Kid Hungry and have worked in collaboration to spread the word and improve the quality of meals served to kids at the hundreds of Meet Up and Eat Up sites in Detroit.

Last summer, the Detroit Chapter increased the number of meals served by 30 percent. Although we are focused on nutritious food, we found that Meet Up and Eat Up is actually helping to build community by ensuring that there are enough safe, engaging sites for kids to come together to eat.

Seems pretty simple: Summer vacation begins, and with schools closed kids can get together to eat at Meet Up and Eat Up sites in their communities at parks, schools, recreation centers, and churches. However, in Michigan, only about 15 percent of the kids who eat free or reduced price school lunches are also eating meals in the summer.  We need everyone’s help to spread the word. Meet Up and Eat Up is more than a program, it’s a movement!

Once school is out, there are various ways to let families know about where to find Meet Up and Eat Up sites:

  1. Call 2-1-1
  2. Text FOODMI to 877877
  3. Look up the sites closest to an address here: http://www.mcgi.state.mi.us/schoolnutrition/
  4. Download a Meet Up and Eat Up flyer to hand out in your community or through your organization HERE.

 Sara Gold is director of Michigan No Kid Hungry, a partnership of the United Way for Southeast Michigan, Share Our Strength and the State of Michigan. She can be reached at Sara.Gold@liveunitedsem.org