It’s hard to think clearly about health reform if you ignore the social determinants of health, that is, how each person’s place in the hierarchy of self-determination and power, educational opportunity, neighborhood quality, working conditions, job security, income and wealth shape their vulnerability to illness and premature death. Check your knowledge by taking this true-or-false quiz: Continue reading
News outlets duly noted the recent study showing that injuries and violence kill more young people in the U.S. than any other cause of death. But the coverage scarcely mentioned the researchers’ most troubling and revealing finding: How the burden of these deaths varies enormously by race, ethnicity and social class.
Take a look at figure 2 from the study showing age-adjusted suicide and homicide rates in the U.S. by race and ethnic origin in the year 2010. The unit of measure is the number of deaths by suicide or homicide per 100,000 members of each population:
You can see that rates of suicide are three to four times higher among American Indian and Alaskan Natives and non-Hispanic whites than other populations.
Rates of homicide are more than eight times higher among blacks than among whites, and homicide deaths are three times more common among American Indians and Alaskan Natives than among whites. Continue reading
Hospitals in the U.S. have been abandoning inner cities for years. By 2010, the number of urban hospitals still operating in 52 big cities had fallen to 426, down from 781 in 1970. Meanwhile, hundreds of medical centers built with cathedral-like grandeur have opened for business in affluent suburbs. A hard-hitting series produced by the Pittsburgh Post-Gazette and Milwaukee Journal Sentinel explains the consequences of this trend for people in neighborhoods where hospitals closed.
The series shows how most of the defunct hospitals were small to mid-size community hospitals and public hospitals that had served poor urban neighborhoods. The closures left many low-income neighborhoods without an effective safety net, undermined efforts to recruit doctors, and did away with high-wage jobs for local residents. An incredibly detailed interactive map allows readers to track where old hospitals have closed and new ones have opened in cities across the U.S. since 1991. Continue reading
KBIA Mid-Missouri Public Radio listeners were recently offered an insightful report on the problems poor adults in the state have been facing in getting dental care.
Nearly a decade ago, Missouri eliminated funding for all Medicaid beneficiaries except children, pregnant women and the disabled.
The move “left a lot of people with only bad options,” reporter Katie Hiler explained, borrowing a quote from the film “Argo.”
To illustrate the point, Hiler invited her audience along on a visit to a rare charity clinic called Smiles of Hope, run out of a converted church attic. At the clinic, dentist William Kane spoke of his efforts to meet the overwhelming need for services such as emergency extractions.
Hiler ended her report with some news. A decision by the Missouri legislature to restore funding for adult dental care under Medicaid is expected to help to give some poor Missourians more options, she observed.
Yet at the same time, 300,000 low-income adults who would qualify for Medicaid under the Affordable Care Act are at this point shut out because of the state’s refusal to expand the program.
“Which means,” Hiler noted in closing, “Smiles of Hope isn’t going anywhere.”
In a Q&A for AHCJ, Hiler offers some thoughts on what got her started on this story and how her work unfolded. She also shares some wisdom on what it takes to make a radio story come alive.
When online commenters get nasty, it’s tempting to just write them off as trolls. But is it possible that sometimes journalists set the stage with cartoonish, stereotyped portrayals of the subjects in our stories, particularly when writing about people who are poor or homeless or undocumented immigrants? Can well-meaning but uncareful journalism about marginalized people do more harm than good?
These are worthy questions posed in a blog by Lori Kleinsmith, who works as a health promoter for a community health center in Ontario, Canada. Kleinsmith says:
The challenge with writing a story about someone living in poverty is that it is really just a snapshot that is unable to display a deeper context of the experience of poverty firsthand. The pathways into and out of poverty are much more complex than a snapshot and many readers are unable to see beyond the surface and to be empathetic to a person’s circumstances, choosing instead to speculate or criticize. There can also be a pitting of the working poor against those in receipt of publicly funded social assistance programs, an “undeserving poor versus deserving poor” battle. The real systemic issues about how to address poverty get lost in the war of words and degrading comments about one’s choices and lifestyle.
Kleinsmith asserts that journalists need to tell more complete stories “that provide evidence and not just emotion, and that do not further victimize those who are brave enough to speak out.” Continue reading
The rumblings in Tennessee started earlier this year, after a new company took over the contract to provide dental services to the state’s children covered by Medicaid.
Now the state dental association, a number of black dentists, a youth-home operator and at least one angry grandmother are weighing in against the Boston-based dental benefits giant DentaQuest. They claim the company is making it harder for poor kids in the state to get dental care.
It didn’t sit right with Olga Khazan, an associate editor at The Atlantic, seeing so many people focus on individual behavior as the root cause of public health problems such as obesity, diabetes and heart disease. She’d come across too many studies revealing how health is shaped by external factors such as educational opportunity, the physical environment and social quality of neighborhoods, and the corrosive effects of prolonged exposure to stressful living conditions.
In How Being Poor Makes You Sick, Khazan came up with an appealing lede to draw readers into a deeply reported story about the complicated, nuanced realities of the social determinants of health:
When poor teenagers arrive at their appointments with Alan Meyers, a pediatrician at Boston Medical Center, he performs a standard examination and prescribes whatever medication they need. But if the patient is struggling with transportation or weight issues, he asks an unorthodox question:
“Do you have a bicycle?”
Khazan found an efficient, compact way to frame the story to make it highly readable, while fitting in a tight exposition of the research linking social adversity to poor health via stress, lack of education, poor nutrition, environmental toxins, altered gene expression, and other pathways. I talked to Khazan about how she came up with her idea and executed the reporting. Read more …
Health Equity Resources is an impressively thorough roundup of the latest news, research, and events related to health disparities and the social determinants of health. It’s curated and delivered by email twice a month by Carly Hood, a population health service fellow at the University of Wisconsin’s Population Health Institute.
What follows is just a sampling of the latest installment – the full version is nine pages and available here, along with past issues. If you’d like to join the list, send an email to Hood at firstname.lastname@example.org. Follow her on Twitter @cm_hood. Continue reading
Along with coverage of everything from Congressional wrangling over the Farm Bill to livestock management to wildlife conservation, High Plains/Midwest Ag Journal’s senior field editor Larry Dreiling finds time to tackle health stories. He sees access to health services as essential to sustaining rural life.
His neighbors in rural America may live many miles from a needed specialist or emergency room. Or, as he points out, they may need to drive two hours to get to a dentist.
Dreiling was kind enough to take some time recently to talk about his coverage and to offer advice to other reporters about telling health care stories in rural America.
“Since when in America do we have classes? Since when in America are people stuck in areas or defined places called a class? That’s Marxism talk.”
– Rick Santorum, former U.S. senator
Unlike most other wealthy countries, the United States doesn’t keep good records on social class, so it’s taken longer here than in other wealthy countries to understand the profound impact of social class on people’s health.
“As a nation, we are uncomfortable with the concept of class. Americans like to believe that they live in a society with such potential for upward mobility that every citizen’s socioeconomic status is fluid,” Stephen L. Isaacs and Steven A. Schroeder observed a decade ago in an essay that has only become more relevant.
The latest data suggest that lack of social mobility remains as significant a problem as it was decades ago. In the generation entering the U.S. workforce today, those who started life in the bottom fifth of income distribution have about a 9 percent chance of reaching the top fifth. That compares with an 8.4 percent chance for kids born in 1971, according to research by economists Raj Chetty of Harvard, Emmanuel Saez of the University of California, Berkeley, and colleagues.
What’s astonishing are the huge differences in mobility depending on where you grow up, The odds of escaping poverty and gaining prosperity are less than 3 percent for kids in many places across the South and Rust Belt states. But in some parts of the Great Plains, more than 25 percent of kids born to the poorest parents move into the upper-income strata as adults, the economists found. The datasets are available here.
I don’t think it’s a coincidence that the places on this map with the lowest social mobility also tend to have the worst health outcomes. Lack of mobility is strongly correlated with worse segregation, greater income inequality, poor local school quality, diminished social capital, and broken family structure – factors that are also linked to poor health.
Even when poor children manage to escape poverty, a “birth lottery” may still determine who gets to live longest and healthiest. Exposure to adverse conditions during fetal development and early infancy appears to be capable of causing irreversible consequences decades later, such as increased vulnerability to weight gain, diabetes, heart disease, and premature death.
The U.S. made steady progress reducing socioeconomic and racial/ethnic health disparities during the 1960s and 70s. (This period, in fact, was the only time in modern U.S. history when the health of African Americans improved more rapidly than the health of whites, occurring with civil rights and anti-poverty programs that narrowed the black-white income gap.)
Progress stalled around 1980. Since then, health inequities have grown wider between members of the lowest and highest social classes. Life expectancy, for instance, has changed very little among the less-educated and virtually all gains in life expectancy occurred among highly educated groups, one study found. If everyone in the U.S. attained the longevity of the highest-income one-fifth of the white population, we would have seen 14 percent fewer premature deaths among whites, and 30 percent fewer deaths among non-whites between 1960 and 2002, another study calculated.
Ten years ago, Isaacs and Schroeder argued for what is now called “health in all policies.” That’s the idea that we should explicitly consider the health impact of the priorities we set in education, taxes, recreation, transportation, and housing. A handful of state and local governments have taken steps in this direction.
A development worth watching is the growing use of health impact assessment to scrutinize the effects that a government program or project may have on the health of a population. The systematic assessment is supposed to help policy makers avoid unintended harmful effects and take advantage of opportunities to promote health.
After a health impact assessment in Alaska, for example, the Bureau of Land Management in 2007 withdrew part of an oil and gas development lease that threatened the health of native populations, and the approved lease required new pollution monitoring and controls. In Boston last year, the regional transit agency held off imposing steep fare increases and service cuts after a health impact assessment concluded that it would lead to significant health and financial costs because of increased automobile use.
The number of health impact assessments has mushroomed from a few dozen in 2007 to more than 240 completed or in progress in 35 states, Washington, D.C., Puerto Rico, and at the federal level as of last year, according to a recent Institute of Medicine report.
But big hurdles do pop up. The Robert Wood Johnson Foundation recently analyzed 23 health impact assessments completed between 2005 and 2013. Most weren’t given enough time or money, the authors concluded. People doing the assessments struggled to find relevant, neighborhood-level data. And they found it tough to make headway in politically charged situations. In some cases, agencies moved ahead on project decisions without waiting for completion of the health impact assessment. The behind-the-scenes maneuvering strikes me as something journalists might want to dig into.