BY DR. DANIEL FRAYNE
There’s a shift underway that’s causing health care providers to move beyond the walls of their clinics and hospitals and into the community to better support their patients’ well-being.
For a century, our health care system focused on treating disease. More recently, we’ve started emphasizing preventive care and access to primary care. In 2017, the U.S. spent $3.5 trillion on health care — far more than any other developed country. Yet our overall life expectancy as well as infant mortality, maternal mortality, disease and disability rates are far worse. Why?
Four words: social determinants of health. This has been public health professionals’ focus for decades. But for your doctor and the health care system? Not so much.
Social determinants of what?
People’s health begins where they live, learn, work and play, not inside a doctor’s office. Medical care accounts for only 15-20 percent of what promotes long-term health and quality of life. Far more significant are the conditions we live with every day, most of which are caused by forces beyond individual control. Our well-being is greatly affected by whether we have access to stable housing, safe places to walk and play, education, transportation, employment, and supportive friends and family; whether we experience racism, toxic stress or adverse childhood events; and even by the health of our parents before we were born.
Our current health care system doesn’t typically address these social determinants — which may explain why our community isn’t achieving the health outcomes we would expect, given our large financial investment.
It takes a village (to be healthy)
Make no mistake: Your individual health is influenced by your community’s health. And that, in turn, is impacted by the distribution of power, money and other resources, which varies widely among neighborhoods. In fact, your ZIP code is a better predictor of your health status and life expectancy than your genetic code.
Consider childhood obesity. More than a third of Buncombe County’s elementary students are overweight. But while many ascribe this to individual choices, research shows that low-income children and youths are more likely to be overweight or obese. And being overweight or obese as a child or teen leads to being overweight or obese as an adult and having health problems such as high blood pressure, high cholesterol and diabetes. Further complicating the picture is the fact that children born to obese mothers or mothers who have diabetes are more likely to have obesity and diabetes themselves — it’s a cycle. In order to break it, our community needs to focus on the things that can have the biggest impact on women’s and children’s health by targeting poverty, food insecurity, toxic stress, access to health care before and after pregnancy, housing, educational opportunities and other social determinants.
In Buncombe County, about 21 percent of children live in food-insecure households. An estimated 20 percent of women of reproductive age have no health insurance coverage (except during pregnancy). If we look at the data by race, the intergenerational impact of racism is painfully clear. People of color in our community fare worse in every area — including health outcomes, educational achievement, employment opportunities and housing. Black infants are three times as likely as white infants to die before their first birthday. Only about 70 percent of black students graduate from Asheville High in four years, compared with about 90 percent of white students.
How can we strengthen our determination?
Poverty, food and housing insecurity, violence, lack of transportation, racial disparities and other social determinants are complex problems that no one person, organization or sector can solve.
The only way we can ensure that everyone has the opportunity to achieve optimal health is to work together with a shared and well-coordinated commitment to improving our community’s health. And by everyone, I mean community members, health care providers, schools, businesses, service organizations, government agencies and policymakers.
Here in Western North Carolina, we’re uniquely poised to take advantage of multiple opportunities that are aligning to make real systems change and health care transformation possible.
Our robust integrated network includes many talented, dedicated health care providers. WNC Healthy Impact, a partnership between local health departments and hospital systems, is helping guide community health improvements across the region. Asheville and Buncombe County officials are prioritizing and investing in early childhood health, affordable housing and transportation.
Here at the Mountain Area Health Education Center, we’ve partnered with the University of North Carolina to expand and train our rural health care workforce, develop a new master’s degree in public health and establish a research division focused on population health issues. MAHEC employs all of Buncombe County’s school-based nurses, and we’ve partnered with Pisgah Legal Services to embed a lawyer in our clinics to help patients with housing, transportation, intimate partner violence and health insurance coverage issues.
The Buncombe County Health Department recently committed to a 10-year focus on reducing infant mortality. Mothering Asheville, a community partnership, seeks to address this and other health disparities by providing community-based doulas, employed by MAHEC, who support high-risk, low-income mothers to improve birth and maternal outcomes. Programs like this have gained national attention as models for how communities can address social determinants of health within their borders.
With this solid foundation, our community is well-positioned to use the potential influx of resources from the Dogwood Health Trust to address social determinants of health, as encouraged by the Medicaid Transformation Project. The time is right to strengthen our determination to address these bigger influences.
Imagine what would happen if all of us committed today to focusing on the underlying social determinants of health. What if every child born in WNC were healthy and well-educated, regardless of race, ethnicity, family income or ZIP code? How would it look if we all stood shoulder to shoulder, partner to partner, and closed the gaps for all our children?
In 20 years — a single generation — we could create a community where everyone thrives.
Daniel Frayne, M.D., a practicing family physician who is president of MAHEC, is a national consultant on women’s preconception health issues.