Make the Health Desert Bloom

Forty years ago this month I moved to Salt Lake City to continue my medical training. It was an exhilarating time in health care. Major advances in medical technology seemed to occur every week. The first clinical CAT (computerize axial tomography) scanners came online just as I started my residencies. That advance was bracketed by the “Babybird” respirator, infant incubators, MRIs, ultrasound, fiber optics, the Jarvik artificial heart, lithium batteries, lasers, and many others. These new technologies allowed clinicians to diagnose and treat conditions in ways unimaginable ten years earlier; saving smaller and smaller babies and more seriously ill children and adults than ever before.

During this time, our medical care system was transformed. The new medical technologies fostered the development and expansion of newborn intensive care units, tertiary care hospitals, implantable pacemakers, medical transports, in vitro fertilization, and new micro surgical techniques to name just a few. They accelerated the trend toward specialization within the medical profession. We had great hopes and expectations that a technology-enhanced clinical care system would lead to a new level of health in our country.

Last week I returned to Salt Lake City for the “State Health Departments’ Senior Deputies and Legislative Liaisons Meeting” conducted by ASTHO (Association of State and Territorial Health Officials). As I entered the city, I was struck by how much it had changed in forty years. The Wasatch Mountains and the Great Salt Lake appeared the same but, due greatly to the influence of the 2002 Winter Olympics, there were more hotels, light rail, and one could now purchase alcohol in restaurants. There was also a large homeless population – something non-existent in SLC forty years ago. But the biggest change for me was the focus of the meeting presentations and attendee conversations. They were not talking about the promise and potential of our medical care system to improve health; they were talking about its failures and limitations.

With forty years of hindsight it is evident that, despite all its benefits, technology has not made us healthier when compared with similar countries. In almost every health category, including infant mortality, longevity, and health disparities, the U.S. has fallen farther and farther behind other OECD (Organization for Economic Co-operation and Development, i.e. industrialized) countries. And we have achieved those poorer outcomes at a tremendous cost – both human and financial. Until 1975, the percentage of the U.S. GDP (gross domestic product) spent on health care paralleled that of other OECD countries. Since then, our skyrocketing costs have significantly outpaced every other country.

Our supersized investments in medical care have been mostly at the expense of investments in public health and human services. The U.S. has the lowest percentage of GDP spent on human services among the 28 OECD countries which spend more than 15% of their GDP on the combination of medical care and human services. Yet, it is these investments in public health and human services that are proving to be the most effective in improving health. Moreover, the huge investments in high-tech medical care has also lead to lost opportunity costs by stifling investments in education, housing, transportation and other social determinants of health.

As I sat in the room listening to how we need to create a new 21^st century approach to protecting and improving health, I thought back to the Mormon and Utah history I learned during my three years in that unique state. On July 24, 1847, Brigham Young, sick with Rocky Mountain Spotted Fever, saw in the distance the Salt Lake Valley for the first time. Remembering an earlier vision about leading his followers to a place where they could "make the desert blossom like a rose," he proclaimed from the back of his wagon, "It is enough. This is the right place. Drive on." The Latter Day Saints did just that, they drove into the valley and helped make Young’s vision a reality.

The comments and questions from the senior deputies and legislative liaisons from state health departments throughout the country, made me aware that they were in one respect in the same place, both literally and figuratively, as Brigham Young. They understood that we’ve got enough data to know what creates health; that we’ve invested enough in the health care path we’ve taken over the last 40 years; that we know what needs to change to improve our health status; and that we don’t have to look further for the time and place to start. The question they had was how to instigate those changes? How do we invest in and implement a “health in all policies” approach that addresses the physical, emotional, environmental, and social determinants of health?

From what I heard last week in Salt Lake City and what I’m observing throughout Minnesota and the rest of the country, people are answering those questions. There is a growing consensus that, relative to our investment in health care, “it is enough.” There is a recognition that change needs to occur in the states because “this is the right place.”

The place and time are right to make our health deserts bloom so let’s “drive on” to create the policies, systems, programs, and conditions in which all people can be healthy. It’s a great time for you and me to be in public health and help shape the vision and the direction for all 21^stcentury health pioneers.

Ed

Health is Community

Every year I have the opportunity to provide the closing keynote address at the Minnesota Rural Health Conference. Not wanting to be repetitious, I continually look for new perspectives on rural health that might be helpful to conference attendees. As I began to prepare this year’s remarks, I was made aware of a book of essays by Wendell Berry, a poet, writer, and farmer from Henry County, Kentucky. Knowing that his writings deal with healthy rural communities, sustainable agriculture, appropriate use of technology, connection to place, and the interconnectedness of life, I thought he might provide some inspiration. 

I wasn’t disappointed. 

In his essay “Health is Membership” Berry wrote that “…the community in the fullest sense is the smallest unit of health…to speak of the health of an isolated individual is a contradiction in terms.” That statement both stunned and energized me. Public health is based on data and measurement of health and this statement challenges how we currently think about, define, and appraise health. Although we are learning how individual health is profoundly affected by the environment in which people live, work, and play, we struggle to find ways to measure and assess that influence and appropriately improve it. The question is why?

You don’t have to go further than the guiding mantra of today’s health care reform, the “Triple Aim,” to find the answer. The “Triple Aim of Health Care” is: better care for individuals, lower per capita costs, and better health for populations. The focus is entirely on individuals. Even the population health aim looks at populations as the summation of individually-focused data and interventions. There is no direct or implied acknowledgement of the importance of community, which reinforces the common narrative that health is due solely to high quality health care and good personal choices. 

The “Triple Aim” reinforces an industrial model of health care that rewards efficiency and assumes bigger is better. It focuses on the care of each individual and assumes that a person can be healthy independent of outside factors. It strives for standardization and evidence-based, best practices although only certain kinds of evidence are acceptable. To best treat individuals with specific disease conditions, health care has become increasingly specialized and technology dependent. This model, effective as it is in providing excellent care to some individuals, discounts the importance of communities.

With that perspective, I had to conclude that the “Triple Aim of Health Care” is potentially detrimental to health – particularly rural health and health equity – and made that the premise of my speech. Knowing that my audience would be mostly health care providers, I made note to emphasize that health care is not detrimental to health rather it’s the health care systems put in place by the values represented by the “Triple Aim.” Health care is an important and necessary contributor to health but how it’s organized and funded is not necessarily best for the health of communities and health equity. In other words, what’s good for our health care system may not be good for communities or health equity. 

The “Triple Aim” reinforces the notion that health is the responsibility of the health care system. It crowns our health care system as the benevolent dictator of health in our country. All of health is viewed through a health care lens further reinforcing the narrative that health is solely about health care. It allows the health care system to dictate where health investments are made. That’s why public health and social services are underfunded in the United States compared to other countries and why other sectors that influence health are also under-resourced due to the overly-resourced health care system.

Knowing that people would not want to leave the conference on a negative note, I decided to offer an alternative triple aim for consideration – the Triple Aim of Community Health and Health Equity:

• Expand our understanding about what creates health
• Implement a Health in All Policies approach with health equity as the goal
• Strengthen the capacity of communities to create their own healthy future

The value underlying these three components is community connectedness – the social capital and social cohesion that’s essential for individual and community health. 

The Triple Aim of Community Health and Health Equity is built on a community health model, not an efficiency model. It recognizes that health is created in communities by the social, economic, and environmental conditions in which people live, work, and play. It acknowledges that every sector of the community (including health care) impacts the community’s health. Most importantly, it recognizes the need for communities to possess the power to address the conditions that impact their health. 

To build healthy communities, the health care system should not be in charge of health nor should the public health system. The community needs to be in charge of health. Health care and public health are crucial to creating healthy communities but are only two of multiple partners who need to be at the program and policy tables where decisions are made about how to invest in health for current community members and for generations to come.

I made the above points in my speech and it was met with polite applause. No one commented or challenged me or even asked a question during the Q and A session so I was left wondering how the speech was received. That was partially answered when three different people approached me after the session and said, “We’ve been waiting for this speech for twenty years. Our present system isn’t working for rural communities. You explained why and you gave us a framework to change that.” 

As a farmer, Wendell Berry knows that the seeds he plants determines the crop he harvests. The seed in his essay that “health is membership” blossomed into my understanding that health and health equity is community. Who knows what crop will spring from my speech? If something grows, I hope it’s a crop of social connectedness that shows us that community really is the smallest and most basic unit of health.

Ed