March 19, 2021
Dear Interested Readers,
To Discuss The Social Determinants of Health Is To Discuss Poverty
The Kaiser Family Foundation published a paper this week that detailed the impact on the social determinants of health of the 1.9 COVID Rescue Bill signed by President Biden last week. The article begins:
Even as the COVID-19 vaccine roll-out is accelerating across the country, the public health and economic effects of the pandemic continue to affect the well-being of many Americans. The American Rescue Plan includes additional funding not only to address the public health crisis of the pandemic, but also to provide economic support to many low-income people struggling to make ends meet. Millions have lost jobs or income in the past year, making it difficult to pay expenses including basic needs like food and housing. These challenges will ultimately affect people’s health and well-being, as they influence social determinants of health. This brief provides an overview of social determinants of health and a look at how adults are faring across an array of measures one year into the pandemic.
My post on March 9 written after the Senate had passed the bill and before President Biden signed it into law made many of the same points. This huge bill is filled with funds for Americans who were struggling to survive poverty before the pandemic and have suffered the most from the economic consequences that are second only to the loss of life as the damage this disaster has created. I was delighted when my friend Joe Knowles responded to the post:
Terrific piece, Gene — most especially your conclusion, that change must be driven from within.
That conclusion was:
Many studies have shown huge returns on investment from programs that improve health and well-being for previously impoverished populations. It’s time to set our biases against the poor aside and do what is good for them and will be ultimately good for all of us. We could do away with the conversation about the social determinants of health by effectively addressing the problems and situations that perpetuate them.
Joe and I met when we were both serving on the board of CRICO, the captive malpractice organization that ensures the physicians working at Harvard Medical School-affiliated medical practices and hospitals. You might remember Joe from his previous contributions to these notes. Joe is a “serial entrepreneur” who co-founded the Institute for Health Metrics in 2003 where he is now CEO. In recent years Joe has followed his passion for public health and has launched projects aimed at improving maternal and child health. His projects have brought him into close contact with federally qualified health centers and the MGH Institute for Health Professionals.
The September 3, 2019 post entitled “Guns In Homes: Time for a Safe Home Credit” was the presentation of one of Joe’s great ideas. He advocated for the use of homeowner insurance as a way of improving gun safety since so many gun-related deaths occur in the home as accidents or impulsive acts. Currently, homeowners do not pay a premium for having guns in their homes. You do pay an extra premium for a swimming pool. There are more deaths in the home from guns than from drowning in home pools. Joe likes to conceptualize creative, frequently nongovernmental, solutions to public health problems. One methodology he uses is to launch pilots with private funding that then might scale up to population-wide solutions.
Prior to the pandemic Joe and I would frequently meet for lunch and a conversation in Manchester, New Hampshire. Manchester is about fifty miles from my home and fifty miles from Joe’s home in Massachusetts. We have not been able to enjoy these conversations over the last year. I have really missed the contact. His response to my post initiated an exchange of emails that were followed by a couple of Zoom calls to catch up.
Early on in our conversation, we concluded that the term “social determinants of health” was a “whitewash” or an academic or bureaucratic term for the issues that contribute to “poverty.” Poverty is a tough subject. It is especially a tough subject in medicine because you can’t fix it in an exam room or an operating room, but it is the root cause of much of the poor health we try to improve in an exam room or the broken bodies and diseased organs that we try to repair or improve in an operating room. I have frequently heard practitioners say, “I am not a social worker!”
The Kaiser Family Foundation article was written by Kendal Orgera, Rachel Garfield, and Robin Rudowitz. They include a graphic that demonstrates the relationship between poverty and the social determinants of health if we imagine shortages or inadequacies in each item in the five columns to the left. If we cast all of those items as deficiencies and then realize that for the poor the components of the far-right column are also likely to be deficient, they have less contact with our healthcare system, it is easy to see that we can never significantly impact the social determinants of health or improve health in an environment where poverty exists. If it was not obvious before it should be obvious now that we can never achieve the Triple Aim without improving the social determinants of health and to do that we must lift people and families out of poverty.
Martin Luther King, Jr. found America deficient in many ways and called for the nation’s attention to the repair of those deficiencies in his famous “I Have A Dream Speech” delivered on the Mall in front of the Lincoln Memorial in August 1963. In the few years between the 1963 March on Washington and April of 1968 when he was assassinated, he concluded that a consistent thread that ran through the issues that he felt compromised the lives of millions was not only race but poverty. He called for a coalition of the poor of all races to demand justice. That is was the purpose of the Poor People’s March on Washington that he was planning when he was killed. The leadership of the Southern Christain Leadership Conference that assumed his responsibilities after his assassination made sure that his plans came to fruition. When he conceptualized this second march on Washington he must have hoped that he could catch the attention of the nation for the poor in the same way he had captured their attention in 1963 leading to the Civil Rights Act of 1964 and the Voters Rights Act of 1965. Martin Luther King, Jr. knew that this country had enough wealth in 1968 that it could abolish poverty, and he demanded that it should happen. In his speech at the time he received the Nobel Prize in 1964 he had said:
“There is nothing new about poverty. What is new, however, is that we have the resources to get rid of it.”
What is amazing is that he was not just talking about the United States, he was talking about the whole world. It seems to me that what he said, at least in reference to America, is definitely still true. We have the resources to end poverty and remove the inequalities that are driven by inequities and result in poverty and are sanitized by the phrase the “social determinants of health.” What Joe and I discovered this week is that we both believe that poverty is a solvable problem, if we only had the collective will to make an effective effort.
There are several barriers to clear to do what is doable. Perhaps the first barrier is what Heather McGhee calls “zero-sum thinking” in her book, The Sum of Us: What Racism Costs Everyone And How We Can Prosper Together. Fixing poverty would not be a transfer of wealth from the rich to the poor. Today there is a huge body of economic literature that asserts that fixing poverty would create wealth. An investment in ending poverty that we all would make together would create capital in the same way that a savvy entrepreneur invests to create a product that produces capital or wealth for its shareholders. Giving people the resources to improve their lives and become healthy and active participants in the economy is good for the economy. Even better, creating jobs with the government’s investment in infrastructure creates capital in the private business world. An example is that the government’s wartime investment in manufacturing during World War II left America with a strong manufacturing capability in the post-war years of my childhood.
A second barrier and there are many more, is the idea that the poor are poor because they are morally deficient, lazy, and deserve their poverty. It’s an old idea that becomes a self-perpetuating reality like racism that no one admits they hold, but it is there under the surface mostly exerting its influence in our lives and observable in the barriers and conditions that have been woven into our inadequate social safety net. One most public demonstration of the power of the concept was Ronald Reagan’s dog whistle about “welfare queens” who have babies to increase their welfare payments. Poverty is often a prenatal trap. The majority of us are born into a position in society and stay close to where we entered the game because of the power of existing inequities and the culture of our shadowy “caste” system that keeps most of us in our place, as Isabelle Wilkerson demonstrated in her book Caste: The Origins of Our Discontent.
Joe Knowles believes that if we are to take on poverty one of the most effective places to make a landing would be the beachhead of childhood poverty. The authors of the KFF article referenced earlier consider that Biden’s 1.9 trillion dollar COVID Rescue bill is in part a remarkable start on improving the social determinants of health for the poor. They write:
Across a wide range of metrics, large shares of people are experiencing hardship. The Census Bureau’s Household Pulse Survey was designed to quickly and efficiently collect and compile data about how people’s lives have been impacted by the coronavirus pandemic. For this analysis we looked at a range of measures over the course of the pandemic. Since the start of the pandemic, shares of people reporting hardship across various measures has been relatively constant, with a slight peak for the December reporting periods (Figure 2). For the most recent period, February 3-February 15:
- Nearly half adults (47%) reported that they or someone in their household had experienced a loss of employment income, and one in five applied for Unemployment Insurance (UI) benefits since March 2020;
- More than six in ten (61%) adults reported difficulty paying for usual household expenses in the past 7 days, and 27% used credit cards or loans to meet household spending needs;
- More than 7% of adults had no confidence in their ability to make next month’s housing payment (across renters and owners), and 11% reported food insufficiency in their household;
- Three in ten (30%) adults reported delaying medical care in the last four weeks due to the pandemic and 39% reported symptoms of depression or anxiety.
The bill is even better than a straight check to the poor because it is structured to improve the lives of children and because of its potential to reduce family stress. They write about the impact of the pandemic on children:
Across most measures, adults with children in their household fared worse compared to overall adults. For example, 53% of adults with children in the household experienced loss of employment income in the household compared to 47% of adults overall, and just over two-thirds of adults with children in the household reported difficulty paying for household expenses compared to the overall population of 61%. Notably, adults in households with children were more likely to report food insufficiency than the general population.
There are other benefits that will ameliorate poverty like the money it allocates to cities and towns, and the money that it allocates to education. It is possible that when Biden produces an infrastructure bill it will also be an investment that has the potential to improve poverty and the social determinants of health. The only problem with the “rescue” bill is that most of its benefits run out at the end of the year. It does not represent an ongoing antipoverty program.
You might remember that my post that Joe responded to included descriptions of a couple of experiments in universal basic income (UBI). UBI was the core issue in Andrew Yang’s campaign for the Democratic nomination for the presidency. In my post I referenced two UBI-like experiments, the Canadian Mincom experiment of the mid-seventies, and the more recent income support project in Stockton, California. What I did not know was that Joe was well on the way to implementing his own income support/health care disparities/ social determinants of health improvement project. Please read the overview below that Joe sent to me and see if you agree.
Family Health Project overview
Almost 1 in 5 children in America live in families with incomes below the poverty line. Growing up in poverty increases exposure to factors that can significantly impair child brain development and lead to poor health outcomes.
Family Health Project will undertake a simple, replicable program to help new mothers and their babies facing life without enough money.
Family Health Project will provide new mothers $400 each month for 36 months, through use of a debit card. Money will be provided without condition. Participants will be referred into the program by federally qualified community health centers. Funds will be managed and distributed through a corporate debit card partner. Participant onboarding and ongoing support services will be provided by an independent social services firm.
Family Health Project, an independent 501(c)3 organization, is led by John H. Knowles, Jr., MBA, MPH, and funded solely by private philanthropists.
Family Health Project’s initial program will launch in collaboration with Lynn Community Health Center, GreenPhire (debit card company), and Wellspring House, Gloucester, MA. Family Health Project will begin with 15 families participating and will grow as funding becomes available.
Family Health Project’s goal is to help prove the benefits that accrue to families from funds made available predictably and without condition over the first three years of a child’s life. With our initial pilot program in Lynn, Massachusetts, we hope to demonstrate the scale-ability of this simple, reliable service delivery system.
Embedded in this project is the belief that every mother wants the best for their child but what she can do is often limited by resources that are inadequate and inconsistent. What other studies have suggested that small investments that are guaranteed in time yield big benefits in improvement, especially at the beginning of life. $400 a month may not seem like much, but it is $3600 a year and $10,000 dollars over the three years that the study will run. The program will include educational and support sessions for the recipients that I would imagine being much like group therapy sessions where the recipients share experiences and receive helpful information from a facilitator.
Joe is “walking the talk.” He is an individual who has heeded the theologian Richard Rohr’s advice and has gone from “contemplation to action.” Many of us as individuals and as members of practices and institutions aren’t even at the stage of contemplation of the issues of poverty much less taking action to improve poverty or if you prefer the circumstances that constitute the social determinants of health. Martin Luther King, Jr’s admonitions and Lyndon Johnson’s call for a Great Society are faint echoes from more than a half-century in the past. The problems they described are still with us and we collectively suffer from our failure to hear the call to be concerned for the health and welfare of everyone. We need more people Joe Knowles who not only get it but who also realize that just “getting it” is useless unless you begin to explore how you might join the effort to take action. Lean thinking teaches us that even efforts that fail yield useful information for the next attempt at success. What leads to universal loss is complacency and a lack of engagement. Over to you.
It’s Maple Sugar Time In New Hampshire
Cold nights and warmer days make the sap rise, or so my friend Steve tells me. Our weekly town paper, the Intertown Record had a “front page, above the fold” story about “sugaring” this week and all of our social circle got a hoot out of the article because it featured Steve, his wife Nancy, and their grandchildren. What was really funny were the inaccuracies in the story about Steve and his sugaring that make me wonder about the other “facts” presented by the author. The article began on solid ground:
One of the most beautiful and tasty gifts of nature is celebrated this time of year, maple sugaring season.
Maple [syrup] producers anticipate the season, wondering what Mother Nature will present each year. Preferable conditions are cold nights and warm days, but the weather patterns vary and dictate how the season will unfold.
I don’t “sugar” but I do hang out with Steve and have heard him say the same things. Each year is different. It is like producing wine. Some vintages are better than others just because the weather varies from year to year. Unfortunately, this year seems to be off to a slow start because until this week we had not had the warm days to go with some very cold nights. One producer who was interviewed reported that by this time last year, and most years, he had produced three hundred gallons, but this year only one hundred and fifty. It takes about fifty gallons of sap to produce one gallon of syrup by boiling off the excess water. Most producers use wood-fired evaporators. If you know anything about using wood to heat things, you know that the process is labor-intensive. After the sap is boiled down to the desired specific gravity it is carefully filtered (finished) and bottled. There is nothing that is better than sipping the freshly boiled syrup right after it is filtered while it is still warm.
The article begins with quotes from some people who produce maple syrup for income, and there are several that do sugar commercially in the Kearsarge Region. Most years their “sugar houses” welcome visitors, and there are special weekends when they often offer enticements to attract visitors, like maple candies and pancakes but this year the pandemic has partially spoiled that fun, although some will be open to the public. After that sad note, the remainder of the article shifted to my friends Steve and Nancy, and that is where the inaccuracies began. The writer began by talking about the “Allenby Farm.” Steve and Nancy do have three or four acres behind their house, but there is no way you could describe the open field where he has built his “sugar house” as a farm. Nancy is a productive gardener but all that she produces is consumed by family and friends. I hauled out a lot of raspberries last summer.
Steve “taps” only about 120 trees and usually produces about fifteen gallons of the good stuff. He hangs an old fashion bucket on forty trees and has plastic tubes, which is the modern method of sap collection, draining another 80 trees in the wooded areas around his house and the big field that the writer called a farm. Some of the trees he taps are on the land of neighbors. The commercial producers may tap several thousand trees with tubing and vacuum devices sucking out large volumes of sap.
The writer then concocted a story about how Steve and another friend of ours, Bob Messer, got started with old apparatus they found on the Messer farm when Steve bought it. The Messer farm was sold, but it but not to Steve. It was sold to another friend named Len who is active in our non-profit, Kearsarge Neighborhood Partners, and allows KNP to store its wood there and use his truck to make deliveries to families in need. Steve and Bob did find an old evaporator on the Messer Farm. The remainder of the article is mostly right in feel if not in fact. She writes:
Although the Allenby Farm is not open to the public, friends gather during this time.
“We are a community center that happens to have an evaporator,” Steve said lightheartedly. “We have a group of eclectic friends and everyone gets to meet different people.”
Food and drink are contributed to the occasion. Steve said it’s a great social event and people like to grab a bucket and later sample.
I helped just a little to put up the walls of Steve’s sugar shack a few summers back. Now, I really enjoy sitting next to the evaporator in a high-backed rocker with the sweet-smelling steam filling my nostrils while I enjoy my beverage and snacks during a great conversation with friends. I often wonder about the next life. Is there more and what will it be like? If it is anything like those cheery afternoons and evenings in the sugar shack it will be infinite joy.
If you want to know more about sugaring, check out the website of the New Hampshire Maple Producers. This is an off-year because of COVID, but some producers will be open for visitors that wear masks and practice social distancing. You can find them on the last link.
Be well. Get out and get about but remember your mask and practice social distancing.
Gene
