18 January 2019
Dear Interested Readers,
Don Berwick On Our Responsibility to Address the Social Determinants of Health
If you have not read the last few postings, let me suggest that you quickly catch up by skimming last Friday’s note. In that letter I referenced the German philosopher Georg Wilhelm Friedrich Hegel who is credited with promoting the analytical triad of thesis, antithesis, and synthesis. I used the comments of “Joe,” a loyal interested reader, as the “thesis.” He took the position that even though the issues of poverty and the social determinants of health were difficult to address from a traditional practice environment it was the professional responsibility of healthcare professionals to be concerned about these issues that threaten the health of their patients and be active in efforts to mitigate them. Chris, another long time loyal interested reader and very experienced healthcare professional, disagreed and presented a vigorous “antithesis” as he expressed his concern that physicians should focus on their practices and leave the social and health policy problems to those with the training, expertise, and the specific responsibility to address them.
In the last paragraph of the letter I wrote:
Whether you see the issues as Joe sees them, or whether you share Chris’ honest skepticism about the possibility or advisability of medical professionals accepting the challenge of addressing poverty as a professional responsibility worth their time and effort, let me invite you to join the conversation.
If Joe had stated a thesis, and if Chris had joined the dialog with an antithesis, I was hoping that another voice would take on the responsibility to produce a synthesis. My wish was granted. Adam, a long time reader and healthcare professional from the Midwest wrote to say:
Gene,
Thank you for this thoughtful, nuanced article. After being persuaded by Joe that “doctors do have standing and credibility” to influence poverty through healthcare, I was fully primed to dismiss Chris as a jaded curmudgeon. To my surprise, of course, I found myself equally persuaded by Chris that healthcare providers aren’t policymakers and most don’t desire to be, nor do they have the aptitude to be, policymakers.
Still, as I reflect on the two points of view, I sense the opportunity for middle ground.
Joe says “It may be that doctors must now take responsibility for advancing solutions to address the social determinants of health, to take the response ‘upstream’ as it were.”
Chris says that if you want “physicians to become social advocates, which policies should they advocate for, social welfare policy or full-employment economic policy?”
I think of how the best healthcare delivery networks take input directly from patients and families — not because patients and families know how to run a medical practice, but because patients and families have valuable information to share thanks to their unique perspective.
Of course doctors shouldn’t be driving nationwide poverty strategy. But they DO have unique perspective that would be valuable to policymakers. Doctors can see firsthand how the current system incentivizes their own behavior and their patients’. Doctors can help policymakers design smarter incentives without taking the onus of designing the entire system.
And it doesn’t have to be all doctors. Just the ones who care and have aptitude.
Regards,
Adam
I want to extend my gratitude to Joe, Chris, and Adam. There is wisdom in each of their positions. I was ready to let Adam’s wisdom be the last say, but then in Monday’s email dump I noticed that the IHI was offering Don Berwick’s keynote address from the annual meeting in Orlando last December. The invitation to spend almost an hour listening to his speech was clever:
What Would A Martian Think of Our Health Care System?
“If a man from Mars showed up, he would probably have some pretty serious questions,” says IHI President Emeritus & Senior Fellow Don Berwick about the US health care system. Berwick’s 2018 National Forum keynote — featuring a surprise visit from an extraterrestrial — describes eight ways health care can start addressing social determinants of health, such as education, income, and equity.
I was hooked. I have really missed going to the IHI meeting over the last several years in retirement. The highlight of every meeting is to sit with five or six thousand other healthcare professionals to hear what Don Berwick has been thinking about lately.
The official title of his speech said nothing about Martians. It was, “Start Here: Getting Real About Social Determinants of Health.” That was much better than a Martian’s opinion about healthcare. What would Don say about our responsibility as healthcare professionals to address poverty and the other social determinants of health? I was about to find out. Where would he come down in the dialectic that Joe, Chris and Adam had been so generous to join?
Don began his speech by giving us a fact about the Shona people of Zimbabwe. He told us that their usual morning greeting translated as, “Did you you sleep well?” The courteous and usual response translates as, “I slept well, if you slept well.” Hold that thought.
He then announced that the address was dedicated to Sir Michael Marmot, imminent British epidemiologist, and Alan Kurdi, a child whom we we learn more about later. He had died very early in life. Sir Michael is the Director of the Institute of Health Equity at the University College of London and is the author of an important book that Don thinks that everyone should read, The Health Gap: The Challenge of an Unequal World. The review behind the link says,
“Page after page rams home the message that the poorer you are, the more likely you are to live a shorter, less healthy and in all likelihood less happy life.
Don then announces that the book is on sale at the conference. There is no reason to listen to the rest of his talk, if you buy the book. He suggests buying the book and taking a walk. He then launches into a review of data that you may have seen before that shows how America offers great care for illnesses but lousy care for health. He does not limit his examples to the USA, but shows how in America and in England you can travel quickly by bus or subway from neighborhoods of means that enjoy a long life expectancy to neighborhoods where the life expectancy is 15 to 25 years shorter.
Sir Michael Marmot asks why does life expectancy vary dramatically within a few miles. Life expectancy between the world’s richest and poorest countries varies by 35 years, but Don contends that does not explain variation in life expectancy by zip code. He reiterates that healthcare has done miracles, but our accomplishments treating serious disease have not improved the health of the nation. He then gives many graphic examples. Treating everyone with a statin who has an elevated cholesterol improves life expectancy of the whole population by a few days at enormous cost. If by some miracle we could totally eliminate heart disease, we would extend life by four years. In other nations, even as poor as Nepal, investments in improving the social determinants of health have improved life expectancy by decades in just a few years. He notes that riding the “D” train in New York from 85th Street on the upper East Side to 165th street in the South Bronx takes just a few minutes, but the life expectancy falls by many years over the short trip at a rate of 2.3 years per mile. The benefit of statins “is wiped out in the first seven seconds of the ride.
Don then notes that Sir Marmot was one of the authors of the “Whitehall” study. Whitehall is the center of the British bureaucracy. The study showed that life expectancy varies predictably by position. If you are a manager you don’t live as long as your boss, but you do live longer than the people you supervise. Your life expectancy varies by your position in the social spectrum. Everyone is better off than those below them in the social hierarchy, worse than those above them. The cause? The social determinants of health. The deeper point is that you can not improve health with healthcare. Risk factors do not cause much variation in outcomes. It is the social determinants of health that make the difference. He quotes Marmot who has a simple construct:
“Inequities in power, money, and resources give rise to inequities in the conditions of daily life, which in turn lead to inequities in health.”
Don’s analysis is logical:
“If you want to improve health, you have to reduce inequality.”
Both Berwick and Marmot agree that things do not have to be this way. Marmot talks about a practical approach to addressing the “causes of the causes” of the social determinants of health. He has a short list of observations:
1. Early childhood matters: The ACE questionnaire (Adverse Childhood Experiences) developed at Kaiser is a great tool for evaluation. Improve the health of children and you improve overall health. You can improve the health of children with public policy.
2. Education: Especially of girls and women which reduces the problems from pregnancy. The more education you get, the longer you live, as long as there is inequity. Reducing inequity abolishes the advantages of education.
3. Conditions of work: Pay, security, minimal income for healthy living. Toxins in the environment, control of work, isolation, loneliness. Don quotes Dr. Jerry Morris on the subject of “minimum” income or the proper income floor. Morris says, “ A minimum income includes not just what is necessary for food and shelter, but what is required to live a life of dignity and to take one’s place in society.”
4.Aging: How we care for our older citizens matters. It helps to give elders a chance to stay employed or be useful. Older workers do not reduce opportunities for younger workers. Work gives purpose and is a source of empowerment and the chance to stay active and contributing improves health.
5. Resilience of communities: Communities contribute to health when members feel “self efficacy.” The communities that can hold on to their history, and direct their own collective future, have lower suicide rates.
Marmot sums it up:
“What happens at the local level can contribute to crime, alcohol-related deaths, obesity, road traffic injuries, depression, health problems linked to pollution of air and water, problems with housing. On the plus side, the local level can improve health through a high level of social cohesion and social participation, security and low fear of crime, active transport, provision of green space, walkability, availability of healthy food, good services.”
Don then asks the big question. What would lead us to invest in the reduction of inequity? We know that people live longer in the countries that do invest in eliminating inequality.
At this juncture Don is interrupted by a video transmission from Mars. A little green man in a funny suit who looks remarkably like Don appears on a video screen behind Don and begins to ask Don about healthcare in America. [This is good theater and enjoying Don’s showmanship, as well as the points that he is making, is reason enough to view the whole speech or fast forward until you see the little green man.] As Don tries to defend what we do to treat disease, the man from Mars gets more and more frustrated with Don’s ignorance. Finally in a gesture that suggests he is giving up in frustration, the Man from Mars signs off because he has better things to do. His last words were, “Work on the causes, not just the consequences.”
Don’s next move it to present six examples of effective community action here and in the UK that have measurably improved outcomes, reduced healthcare utilization, improved high school graduation rates, reduced dependence on welfare, and reduced crime.
- East Lake, Georgia: led by Tom Cousins, is a “purpose built community.” Since 1995 when East Lake was launched there has been 90% less violent crime. There is virtually no unemployment. Graduation rates are up. Welfare recipients are down from 59% to 5%.
- Florida Hospital/Orlando Health: Have also become part of the “purpose built communities.”
- Community Medical Center: Kershaw County, South Carolina: programs have substantially reduced EW use.
- Cleveland Foundation: Living cities ,500 million investment in 7 zip codes.
- Treasure Seekers, Gloucestershire, UK: Opened “The Cavern”, a club for 700 severely affected mental health patients who are frequent users of the mental health services. It is an integrated care systems around an entertainment venue with music. The result has been a substantial reduction in hospital utilization and improvement in health status.
- Montefiore Health System. Treating 3.2 million patients. Teams use high risk registries and anticipate problems while paying attention to “hotspots.”
- Rush Medical Center: Anchor Mission Approach:
“A commitment to apply […] economic power in partnership with community to mutually benefit the long term well-being of both. For instance, anchor institutions can use their position as major employers and purchasers to improve economic opportunity and well being in low-income and underserved communities.”
Don suggested that everyone buy The Anchor Mission Playbook from Rush Medical Center. He lifted a quote from the playbook that he feels demonstrates the opportunities that exists and that we could exercise:
“When hospitals and health systems nationwide collectively spend more than $782 billion annually, employ more than 5.6 million people, and hold investment portfolios of $400 billion, the potential game changing impact on the health and wellbeing of America’s communities cannot be overstated.”
His last example was from his hometown, Newton, Massachusetts. The new mayor, Ruth Ann Fuller, read an article in the New York Times last October by Emily Badger and Quoctrung Bui that showed where children live matters deeply. The article caused her to identify the two areas of poverty in Newton. She has pointed to those neighborhoods and instructed her staff to “Start here!” whenever they initiate any program. Don repeated “Start here!” where the “causes of causes lie.”
It was a long speech but it had a trajectory. He next introduced the “Universal Declaration of Human Rights” which Eleanor Roosevelt authored for the UN and has just turned 70 years old. He quoted article one”
“All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood.”
Don then put everything into perspective for this moment in time and closed the loop back to the salutation of the Shona people of Zimbabwe:
Are we one? Do we care? In this vicious, unconscionable time in America, a time when our leaders have the audacity, the meanness, to divide us, and make us fear each other, we have a moral obligation to say no to that meanness, no to that division. (applause) We have an obligation to insist on compassion. We have an obligation to insist on solidarity, to insist that we are one, or we are lost. This is not just about health of course. It is about peace. It is about a livable planet. It is about a future for my grandchildren. Do you sleep well? I sleep well, if you sleep well.
He then showed the picture of the body of a little Syrian boy lying face down on the beach in Turkey. You have probably seen it before. It is one of the most moving photographs of our times. The little boy’s name was Alan Kurdi. Don said:
The social determinants of health killed this little boy. Forces of fragmentation and self interest. Political ambition, economic inequality neglecting the least among us in the service of what? Forces far, far more powerful than any germ or any gene killed this little boy. Forces far, far beyond the reach of the medical cathedrals that we have built. Forces that need to change now. This death is our death. Who can see this and still sleep well? You, we, we can walk away. We can say, “Not our job, I can’t do everything. Just work here. They don’t pay us enough. I can’t go to the margin…”
Don could have finished there but he challenged his audience to go back to their practices, hospitals, and health systems to begin trying to approach the social determinants of health by “starting here.” He gave a list of eight actions that they could employ in the effort to “start here.”
1. Sign up for 100 Million Healthier Lives (IHI project) and look into Pathways to Population Health.
2. Contact Purpose Built Communities and become one.
3. Find or create a map of deprivation for the area you serve.
4. Do this with communities, not to communities.
5. Become an Anchor Institution: adopt “buy local, live local, and hire local.”
6. Develop a community asset map.
7. Move from reaction to prediction
8. Invest in early years.
Don never gives an easy assignment. He is serious about what we must do if we want to improve health and reach the Triple Aim. He was moved by the image of the little boy on the beach because he died not because disease, but because of the failure of the system. He wants to ask our leaders, “Do you sleep well?” We need to remind ourselves of Marmots wisdom:
Inequities in power, money, and resources give rise to inequities in the conditions of daily life, which in turn lead to inequities in health.
Don’s message is that we have the responsibility to try to change things. It’s time to “start here.”
Mary Oliver, a Poet in Nature, Passes
Mary Oliver died this week. I am almost certain that she could have written a poem about the picture that is today’s header. I have never read a lot of poetry. I can understand a few of the older poets like A. E. Housman, W. H. Auden, Dylan Thomas, and Robert Frost. Most of the poems in the New Yorker are confusing to me, but I can get something from Donald Hall and Maxine Kumin, both of whom lived near me here in New London. I once met Chris Wiman and his poetry and prose can challenge and inspire.
One modern poet that I can understand is Mary Oliver. I loved her little book of essays, Upstream. She wrote poems about what she saw in nature and what nature stirred within her being. She wrote about dogs, and she wrote about winter. I like “First Snow” which may be an appropriate poem for my readers in Boston this weekend where the weatherman is excited about what is coming for Sunday. The first lines are a good fit:
The snow
began here
this morning and all day
continued, its white
rhetoric everywhere
calling us back to why, how,
whence such beauty and what
the meaning;
Here in a colder, higher place we are expecting 12 to 24 inches of fluffy white stuff. The picture for today is from a previous storm. It is a screen shot from my neighbors drone photography. I think Mary Oliver would have liked it.
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
