Editor’s note: This article is part of a series of blog posts by leaders in health and health care who participated in Spotlight Health from June 25-28, the opening segment of the Aspen Ideas Festival. This year’s theme was Smart Solutions to the World’s Toughest Challenges. Stayed tuned for more.
Population-level disparities in health care cost the United States up to $309 billion annually and, if eliminated, would prevent up to 80,000 early deaths each year. Chronic diseases — including cardiovascular disease, diabetes, and heart disease — disproportionately affect underserved communities.
One of the clearest determinants of health disparities is geography — where people live, and the resulting social consequences that create barriers to high-quality care. Because such disparities are local in nature, we must tackle them community by community, reaching people where they spend time — in their homes, schools, neighborhoods, and faith-based communities.
ZIP Codes And Health Outcomes
In today’s America, people live in two distinctly different worlds. The life expectancy for a child born in New Orleans can vary as much as 25 years between neighborhoods just a few miles apart. In Boston, the Census tract with the lowest life expectancy, 58.9 years, is located in Roxbury. That life expectancy is shorter than that of many third-world countries and is similar to how long the average American lived in the early 1920s.
It’s startling how strongly someone’s health and longevity can be influenced by where he or she lives — a person’s ZIP code is a stronger predictor of his or her overall health than other factors, including race and genetics. And it’s not just life expectancy — access to care, access to health information, and quality of life are all affected by where one lives.
You don’t need to travel far, or at all, to see the neighborhoods that have been left in the past. Some of our largest hospital systems are in the same urban communities that are burdened by these staggering mortality statistics — you can literally stand in the hospital lobby, open the doors, and gaze outside upon a neighborhood that experiences 1950s-quality health outcomes. You can travel even further backward on the health quality timeline by riding a few subway stops or walking a few neighborhood blocks.
The good news is that these problems are not intractable — some U.S. states have lower premature death rates from various causes than other states, so they seem to be doing something right. If all states were to achieve the lowest observed mortality levels for the top five causes of premature death (for age < 80 years), we could prevent more than 250,000 premature deaths in America every year.
But with so many public health, policy, social, and economic factors involved in these outcomes, how do we begin to determine what strategy will guarantee these lowest premature death rates in every state and every community? Also, is it possible to improve on even the best observed mortality rates by applying techniques that other regions (including underperforming ones) have successfully used to make incremental advances? Data-gathering can serve as a foundation for answering these enormous questions.
Shedding Light On What Makes Each Community Tick
The first step toward eliminating dramatic differences in health outcomes is to study their causes at the community level. Certainly, we know that smoking, poor diet, lack of exercise, and alcohol abuse remain common in many communities and contribute directly to chronic illnesses. But these behaviors are related to underlying social and economic factors as well, and relevant social data collected at the community level will be critical for informing meaningful changes in health laws, policies, and programs.
The need to collect data is being recognized, and forward-looking organizations are taking action. The Camden Coalition of Healthcare Providers, for example, is pursuing a project to integrate health data with social data. Camden, New Jersey, is among the nation’s poorest and most crime-challenged cities, with an estimated 30 percent of health care costs devoted to 1 percent of the city’s population. These are people beset by poverty, homelessness, or chronic illnesses, who seek inefficient, costly emergency department care for problems that preventive care might have helped to avoid.
With Aetna Foundation support, the Camden Coalition is creating an innovative Social Determinants of Health Database (SDD), which will combine health data with social data, including education level, employment status, information on homelessness, and law enforcement records, aggregated from agencies and departments serving the Camden community. Analyzing the SDD will profile who is vulnerable, inform health care workers about the social issues that affect care, improve care coordination, generate cost savings by facilitating the efficient distribution of limited resources, and eliminate redundancies in care by clarifying the flow of services across Camden.
The database will be accessible by policy makers, community organizations, advocacy groups, researchers, journalists, private foundations, and most importantly, the public. Beyond Camden, the SDD has important implications for policy makers at the state and federal levels, and for social science researchers interested in the potential of integrated data systems and cross-sector approaches to effect large-scale social change.
Beyond what we learn by gathering and processing data, and by the policy changes they might drive, educating people in underserved communities about healthy choices will remain an essential strategy for reducing and eliminating health disparities. Some of the same technologies that have enabled us to gather data are allowing us to reach the people who live in these communities — indeed soon they’ll carry a wealth of health knowledge literally in their pockets.
Mobile Technology — A Foundation For Building Health Equity
Mobile technology will serve as a powerful equalizer in the very communities that are disproportionately impacted by chronic disease — 84 percent of low-income adults have access to a mobile phone, and one in three mobile phone owners report having used their phone to look up health information. Thanks to unrelenting advances in portable technology, we can now provide the tools to empower communities and their residents to create their own sustainable changes in health-related behaviors. Such tools are already encouraging people to adopt best practices that lead to better health outcomes by teaching about and encouraging exercise, good nutrition, and other beneficial behaviors.
Regarding nutrition, we know that residents in areas of most financial need have the lowest access to outlets with healthy food. To respond to this issue, the Fair Food Network in Michigan is drawing on Aetna Foundation funding to test a smartphone app that will increase healthy food access for underserved communities while also creating new markets and sales opportunities for urban farmers. The app advances mobile payment technology by processing food assistance benefits more simply and affordably at farmers’ markets. This allows for widespread adoption of Supplemental Nutrition Assistance Program (SNAP) benefits and incentive programs by farmers who grow nutritious foods, thereby helping to ensure that these foods are served at dinner tables across the community.
When it comes to healthy behaviors, people can adopt them more readily if they have a clear picture of their current health status and disease risks. The Washington University School of Medicine in St. Louis published a smartphone app, Zuum, which taps into the university’s Your Disease Risk suite of health risk-assessment tools. The app’s user completes a brief survey and then is presented with a summary reminder of their healthy habits alongside those that they have the power to improve.
The evidence-based app details how one’s risks of acquiring disease can be reduced by making suggested lifestyle modifications, and users can send results to doctors, family members, or friends to create a cycle of positive reinforcement. With our support (Aetna Foundation), Washington University is assessing the feasibility and potential benefits of integrating Zuum into various clinical care settings in urban St. Louis, Missouri, and rural Illinois — areas that serve largely low-income and underinsured populations.
These examples of engaging the community using mobile technology represent only the very beginning of what is possible and what will eventually be achieved. Smartphones increasingly come equipped with sensors that monitor health-related data such as heart rate, steps taken, routes that are traveled, and whether the user is running, walking, ascending, or descending. This human-generated data, carefully collected and analyzed, could be invaluable for measuring the effectiveness of a range of health policies, programs, and initiatives.
A Problem We Can No Longer Ignore
While the size of the health disparities problem may seem overwhelming, we can all contribute to closing the health divide—nonprofits, corporations, communities, and individuals—all have a role to play. I’m very proud to lead an organization like the Aetna Foundation, which works shoulder-to-shoulder with national and grassroots partners in addition to providing the resources needed to implement innovations and community programs that get to the root of health disparities.
Working community by community, we all can have an impact in curbing these trends — and the core of all of our efforts will be to empower people to take charge of their health outcomes and enjoy the quality of life and longevity they deserve.