Building of the global movement for health equity: what health care can do

ScienceDirect – The Lancet : Building of the global movement for health equity: from Santiago to Rio and beyond – Thanks to @katellington for sending this my way.

Contained within is a concise statement of where health care fits into social determinants. Worth a read to see what’s new in social determinants. And from the read, social determinants is more new than I thought….

…. there are three important roles for the health-care system (webappendix p 1). First is to ensure universal access to high-quality care, with increased focus on prevention and health promotion.13 Second, people in the health sector—from the Minister of Health to primary care professionals and medical and health organisations—should be the advocates for action on social determinants of health. There are good examples of cooperative working between health and other sectors. Third, ensure that routine monitoring systems are in place for health equity and the social determinants of health, undertake evaluation of policies on these topics, and increase the knowledge base.

Now Reading: Understanding the science of life expectancy #SDOH

The concept of tracking life expectancy as a measure of a society’s health hasn’t been a part of my (should I say most?) physician’s experience – it’s just been a yearly announcement on a news show. When I went to England in 2010 I was impressed that it’s much more deeply thought of (see below), and more recently in my social determinants reading, as a key metric to understand social determinants of health.

It’s done in the lead in on this paper:

In the Washington, D.C., metropolitan area, for example, there is a nine-year increase in life expectancy as one takes the subway ride on the Blue Line from downtown Washington to Fairfax County, Virginia.

I decided to dig deeper and reviewed the paper referenced in this post, and I was immediately taken aback by this piece of information:

Tracking county disparities after 2002 until 2009 was impossible, because the US government did not release county-level mortality data during this time period.

The paper doesn’t say why this is, other papers from this time period (by these same authors) confirm this lack of access, but none say why (if anyone knows, post in the comments).

What they did here is look at the life expectancy “frontier,” which is the expectation of where the life expectancy of a particular county was compared to the life expectancy trajectory of the countries with the highest life expectancy. And,

  • there’s huge variation in US counties around life expectancy
  • US counties are mostly behind the frontiers of peer nations
  • US counties have been falling behind from 2000-2007

In 2007, county-level life expectancies range from 15 years ahead of the international frontier to over 50 years behind for men and 16 years ahead to over 50 years behind for women.

There’s a nice discussion at the end of what to do about this and how the health system fits in to this issue. Data point: 1.8% of US deaths annually are attributed to lack of health insurance coverage, and there isn’t a difference in access to health care between people in the lowest and the highest life expectancy tiers. It’s worth reading this section because a person can interpret the health system’s role in multiple ways when looking at this data.

As a comparison example, I did some searching around online (okay, a lot of searching around online), to compare the England experience to ours, and the concept of watching life expectancy seems much more ingrained. See: Mortality Monitoring bulletin: Life expectancy and all-age-all-cause mortality, and mortality from selected causes, overall and inequalities . And within a Primary Care Trust (most closely equivalent to a US Health Plan), a thorough analysis of the trend, and causative factors. See page 5 of “Joint Director of Public Health Anuual Report 2011 – Warwickshire NHS” ). There’s even an animated map showing the increase in life expectancy across England.

I don’t know for sure what our health system should be doing differently. Life expectancy is tracked within the United States’ HealthyPeople 2020 under General Health status. What would it be like if we started with life expectancy (or disability free life expectancy) in our health planning and innovation, though? Would people (patients) identify better with “the health system is allowing me to live a longer healthier life” than “the health system is lowering my cholesterol level”?

Of course, I looked up the data for Washington, DC, and in the appendix of this paper, it shows that the 2007 life expectancy of a Washington, DC male and female are 31 and 28 years behind the international frontier. At least this is better than 49 years in 2000 for men, a little better than 29 years for women in 2000. But far worse than Montgomery County, Maryland, just a few miles away that’s 12 years ahead of the international frontier for men, 3 years ahead for women. If you’d like to see a more graphical version, tied to DC metro maps, check out A Short Distance to Large Disparities in Health.

Now Reading: “Behavior is not the whole story” – Social and Economic Determinants are where Health Disparity Begins

Social Determinants – they are the difficult stuff to change, however they may be more influential than all of the individually directed approaches that are out there. I covered a much more thorough analysis in my reading of the Marmot Review (see: Now Reading: Why a focus on lifestyle behavior change may not improve health: The Marmot Review), and this paper is a more concise version of the concepts and research presented there.

Social determinants of health (hashtag: #sdoh), is defined nicely here as:

Exposure to these determinants [of health] is influenced by “upstream” social determinants of health – personal resources such as education and income and the social environments in which people live, work, study, and engage in recreational activities.

The health differences tied to these social differences are huge, trumping what we could do by advising/informing people to change individual decisions they make on a regular basis (if you take into account readiness, uptake, mastery, etc.).

I perceive that there’s been a change in thinking from 1993, to 2002, (and now 2011?) from the landmark studies of their era, as shown below. You can tell the progression from “diseases cause people to die,” to “what people do and who they are cause them to die,” to maybe, “the social milieu that they are a part of causes them to die.” See what you think from the charts I created below, stimulated by the references in this piece:

SDOH Studies Eytan 7659 SDOH Studies Eytan 7660 SDOH Studies Eytan 7661

There are data points in here that are so impressive I went to track them down (and they are real), such as the fact that white households have 20 times the net worth of black households. That’s kind of an “unmentionable” that could come up in an encounter with the health system that makes anything we do less effective.

The authors talk about “health in all policies” – the idea that all social policy has health impacts. We shouldn’t forget those, they may be more important than all the work that the health system does, or the choices people make in their lives. See what you think.

Community Need Index – is this what Health 3.0 is?

Community Need Index – This is another (second of two) useful GIS-based resource that illustrates social determinants of health (again, hashtag #SDOH), this time from Catholic Healthcare West, and sent my way via Richard Roth (@rich_roth), who’s active in the Innovation Learning Network (@HealthcareILN).

As I did with Community Commons, from the last post, I attempted to retrieve two numbers of interest to me, life expectancy, and disability-free life expectancy, for Washington, DC. Here’s what I came up with:

The results are a little different here because this is more of a general index of community need than a peek into multiple health databases. Serves a different need, but also shows the disparities in Washington, DC, that tend to be glossed over in national data (incorrectly, unfortunately).

I think both resources are useful. CNI might be useful to get a snapshot of areas of need (or “deprivation” as they say in the UK) in your community, and Community Commons for deeper investigation into specific data points AND resources active in a particular area that are working to address problems.

And then there’s also County Health Rankings, from the Robert Wood Johnson Foundation.

Clearly the social determinants of health space is getting some attention, is this Health 3.0? If it is, I am supportive, I believe this is work is harder and it is where we’ll make a difference.

Community Commons – A learning utility to create healthy, equitable, and sustainable communities

Community Commons – A learning utility to create healthy, equitable, and sustainable communities – This is one of a pair of resources that was sent my way by smart people who know that I am interested in social determinants of health (hashtag: #SDOH). This one came to me from Tyler Norris, who I met at the Kaiser Permanente Care Management Institute Annual Meeting recently.

Both resources have interactive, graphical information system-type interfaces. I decided to take each one for a test drive to examine two data points, life expectancy, and disability-free life expectancy, in Washington, DC. These data points are important to me based on my read of the Marmot Review, which I blogged about previously.

I couldn’t find disability-free life expectancy, but I did find life expectancy for Washington, DC. This map does show the approximately 7-year difference in life expectancy between a person in Washington, DC and Southern Maryland.

My 3×3 presentation from the #73cents Salon : past, present, future

The video above is the 3×3 presentation I gave at the 73 cents salon on Friday. As I mentioned previously, this was an opportunity for a small group that got together in 2009 to reconnect.

We customized the format of the presentation to be the following (credit, again, to Aaron Hardisty (@aaronhardisty) from the Kaiser Permanente Garfield Center for Healthcare Innovation ( @KPGarfield ))

3 Slides in 3 minutes – Telling the story of YOU

– You will be timed! (in a loving and supportive, yet equal, way)

Slide 1: The Past

– A success or a failure you’ve experienced since 2009
– What did you learn?

Slide 2: The Present

– What is the most exciting thing you are involved in today?
– How are you making an impact?

Slide 3: The Future

– How do you envision yourself making a bigger impact in the future?
– How can the people in this room help you? 

I decided to think broadly about what success means to me. See what you think above, (make your own if you’d like)

If you’re like me and have trouble sitting through 3 minutes of video, the images from the presentation are below. Just click to enlarge. And, thank you 73 cents alums and new alums!

At KP Care Management Institute: The US’ Obesity Rate has Plateaued – What is our opportunity?

Milestones of Kaiser Permanente’s work to prevent and treat obesity, since 2002

I am returning from the Kaiser Permanente Care Management Institute annual meeting, where I (and impressively, 3 Kaiser Permanente members, as well as leaders from our affiliate, Group Health Cooperative) was an invited guest in one of the two tracks covering obesity prevention and treatment.

I was invited to bring my knowledge of social media / technology applications (in addition to several other experts in this area) and maybe because I think a little differently sometimes…I have an interest in this topic along with my colleagues in this post-EHR organization, because now it is about how the technology and other talents will be used to solve important problems. Exactly where we wanted to be.

Bill Dietz, MD, from the CDC, pointed out (and this is illustrated in the photo above) that Kaiser Permanente was one of the first health systems to engage in this health issue. I expected to learn a lot, and I very much did:

  • The title of the post describes the situation William Dietz, MD, relayed to us in his presentation – the obesity rate for men and women has leveled off. I am not sure this piece of information has infiltrated our culture yet (and to read more, you can go to this New York Times Article and JAMA article) . This could be good news – this is what happened in 1964 before tobacco rates dropped dramatically in the United States. On the other hand, significant inequalities exist between racial/ethnic groups, and many believe (me too) that a reduction in rate without a reduction in inequality is not a reduction.
  • I also learned that it is a myth that nothing can be done. Keith Bachman, MD, one of two national physician leads in obesity management, and Adam Tsai, MD, from University of Colorado, reviewed the data that there are effective approaches (behavioral, some pharmacologic) to reducing weight long term. The hurdle, therefore, is consistency in application. I learned that there are options and probably preference for community-based programs to do what medical care cannot do as cost effectively.
  • We were joined by Matt Longjohn, MD, the Y’s (YMCA) first ever Senior Director for Chronic Disease Prevention, who talked about the Y’s highly publicized success in delivering community-based obesity programs based on evidence. He talked about how the Y is paid on two things : attendance in the classes, and weight loss. 2000 employers are now covering the program.
  • I learned that there are hurdles in the way typical health care benefits are structured. The default emphasis in most of health care is medicalization, with coverage for the very obese for surgery, with less resources available for people who are overweight and obese.
  • “Walk with a doc” – It’s no secret that I am a fan of the walking meeting (see: “The Art of the Walking Meeting“). I have always wanted to expand the concept to health care. And guess what, I didn’t have to, someone else did, notably other physicians in Kaiser Permanente. I learned more about this program and I love it tons. I think it is a great platform for bringing the benefits of walking to the patient-physician relationship, if it is done with great care and attention. I did a prototype in the early dawn up to the Golden Gate Bridge to prove to myself how much I love it.

Collaborative effort between the health system and the community, not just improvement, reduction of inequalities

When I spent time in England last year with groups from the National Health Service, I was enlightened again and again to the benefit/importance of the connection between the health care system and the social care system, which comes more naturally in that country.

I wrote recently about the Marmot Review and the thinking that it is not about improvement of health status, it is about reduction of inequalities of health status across the social gradient, and I can see the opportunity here to apply that thinking, too.

I’ll say I found that thinking in the room with me, and the desire to solve this for our members, the communities they live in, and all of society. I was not the smartest person in the room, which is a very good feeling.


There are things we can do. We have more abilities than we thought we did. There are people, organizations, and industries who will work with us, that’s us with a capital U.

Now Reading: Why a focus on lifestyle behavior change may not improve health: The Marmot Review

Marmot M. The Marmot Review: Strategic Review of Health Inequalities in England post-2010. 2010. Available at:

….attempts to reduce health inequalities have not systematically addressed the background causes of ill health and have relied increasingly on tackling more proximal causes (such as smoking), through behaviour change programmes. Part of the explanation for this emphasis lies with the comparative ease of identifying action to address behaviour, rather than the complexity of addressing social inequalities shaping such behaviours. This has led to the seemingly less challenging route of lifestyle interventions – this tendency has been described as ‘lifestyle drift’.234 The emphasis has been either on downstream actions that affect only a small proportion of individuals, or on approaches that have a socially neutral impact at best. Health inequalities are likely to persist between socioeconomic groups, even if lifestyle factors (such as smoking) are equalised, without addressing the fundamental causes of inequality

I came to Sir Michael Marmot and the Marmot review via social media – he’s not really well known in the United States even though he’s the recent past President of the British Medical Association, but I think his work and writings are very compelling (see what he wrote about spending time with The American Medical Association here).

I actually asked this question on in the quest to understand whether current trends in gamification, mobile and the like are really the answer to societal health problems. I was referred in an answer to my question to this review, which I read from cover to cover, and enlightened me to both a new world of information and connected me to experiences I have had in my public health work as well as connections to other industries who are engaged in improving health, too.

The work, commissioned in 2008 by the British Government, is replete with extensive reviews of the data and some very important concepts that I think can and should extend the current thinking of the American health system.

Life expectancy, disability free life expectancy, and the gradient across social standing

In American health care, we tend to focus on measures that are more about process of care, such as “did the patients receive their antibiotics on time.” A health system typically does not measure itself against its ability to enhance not just life expectancy, but disability free life expectancy, and more importantly the gradient across the socioeconomic status. What do people want to say is success for them in terms of their health? Look at the data for England:


Life expectancy and disability-free life expectancy (DFLE) at birth, persons by neighbourhood income level, England, 1999–2003

Take note of two things:

  • The enormous difference in life expectancy experienced by individuals who aren’t that separated by geography:  “in the wealthiest part of London, one ward in Kensington and Chelsea, a man now has a life expectancy of 88 years. But the contrast is stark. A few kilometres away in Tottenham Green, one of the capital’s poorer wards, male life expectancy is 71. Similar differences are seen all over the country, for both men and women.”
    • These differences happen in the United States, too: There is a 17-year difference in life expectancy between a man in Washington, DC, and one in Suburban Maryland (JAMA, 2009)
  • If, as proposed, the pension age is increased to 68 without changing the gradient, 75% of the population will not make it to that age disability free.

It’s not about absolute income, it’s about the gradient in social status conferred by a host of factors

It’s noted that “India, 76% of the population live on $2 a day or less, yet men in India, on average, have longer life expectancy than the poorest men of Glasgow and about the same as men in Washington, DC.

“Such systematic differences in health do not arise by chance, and they cannot be attributed simply to genetic makeup, ‘bad’ behaviour, or difficulties in access to medical care, important as these factors may be. Social and economic differences in health status reflect, and are caused by, social and economic inequalities in society. The Commission on Social Determinants of Health (CSDH), set up by the World Health Organisation, concluded that social inequalities in health arise because of inequalities in the conditions of daily life – the conditions in which people are born, grow, live, work and age – and the fundamental drivers that give rise to them: inequities in power, money and resources.”

What to do entails addressing social determinants, which means collaboration beyond the health care system

One key approach (among 6) in the report is about investing in early childhood. This chart shows that, currently, “Out of 28 OECD countries, 26 spent more per child in late childhood than in the early years; and 23 spent more on middle childhood than on the early years. In 2003, Hungary was the only OECD country spending more per child on the early years than in later stages of childhood.”

Variation in the distribution of expenditure on childhood education by age in selected European countries, 2003

What this situation describes is an opportunity to attend to the abilities of adults of the future by attending to them in early, as opposed to later childhood. Data presented shows that children with low cognitive ability at age 22 months from a family with high socioeconomic status will recover to a point that they will cross children with high cognitive ability at age 22 months, who will show a significant decline.

The other areas of action include creating “fair employment and good work” which includes the physical as well as psychological work environment, enrusing a healthy standard of living by better defining what an income for healthy living is, and strengthening prevention, and not just for the most disadvantaged, across the entire gradient.

Besides these areas, I was interested in the emphasis on “creating and developing healthy and sustainable communities.” This is where actions including promoting active transportation (biking and walking), access to food, and also things that are currently underemphasized in American health care – the impact of climate change and CO2 emissions. Even in the specialty of Nephrology, for example, something can be done – witness the UK’s Green Nephrology Programme, which works to reduce the CO2 footprint of very intensive medical interventions.

Where does behavior change fit in?

It is in here, in the context of creating the right conditions for this to be successful:

This Review puts empowerment of individuals and communities at the centre of action to reduce health inequalities. But achieving indi- vidual empowerment requires social action. Our vision is of creating conditions for individuals to take control of their own lives.

I think the key message is that this individual action should not be seen as the dominant approach to improving health:

As this Review has demonstrated, policies to modify health behaviours need to address the social determinants of health. Aiming interventions at individuals will not by themselves reduce health inequalities; ‘responsibility for better health should be shared between society and the individual

What can be done differently?

Part of the solution is to think differently. Several of the seminal reviews of the causes of impaired health moved the the discussion away from “medical care” to health promotion and health behavior. The excellent paper by Schroeder from 2004 begins a conversation that goes one level deeper, the determinants that guide and shape the behavior. This report fully vests that concept.

The other part is for the system to behave differently, to collaborate more. There is a natural incentive in England’s NHS to collaborate with the social care system, and yet there are still challenges: “Currently, GPs, like most primary care services – community health services, dentists, pharmacists and opticians, do not see tackling the social determinants of health inequalities as core business.”

And yet, many of the social determinants are better addressed in collaboration outside of the health system with the result being a more effective health system. As I’ve discussed previously on this blog, the health system is under-equipped to manage the “Unmentionables,” and maybe it shouldn’t, by itself. (see: “Are your bills making you fat?”)

What others have said

I am not the first person to read the Review of course, and there is copious commentary available online in the scholarly literature, which you can access courtesy of the link cloud (see: my links related to the Marmot Review) that I have created. I’ve read these pieces as well, as well as Sir Michael’s response to various critiques (does poor health result from social status or is it the other way around?) and I believe this data should be understood before we create the next great behavior change intervention that targets the already-engaged.

I’ll end this blog post with a quote from Andrew Lansley, the UK Secretary of State for Health, in response to this review.

There will be a profound shift in tone, attitude and outlook. Rather than nannying people, we will nudge them by working with industry to make healthy lifestyles easier; rather than lecturing people about their habits, we will give them the support they need to make their own choices; and rather than dictating policies from the centre, we will support leadership from communities, by giving local authorities more power to develop the right approaches for their communities.

Will our health care system be able to do this? Either way, I think I’ll be following the adventures of Sir Michael for a really long time.