The problem. Most of the health problems of older adults do not develop overnight. They are the result of a lifetime of experiences, including healthy and unhealthy behaviors. An unhealthy diet and lack of exercise, for example, can lead to obesity, which, in turn, can increase disabilities in older adults.
In addition, a host of social, economic, genetic, and psychological factors—everything from not having access to decent food to stress from worry about losing a job or a home—can also affect health. Once people begin to understand the importance of those factors, they need to examine how public policy may be leveraged to improve the health of older adults.
Scholar perspective. Dawn Alley’s family moved around a lot when she was a child, and for a time they lived with her grandmother, who managed a nursing home for low-income adults. This made Alley comfortable being around older people, but it was not until she took a class in gerontology while in college at the University of Southern California that she began to take a scholarly interest in their health.
The class introduced Alley to what is known in the field as “population health,” a holistic approach based on the idea that health outcomes are the product of a multiplicity of influences. Alley was hooked. She went on to do her PhD in gerontology at the University of Southern California.
Alley wrote her dissertation on the association between poverty and high levels of C-reactive protein (an indicator for heart disease), and published a journal article about this connection in Brain, Behavior, and Immunity (20(5): 498–504, 2006). Through her research Alley began to develop an appreciation not only for the impacts on health of social and economic conditions, but also the cumulative impact of “life course” experiences.
“The field of gerontology emphasizes that people don’t wake up at age 65 with a random distribution of health issues,” she says. “They arrive there carrying all the life experiences that they bring to old age.”
Alley’s perspective widened even more during her Robert Wood Johnson Foundation Health & Society Scholars fellowship at the University of Pennsylvania (Penn), one of six universities participating in the two-year interdisciplinary program. For more information on the program, read the Program Results Report.
She found herself working and studying with physicians who were among the program’s directors and with physicians participating in the Robert Wood Johnson Foundation’s Clinical Scholars program, which also has a site at Penn. “Prior to that my experience had been multidisciplinary,” Alley says, “but I’d been a multidisciplinary researcher. All of a sudden I was working with people who were not only researchers but also practitioners.”
Investigating influences. Alley’s relationships at Penn led to two key research collaborations that would prove instrumental in shaping her subsequent career. The first of these involved an investigation into changes in the impact of obesity among older adults, conducted with one of her mentors at Penn, Assistant Professor of Medicine and Sociology Virginia W. Chang, MD, PhD.
Earlier studies had found that obese people were living longer, in part due to improved treatment of cardiovascular diseases. Alley and Chang sought to discover whether obese people might be living with more disability despite their longer life spans.
They analyzed the results from two rounds of the National Health and Nutrition Examination Surveys (1988–1994 and 1999–2004). Data included interviews with and clinical examinations of 10,708 non-institutionalized adults over the age of 60. Alley and Chang found that the odds of functional impairment (e.g., having much difficulty or being unable to walk up 10 steps without resting) remained the same among nonobese participants, but increased by 43 percent among obese participants. Obese people might be living longer, but they were probably enjoying life less. Alley and Chang reported their results in an article in the Journal of the American Medical Association (298(17), 2007).
“In gerontology we talk about ‘active life expectancy,’ ” Alley says, “meaning the amount of time you’ll be active and not disabled. If we want to improve active life expectancy, we have to prevent people from getting sick in the first place. With the epidemic of obesity, we’re going in the opposite direction.”
Also during her Health & Society Scholars fellowship, Alley led a study of how material disadvantages (lack of goods and services available to people with higher incomes) in health care, food, and housing might be associated with health disadvantages in later life. Her co-investigators included two alumnae of the RWJF Health & Society Scholars program, Carolyn Cannuscio, ScD, ScM, and José A. Pagán, PhD, and another of her mentors at Penn, David Asch, MD, MBA, a professor of medicine and co-director of the program at Penn.
The researchers analyzed data from the 2004 and 2006 Health and Retirement Study, a nationally representative sample of Americans aged 51 years and older. Indicators of material disadvantages included lack of or inadequate health insurance, difficulty affording groceries, renting instead of owning a home, low-quality housing, and unsafe neighborhoods. Alley and her colleagues used self-reported study data on general health (from excellent to poor) and difficulty walking to assess health status.
In a paper published in the American Journal of Public Health (99 (Suppl. 3): S693–701, 2009), Alley et al. reported finding a “substantial and sustained” relationship between unmet needs for adequate health care, food, and housing and worsening health. “Policies to improve health should address a range of basic human needs, rather than health care alone,” the authors concluded.
Digging deeper into the health policy arena. When she finished her fellowship in 2008, Alley took a position as assistant professor of epidemiology in the gerontology division of the University of Maryland School of Medicine. There she built on the research she’d started at Penn, co-authoring studies on the impact of mortgage delinquency on health and on the increasing Medicare expenditures for older adults who were obese.
Alley’s momentum toward a more active engagement with public policy received a substantial boost with the passage of the Affordable Care Act in 2010. The act made it possible, Alley believed, to put some of what she’d learned about the relationships between environment, poverty, and health into practice.
“I was really interested in having that experience where the rubber meets the road,” she says. “I’d been doing all this research on the intersection between social and economic conditions and health, and I wanted to see what it would be like to actually be in there trying to utilize policy to address these issues.”
In 2012, Alley received an Atlantic Philanthropies Health and Aging Policy Fellowship, which gives professionals in health and aging the chance to work with policy-makers in Washington to develop the skills needed to translate science and clinical experience into sound health policy for older adults.
Alley chose to spend her fellowship in the Office of the Surgeon General of the United States. She has been there ever since and as of March 2014 is a senior policy advisor with primary responsibility for the National Prevention Council, which coordinates health prevention and wellness initiatives among 20 federal departments and agencies. She also still serves on the faculty at the University of Maryland.
Alley considers her work with the National Prevention Council the fruition of all the work she has done in her career. She says she never would have gotten the opportunity had it not been for the RWJF Health & Society Scholars fellowship.
“The fellowship was the perfect preparation for this,” she says. “My work here requires that I speak with a lot of different audiences, making the case for population health approaches to folks from lots of different sectors, communicating regularly with everyone from the departments of education and defense to the Centers for Medicare & Medicaid Services. The skills I earned in the fellowship, the mentors who guided me, my collaborations and conversations with other scholars—all of those experiences sent me in a new direction.
“Without the fellowship I would not be where I am today,” concludes Alley.
RWJF perspective. RWJF created the RWJF Health & Society Scholars program in 2001 to build the field of population health. “There is a growing recognition that health is the result of the interaction of multiple factors including socioeconomic and physical environmental factors and health behaviors,” said Pamela G. Russo, MD, MPH, senior program officer. “The evidence shows that these types of factors play a much larger role in determining health at the population level than do the traditionally considered health care and biological determinants of health.”
“The program seeks to integrate paradigms and knowledge from a variety of disciplines to develop an understanding of how these determinants affect the health of populations, and thereby to design interventions with greater power to reduce health disparities,” said Russo. The final cohort of scholars for the program are entering in 2014 and will complete their fellowships in 2016.