The challenge. When babies are born, medical personnel routinely assess their biological risk factors, which include birthweight, gestational ages and Apgar score (a standard measure of skin color, pulse rate, reflex response, muscle tone and respiration).
But when it comes to predicting poor health and educational outcomes in children, should physicians also assess social risk factors, like the mother's age, parents' marital status and the family's socioeconomic status? Are social risk factors just as important as biological risk factors?
A new way to view health. After completing his medical training at Harvard Medical School and his pediatric internship, residency and chief residency at Stanford University Medical Center in 2000, Douglas P. Jutte, MD, MPH, began working at the community health center and mobile health van in East Palo Alto, Calif. As the primary caregiver for several hundred children from low-income, Spanish-speaking families, the pediatrician quickly learned that "my medical training seemed inadequate to understand what was causing them the greatest problems."
"I would often see immigrant families who came to me to get shots to get their children into school," recalled Jutte. "They were very invested in the kids, but there were so many barriers to their ability to succeed. I found that the most effective thing I could do was to get a window fixed for a child with asthma, or coordinate a ride to school for a child with Down Syndrome because his mother had stopped taking him. Those actions impacted their health more than their access to health care."
Jutte grew frustrated with certain aspects of patient care because "it is focused on the individual, the person sitting in front of you and what you can do for them. You don't think about the larger trends and you can be missing other issues." In 2002, Jutte took a leave from his teaching position at Stanford and cut back on his clinical responsibilities to pursue a master's degree at the University of California (UC), Berkeley, School of Public Health. Drawn to epidemiology, he decided to "break out of the medical mold and step back and understand the fundamental or upstream causes of public health issues."
Tapped as a Robert Wood Johnson Foundation Health & Society Scholar in 2003, he was able to combine his medical background and epidemiology training to address health issues from a research perspective. (For more information on the program, see Program Results Report.) In 2003, he began the two-year fellowship at UC San Francisco (UCSF), followed by a one-year RWJF research training grant at UC Berkeley. "The fellowship completely redirected where I am with my life," said Jutte.
Persuading physicians to focus on social risk factors. As a Health & Society Scholar, Jutte studied the interaction of biological and social risk factors in early childhood, and their relationship to long-term health and educational outcomes. He argued that "While physicians, and the medical field in general, pay close attention to biological predictors of health and well-being, they often fail to evaluate, assess or document social risks to health in the same way."
To demonstrate why that matters, Jutte used a Canadian database that tracked, from birth to adolescence, 4,000 children born in Winnipeg, Canada, in 1984. Three social risk markers—the mother's age, marital status and socioeconomic status—proved to be as good, or better, predictors of poor health and educational outcomes as three traditional biological risk factors—gestational age, birthweight and Apgar score.
Those findings, said Jutte and his co-authors, highlighted the need to make rigorous evaluation of social factors a routine part of clinical assessment. "Paying close attention to the social risk factors makes it possible to identify "otherwise unrecognized at-risk children," said Jutte, who presented his findings in May 2008 at the Pediatric Academic Societies annual meeting, which were subsequently published in Epidemiology. ("Rethinking What Is Important: Biologic Versus Social Predictors of Childhood Health and Educational Outcomes." 21(3): 314–323, 2010. Abstract available online.)
To encourage physicians to consider nonmedical indicators, Jutte found a powerful way to bring his point home. "I use a clinical vignette, explaining that a baby born to a teenage mother has about the same risk of being hospitalized during childhood as a baby born two months premature. Hospitalization is a clear medical outcome that physicians worry about." Though he acknowledges that the social context of these young mothers, rather than teen birth itself, is the primary cause of increased risk, he points out that one purpose of the vignette is to highlight the disparity in resources mobilized by the medical community to mitigate the risk associated with these two clear markers for increased hospitalization.
Lead poisoning is another example he uses to highlight to physicians and medical students the blurred line separating biological and social risk. Forty years ago, he tells them, we believed that some children were simply less intelligent and more likely to be ill simply because they were poor. "Then we discovered this was due in part to the lead in gasoline and the lead in paint. And now, decades later, it is the doctor's responsibility to measure lead levels. They don't go out and remove the paint, but they do see the child back again to check for lead and make sure the problem is being solved."
He believes a similar model needs to be developed for social toxins. He says that putting a process in place to help physicians recognize problems and refer families to appropriate agencies is the minimum first step.
Breaking the mold. For Jutte, making the transition from clinician to population health researcher meant learning to think very differently. One of his mentors used to joke, "It will take years to break down your medical training, which is getting in the way of thinking about the medical population." But after three years focused on population health research, first as a Health & Society Scholar and then as an RWJF-funded researcher, Jutte realized that he could not return to an exclusively clinical focus.
Today, he devotes most of his time to research with this broader focus and teaches medical students how to do that as well. Jutte is an adjunct assistant professor in the UC Berkeley-UCSF Joint Medical Program and the associate director of the master's degree program in Health & Medical Sciences at the UC Berkeley School of Public Health. But he has not put his clinical expertise entirely aside, and continues to see patients as a neonatal hospitalist at a local community hospital.
In addition to his Epidemiology article, Jutte's research was published in the Annual Review of Public Health, the Journal of the International Neuropsychological Society, Academic Pediatrics and elsewhere. In 2010 and 2011, he has coordinated a series of conferences around the country focused on community development and health, which were co-sponsored by RWJF and the Federal Reserve Bank of San Francisco, where Jutte has served as a scientific adviser since 2005.
In his opening remarks at the first conference in Washington, Jutte called the Health & Society Scholars a "remarkable" program, one that had changed his life. The program, he said, "trains people in a variety of disciplines—economists, urban planners, physicians, political scientists—in population health, stepping beyond public health and actually looking at population health. And that's really where I got involved with this and started moving away from a pediatric-specific background."
RWJF perspective. The Foundation 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 and leader of RWJF's Public Health Team. "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.