Culture of Health Blog

The amputation was scheduled for that day. John’s* uncontrolled diabetes had stopped blood flow to his lower leg. With the tissue starting to die, it seemed inevitable that his foot would have to be removed to save his life.

Thankfully, a team I work with had recently helped bring telehealth services to the rural Colorado hospital where John had been admitted. A cloud-based video system connected to electronic health records enabled his doctor to consult with an infectious disease specialist hundreds of miles away in Denver. The specialist suggested one last “cocktail” of antibiotics, to be administered by I.V. The protocol worked. John kept not only his foot, but also his livelihood as a rancher: his ability to graze cattle, grow wheat, and provide for his family.

When her regular job hours were cut, Lulu, who is in her 30s and lives in New York, couldn’t find a new full-time job. Instead she now has to contend with unsteady income and an erratic schedule juggling five jobs from different online apps to make ends meet. Cole, in his first week as an Uber driver in Atlanta, had to learn how to contend with intoxicated and belligerent passengers threatening his safety. Diana signed up to help with what had been described as a “moving job” on TaskRabbit. When she arrived, she had to decide whether it was safe for her to clean up what looked to her like medical waste.

Work is a powerful determinant of health. As these stories about taxi, care, and cleaning work from a new report show, it is a central organizing feature of our lives, our families, our neighborhoods, and our cities. And work—its schedules, demands, benefits, and pay—all formally and informally shape our opportunities to be healthy.

But the world of work is rapidly changing. Job instability and unpredictable earnings are a fact of life for millions. Regular schedules are disappearing. With “predictive scheduling,” a retail worker today is essentially on call, making everything from booking child care to getting a haircut impossible until the work schedule arrives. Health and other fringe benefits are less often tied to the job. Nearly six in ten low-wage workers today has no paid sick leave. Two-thirds lack access to employer-based health care benefits.

Medicaid is the largest health care program in the United States and impacts the lives of more than 76 million Americans, nearly one-quarter of the nation’s population. The program can play a powerful role in influencing the health and well-being of individuals and families.

State Medicaid programs can only be truly successful, however, if they are responsive to the needs and priorities of the clients they serve—not providers, but patients and their families. Medicaid officials understand this. However, in the resource- and time-constrained environments in which Medicaid staff operate, finding the right avenues for gathering meaningful consumer input can be a challenge.

The Robert Wood Johnson Foundation has been trying to address these challenges through its work to transform health and health care systems. As part of these efforts, the Foundation along with the Center for Health Care Strategies recently engaged experts, including representatives from across the patient advocacy world, around this issue. These experts include leaders from Altarum, American Cancer Society Cancer Action Network, Community Catalyst, Georgetown Center for Children and Families, Nonprofit Finance Fund, and the Patient Advocate Foundation.

Editor’s Note: Although foster care placement is sometimes necessary to ensure the safety and well-being of children, research indicates that keeping families together is generally a better for children, parents, and the community. Working with the Corporation for Supportive Housing, RWJF launched Keeping Families Together in 2007. The program helps vulnerable families like Irma’s grow stronger, safer and healthier so that children—and their parents—might thrive. We are resurfacing this post in time for Children’s Health Month.

From too early an age, Irma faced a seemingly endless series of traumatic events that life threw at her as best she could—on her own.

But after a domestic crisis left her hospitalized, homeless, jobless, and in danger of losing her infant son, Irma finally received help from a supportive housing program that changed her life.

Keeping Families Together (KFT)—the Robert Wood Johnson Foundation (RWJF)-supported model for the program that helped Irma turn her life around—has become my own personal touchstone for what building a Culture of Health should look like in the real world.

Irma’s story illustrates both the power of this model and the inner resilience that so many struggling families possess.

As the executive director of Philadelphia Physicians for Social Responsibility in the late 1990s, I worked closely with the local police department, the Women’s Law Project, and the district attorney. At the time, these forward-thinking professionals were frustrated. They were arresting the second and third generation of families involved in the criminal justice system. I knew some of these same individuals, and their histories as survivors of childhood trauma.

We were witnessing the downstream effects of unaddressed trauma in early childhood. Children who grew up traumatized landed in the juvenile justice system first and eventually within the criminal justice system as adults.

As a result, we knew we needed to find ways of building communities that would better support young children. Could we invest more upstream, in early childhood education, for example, and in doing so help prevent violence in our communities in the long-term?

Thanks to innovators like these and reams of new research on how early trauma and later violence affect individuals over a life course, we now understand that community conditions that impede children’s healthy development can impact everyone’s safety down the line.

When Dr. Rex Archer returned to his hometown of Kansas City, Missouri, to lead its health department in 1998, he was shocked by the city’s inequities. Life expectancy for white residents was 6.5 years longer than that of black residents. Gathering more data, he estimated that about half of the city’s annual deaths could be attributed to conditions in neighborhoods like segregation, poverty, violence, and a lack of education.

I also confronted stark disparities by neighborhood in my years as Philadelphia’s health commissioner, as does most every health commissioner/director across the country. It is truly unsettling to see how small differences in geography yield vast differences in health and longevity. In some places, access to healthy food, stable jobs, housing that is safe and affordable, quality education, and smoke-free environments are plentiful. In others, they are severely limited. Data can help us better understand the health disparities across our communities and provide a clearer picture of the biggest health challenges and opportunities we experience.

Louisville, Ky., has one of the highest asthma rates in the United States. To better understand this problem, community leaders blanketed the city with air quality sensors and equipped more than 1,000 asthma sufferers with GPS-enabled inhalers. They also downloaded traffic data from Waze, pulled in local weather information, and used manually-collected data on city vegetation.

Together, this data revealed that people used their inhalers most on days with high temperatures and high air pollution, and in areas with heavy traffic and few trees. Using this information, local leaders are now taking steps to increase the tree canopy and reroute trucks in neighborhoods where asthma is most severe. They are also exploring changes to city-wide zoning policies to improve overall health.

What happened in Louisville isn’t just a story of effective community engagement or savvy data analysis. It is an example of how technology can be used to shape our communities for the good—and with major implications for health.

Does the kind of data we collect and report ensure everyone has a fair and just opportunity to live their healthiest life possible?

As the country grows more ethnically and racially diverse, there is a growing debate among health researchers about the value of breaking down data in more refined ways. The argument is that simply looking at health outcomes through the lens of broad racial or ethnic categories (e.g., black people or Asian Americans) doesn’t paint an accurate enough picture of health and well-being. It masks what’s happening within subgroups and glosses over the nuanced experiences that greatly influence outcomes in these populations.

Recently, the Robert Wood Johnson Foundation (RWJF) partnered with PolicyLink to identify the needs and gaps in how ethnic and racial data are collected, analyzed, and reported for each of the major aggregated ethnic and racial groups.

One year ago, in August 2017, Hurricane Harvey made landfall and then refused to leave. Hovering over Harris County, Texas—home to Houston—it dumped 1 trillion gallons of water, the equivalent of 40 million swimming pools, on the county’s 1,778 square miles. One community saw 10 inches of rain in 90 minutes. Drainage systems—all systems for that matter—failed or were disrupted in unfathomable ways. Water was as high as streetlights in some places. Potentially poisonous chemicals and dangerous bacteria surged through residential areas. People were trapped by flooded roads. Homes and lives were destroyed.

Those 10 days—from August 25 when the storm made landfall until September 4 when the sun finally returned—were some of the most challenging of Umair A. Shah’s career. Umair A. Shah, MD, MPH, is a physician, an emergency responder, and most importantly the executive director of Harris County Public Health (HCPH). HCPH is the county health department for the 3^rd largest county in the nation serving 4.7 million people. He and his staff were in rapid response mode leading up to the storm, during the storm itself, and for several weeks in the recovery phase of the storm, often operating 24/7.

During a visit to the Robert Wood Johnson Foundation (RWJF), I had the pleasure of discussing Harris County’s response with Dr. Shah. “My staff came every day to do their jobs,” he told me, “while they too wondered about their own homes or how their family members were faring. I am so amazed by their absolute dedication to the needs of our community despite it all.” Dr. Shah himself drove 2,200 miles in 10 days visiting neighborhoods that were heavily impacted from the storm.

Many of us have had those moments in life where the decisions we make alter the path our lives take. Brian Castrucci, the newly appointed CEO of the de Beaumont Foundation, had one of those pivotal moments back when he had completed his first year of graduate study in public health.

At 24 years of age, Brian had a decision to make: return to school to complete his master’s degree in public health or accept a one-year internship at the Robert Wood Johnson Foundation (RWJF). He chose RWJF, and, he says, “it’s made all the difference.”

“What would I have missed if I hadn’t done that internship?” Brian told me in a recent conversation. “Simple. How to think. How to dream. How to boldly take on a change that is needed even when you know it’s going to be really hard.”

He considers that year the base for much of his early career success. Not only did he learn to think strategically and tackle big problems, like youth tobacco and substance use, but he saw models of partnership, collaboration, and how people at the top of their game work together to advance the field and change lives. “I had a chance to interact with, and learn from, leaders who I had read about in class. It was like a public health fantasy camp.”

And then, just as he was considering a career in philanthropy, he was encouraged to walk through another door. As his internship was ending, Brian told RWJF Senior Scientist Tracy Orleans, one of his mentors, that he was interested in staying on at RWJF. She wisely noted that wasn’t the best idea for a young person with a spark of public health passion. If he was to be truly effective in philanthropy, she told him, he needed time in the trenches.