Culture of Health Blog

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.

In January 2018, the Hollis Innovation Academy, a K-8 school, opened a dental exam room. Though it may seem unusual to see a dentist’s chair in a school, its presence reflects years of learning within this Atlanta community. Hollis's students live in English Avenue/Vine City, an area with one of the highest poverty rates in Atlanta. They also reside in one of three zip codes with the highest oral cancer rates in the city.

Early in my career as an ear, nose and throat specialist, I witnessed a deeply troubling pattern: on my first visit with a patient, I would diagnose him or her with advanced head and neck cancers. There would have been good treatment options if these patients had been seen much earlier. But time and time again, all we could do was rush the patient into an operating room, put in a tracheotomy to control the airway, and set up end-of-life care. I kept thinking that someone needed to get to this issue much sooner so that people wouldn’t die from something that could be treated effectively if caught sooner.

Eventually, I decided that person was me.

It has been said that inspiration comes when you least expect it. My visit to Melbourne, Australia, inspired me to take an international look at place-making. I was standing in Federation Square, restlessly waiting for my daughter to finish her shift. I hadn’t seen her in nearly a year. I was wearing my mom hat, not my urban planner’s hat.

Nevertheless, as my eyes swept the Square, I had the sense of being in a very special place. And while I didn’t know it at the time, I was not surprised to later learn that Federation Square in the heart of Melbourne has been recognized as one of the best public squares in the world. Fed Square, built on top of a working railway, comprises sculpted and natural elements; it has small spaces like fire pits; and large and medium-size open spaces for planned and unplanned activity. There is a large TV screen that broadcasts international and national sporting events (it is not always on). The Square is open 24 hours a day; has free Wi-Fi for all; rest rooms; and no signs prohibiting activity or lingering. Restaurants open their doors to it; and transit lines and shops surround it.

I visited Fed Square daily for eight days, and what impressed me was how well it reflected Melbourne’s rich cultural diversity; how seamlessly it connected to the streets, buildings and facilities on its periphery; and how welcoming it always felt. It is a place for people—the well-heeled, the not-so lucky—and everyone in between. I should note, though, that Federation Square’s value as an open public space and cultural hub is currently being tested. Controversial changes to it are pushing forward sans public review and participation.

Although smoking rates have dropped by more than half over the past 50-plus years, tobacco use remains the number one cause of preventable deaths in the United States.

And not everyone has benefited equally from reduced rates in smoking—there are deep disparities in tobacco use and quit rates, depending on where people live, how much money they make, and the color of their skin.

Tobacco products disproportionately harm people with lower incomes and less education; people with mental illness and substance use disorders; people who identify as lesbian, gay, bisexual, and/or transgender (LGBT); and racial and ethnic minorities.

What’s causing these inequities? Part of it is marketing. Tobacco control efforts have not focused on closing racial, ethnic and socio-economic gaps. In fact, we know that the tobacco industry targets certain populations—women, people who are black or Latino, and members of the LGBT community—with higher levels of marketing, exposing them to more tobacco product ads.

In addition, people in many of these groups are less likely to have health insurance—and, as a result, less likely to have access to smoking cessation products and services.

Health care delivery often involves a one-size-fits-all approach. As clinicians, we treat a patient with a particular diagnosis similar to the last patient we saw with the same diagnosis because it’s efficient—we think. But shifting that mindset is one of the best opportunities we have to help people truly thrive. An individual’s lived experience is rich, diverse, and complicated. And what it takes for each individual to live his or her healthiest life possible is as unique as each person is. In other words, a patient’s full life experience should inform how we shape their treatment.

To achieve a deeper understanding of our patients, it is essential for providers to practice “cultural humility” and acknowledge the unique elements of every individual’s identity. Many of us may be familiar with cultural competency—being respectful and responsive to the health beliefs and practices—and cultural and linguistic needs—of diverse population groups.

But cultural humility goes even deeper. It requires you to step outside of yourself and be open to other people’s identities, in a way that acknowledges their authority over their own experiences.

Weekend after weekend, the wave of emergency department (ED) patients would arrive. Oral and maxillofacial surgeon Jonathan Shepard would treat shattered jaws, knife wounds and other facial injuries at the hospital in Cardiff, Wales. These injuries stemmed from brawls in bars and nightclubs where broken glasses and bottles were wielded as weapons. Strangely, Dr. Shepard found that only 23 percent of these assaults treated in the hospital were reported to law enforcement.

Harnessing the Power of Data for Violence Prevention

Determined to find a way to stem the violence, Dr. Shepard mobilized health care providers, law enforcement heads, city officials and other local leaders in working together to address what was happening within their community.

Local hospitals agreed to gather basic anonymized information from each assault victim admitted to the emergency department, including the specific location of the violent incident, time of day, and weapon involved. They removed patient identifiers and shared the anonymous data with local law enforcement officials, who combined those data with their own records.

With these data, police were able to map when and where violence might happen, and concentrate resources on hotspot locations such as specific streets, businesses, schools, or transit stations, and during particular times of the week, to help prevent incidents.