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Frandal Wright, who went 27 years without health insurance before getting HIP 2.0 coverage last year, makes his $1 monthly payment at the Wal-Mart in Anderson.

Because the store is on the other side of Anderson from where he lives, Wright tries to pay as much as he can at each visit to minimize the number of times he has to make the trip. Right now, he says, he’s trying to find someone to give him a ride to make his payment and determine if he has enough money to make a lump sum payment.

“I’m a little behind now because I almost forget about it,” said Wright, 46. “I want to pay for the whole year. I’m trying to do that this time. I’ll probably give them $20 if the Lord blesses me.”

Do Indiana’s poor Medicaid recipients really have skin in the game?

As I viewed my electricity bill today I was told by Alabama Power “You pay on average $5 a day for your electricity.” This means I have “skin in the game.” I have the power to determine if I pay nothing per day or $20 per day. Well, only a little as it turns out.  It seems that Alabama Power won’t let me come off the grid easily, so I will end up paying something no matter what. Also, my major non-air conditioner power usage corresponds to my use of the clothes dryer. I can minimize the use of the dryer by hanging a clothesline, I suppose, but elect not to.  What I have decided is that I cannot do  without electricity. So, although I have skin in the game, I can’t say “no, thank you, I’m using a cheap alternative to electricity so go away Alabama Power.” I rely on the Public Service Commission to negotiate fair rates and rely on the government to force my appliances to become energy efficient. Oddly, as appliances become more energy efficient, rates per kilowatt hour tend to go up. I now have less skin in the game (using efficient appliances less frequently still costs the same because I pay more per kilowatt hour) but still reflexively try to use less electricity. Modern life is confusing at times.

Many folks have asked me what I think is going to happen with health care. Conventional wisdom is that the people appointed dictate policy. Seema Verma, who helped design the Medicaid expansion in Indiana, is the new director of CMS (the agency responsible for Medicaid and Medicare). The buzzwords for poor people and perhaps all sick people will likely be “personal responsibility.”

Ms Varma has written on the philosophy she has used to design the system in Indiana (article found here). It seems that this is not just about making sure poor, sick folks have needed care but importantly involves  bootstrap repair as well:

[M]any of Medicaid’s enrollment and eligibility policies, which might make perfect sense for certain vulnerable populations, are not always appropriate for able-bodied adults possessing different capabilities and earning potential. Able-bodied adults need coverage, but not the same set of policy protections.

One of the precepts of President Lyndon Johnson’s War on Poverty, from which Medicaid arose, is that government assistance should exist to provide a temporary pathway for people to lift themselves out of poverty toward a state of self-sufficiency.

The recipients are given a Health Savings Account and are required to make their personal contribution to teach them responsibility (as was the client in the anecdote above). Finding frequent rides to the insurance payment window and personally making a payment which provides continued access to lifesaving insulin and health failure medications, apparently, is freeing:

HIP respects the dignity of each member by setting a fair expectation of personal investment and engagement in his or her own well-being. Contributions are a way for members to demonstrate personal responsibility, but they also encourage members to stay engaged with their health plan, providers, and overall personal health. Because HIP Plus members’ own dollars are at stake, they have “skin in the game” and therefore an incentive to make cost-conscious health care decisions.

Well, maybe not…Turns out that for “frequent flyers” hospitals are seeing to it that the $1 premium is being paid. Because, if you miss a payment, you are kicked out. So it does seem that someone has skin in the game, just maybe not the patient.

As a pragmatist, I believe that the motive is unimportant if the desired result is achieved. Results to date are mixed. Ms Varma points out that those who have paid their premium continuously (folks with “skin in the game”) are more likely to have a primary care doctor, less likely to go to the ED, and more satisfied with their care. Critics point out that enrollment is not by any means what it should be as many folks can’t get a monthly ride to pay their dollar. Also, less that half of folks who were enrolled knew that they even HAD a health savings account much less how to use it. As they say, further study is needed.

In my professional experience, people believe they are healthy until they are sick. A monthly trip to Walmart to pay a dollar is likely not to change that. I hope that we choose to look at real measures of health and not try to do social engineering with our healthcare dollars.

Uwe Rheinhart, a noted health economist, was asked to predict what would become of healthcare under Trump leadership. He said “My hunch is that the “replace” in what is coming will reflect that conservative vision. It is bound to spell more hardship for the poor, the old, and the sick.” I am afraid that that is what “skin in the game” means.

I have a saying I use with my patients who are prone to fret as they grow, and feel, older.  “Every day on the green side,” I say to them, “is a good day.” Now that my wife, Danielle, is no longer here to share these days with me, I appreciate very much the effort she put in to making our “green side” as pleasant and inviting as possible.

We recently spent a long weekend mucking out the backyard pond and removing several dozen crawfish so the tadpoles and dragon flies would come back. They are back in force. The blueberry bushes, including the new ones we brought at the Botanical Gardens plant sale, are producing berries and the birds are, with the help of a netting reminder, leaving them on the bush long enough to stay ripe. The chickens continue to lay even after the flock has been reduced to a more manageable three birds. The citrus trees are loaded with fruit. Even the leak in the fountain has slowed, allowing me to keep the water feature flowing and providing the birds with a place to bathe. Here, in Danielle’s urban patch of green, the promise of renewal that spring brings to the gulf coast continues. Danielle is still with us, in her way, here on the green side.

Sudden cardiac death. That, in stark “doctor words,” is how she left those of us still on the green side. Although because of prompt paramedic response she still had a heart rhythm on and off after arriving at the hospital, it soon became clear that, clinically, she had left us on that Sunday, three weeks ago, while still in the house. I like to think that, once called, she decided to stick around. At the very least, she intends to make sure that the crawfish population stays down so she can continue to watch the dragon flies from the kitchen window. I choose to believe that is the case in part because draining that pond was very hard work.

Very few people study sudden cardiac death (SCD) in the general population, mostly because there is little clinical information to be had after the fact. If people make it to the hospital while having their heart attacks, we can mobilize millions of dollars of equipment and personnel to preserve their heart function. When we know that a person is at significant risk for sudden cardiac death, we implant defibrillators which stand at the ready to shock the heart back into compliance should it get out of kilter.

Most SCD happens to relatively healthy people, as it did with Danielle. As documented on the American Heart Association web site, every year about 300,000 people will succumb to SCD. This is about 15% of the deaths that occur in America annually. Of those, about half of the men and two-thirds of the women will have no reason at all to suspect a problem. The modifiable risk factors (hypertension, hypercholesterolemia, diabetes mellitus, kidney dysfunction, obesity, and smoking) have all been brought to the attention of the public. Improvements in management of hypertension and diabetes and reduction of smoking has lead to a reduction in all deaths from heart disease, including SCD.  A surprising number of these events occur during exercise (which tends to make the news and provides an excuse  for those who embrace the couch potato lifestyle). Jim Fixx perhaps is the most famous victim of sudden cardiac death while exercising. For the most part, habitual exercise is protective. That is, once it becomes a habit.

In Danielle’s case, genetics clearly played a role. However, saying “genetics plays a role” is not the same as saying “it runs in families” like red hair. There is a complex interaction between genes that makes us all unique. Family history doubles the risk of SCD. A rare event becomes half as rare. So far, researchers have identified 23 different gene areas that might play a part. Mathematics suggests that finding a pattern useful for screening or targeted treatment is still many years away.

So, what does this mean for SCD? In the words of the investigators, “Our ability to accurately identify individuals most at risk for SCD within the population remains poor.” Preventing SCD, as of now, is the same as preventing all heart disease. Eat right, exercise regularly, monitor blood pressure and get checked for diabetes if you are one of those at risk. Make exercise a habit and report unusual symptoms such as passing out, chest pain while exercising that improves with rest,  or unusual amounts of fatigue. Fund emergency services adequately but realize they are not the answer. Support policy efforts to make exercise more accessible.  Bike lanes are one such example. Support policies to reduce exposure to cigarette smoke and access to healthy food. Support research but realize the research will be difficult and expensive to perform.

How about for those of us still on the green side? Support dragon fly habitats. Eschew backyard crawfish breeding. Plant fruit trees. And remember, every day on the green side is a good day.

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“Of the many painters I have known, almost all I found unhealthy … If we search for the cause of the cachectic and colorless appearance of the painters, as well as the melancholy feelings that they are so often victims of, we should look no further than the harmful nature of the pigments…”

Italian physician Bernardinus Ramazzini in De Morbis Artificum Diatriba

Humans have had  love-hate relationship with lead. Easy to find and convert from an ore to a malleable metal, lead was in cosmetics, eating utensils, and used to create the pipes that move water from the Alps to Rome. The Romans were not universally impressed. Per Vitruvius:

“Water conducted through earthen pipes is more wholesome than that through lead; indeed that conveyed in lead must be injurious, because from it white lead [ceruse or lead carbonate, PbCO3] is obtained, and this is said to be injurious to the human system. Hence, if what is generated from it is pernicious, there can be no doubt that itself cannot be a wholesome body. “

We now know that lead poisoning, or plumbism, is a very real problem (image from Wikipedia).

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For those of us who live in older houses, lead is a constant concern. Our pipes are made of lead, there is lead in our paint, there is lead on the dirt from leaded gasoline. My children were at continuous risk from lead growing up. From the CDC:

Lead-based paint and lead contaminated dust are the most hazardous sources of lead for U.S. children. Lead-based paints were banned for use in housing in 1978. All houses built before 1978 are likely to contain some lead-based paint. However, it is the deterioration of this paint that causes a problem. Approximately 24 million housing units have deteriorated leaded paint and elevated levels of lead-contaminated house dust. More than 4 million of these dwellings are homes to one or more young children.

What those of us who live in old houses and old cities know is that lead much less of a problem if you leave it alone. As long as  the paint is not peeling, the kids won’t eat it. As long as the dirt is not disturbed, the kids (who always eat dirt) will only eat lead free dirt. As long as the pipes are not disturbed, the water will be lead free. Those of us that live in older cities rely on the water board to do the right thing and not create a problem where none exists. And it turns out there is a lot they need to take into consideration.

Flint Michigan is an old city full of old houses. The older houses were mostly lived in by poor people, who unfortunately were living in a town with an infrastructure built for many, many more people than are currently living there, making the infrastructure very expensive. The people, unable to pay for existing services, were taken over by the state. The state, in a story worth reading, elected to go with cheaper drinking water from the Flint River. The cheaper drinking water, in a predictable chemical reaction, leached the lead out of the pipes and put it into people’s drinking water.

What are the lessons to learn? First, our public infrastructure is aging and that will affect people’s health. Clean water and sanitary sewer systems were a game changer in the 1880s but that was 100 years ago. We need to pay attention. Second, poor people are disproportionately affected by our failing infrastructure. They are more likely to live in poor cities and more likely to live in older neighborhoods. Third, listen to the patient/constituent. The state of Michigan looks especially bad because they tried to substitute toxic waste  for water and when people caught on they tried to cover it up.

Hopefully, Flint will overcome this though it may not be financially feasible to rebuild the water delivery system. I only hope leaders in other towns with aging infrastructures (such as Mobile) heed the warning.

 

 

 

 

For those of you who read headlines off Google, the one that said 41% of Americans Obese by 2030 should have caught your eye. It did mine. Fortunately, in an odd coincidence, the Institute of Medicine has put out Accelerating Progress in Obesity Prevention, a document on what we as Americans can do to prevent becoming like the cruisers in Wall-E.

From their report, here are the actions we need to take:

Recommendation 1: Communities, transportation officials, community planners, health professionals, and governments should make promotion of physical activity a priority by substantially increasing access to places and opportunities for such activity.

Recommendation 2: Governments and decision makers in the business community/private sector should make a concerted effort to reduce unhealthy food and beverage options and substantially increase healthier food and beverage options at affordable, competitive prices.

Recommendation 3: Industry, educators, and governments should act quickly, aggressively, and in a sustained manner on many levels to transform the environment that surrounds Americans with messages about physical activity, food, and nutrition.

Recommendation 4: Health care and health service providers, employers, and insurers should increase the support structure for achieving better population health and obesity prevention.

Recommendation 5: Federal, state, and local government and education authorities, with support from parents, teachers, and the business community and the private sector, should make schools a focal point for obesity prevention.

Anyone up for a fight???

As the Alabama legislature begins an uphill battle to institute a user fee (not a tax because, well, you know) on cigarette smokers that will be collected at the cash register to fund Medicaid, folks still wonder why Medicaid should get the money. From a Montgomery Advertiser reader:

Wait, HOW THE HECK do people on Medicaid afford cigarettes? They need to figure THAT out! I’m going to be pizzed if they tax me and my money goes to Medicaid after they overspent by 80 mil that’s unaccounted for!

Should it not be apparent, people with severe disease due to tobacco usually cannot work so are typically “a burden” to the healthcare system unless they conveniently die fast or are killed by fiscal conservatives on the prowl.For people who want further reason to support the user fee, let me be helpful and point out that the effects of cigarettes are not limited to that of the smoker. From a 2011 report on the Burden of Tobacco in Alabama, here is the annual burden for non-smokers:

  • 789 deaths due to secondhand smoke (SHS) and smoking-related fires
  • 1,237 years of potential life were lost by infant deaths due to maternal smoking during pregnancy in 2009
  • $83 million in medical costs due to excess morbidity and $83 million in productivity losses due to excess mortality and disability from second hand smoke.

This additional dollar would add $220,000,000 to Medicaid (and with the Federal match potentially add another half a billion) to pay for these illnesses and reduce cigarette use by 10% to prevent even more illnesses. Hope this makes a “user fee” easier to support.

 

 

 

Why, when we spend such money on health care, do we not do better when we measure ourselves against other countries regarding preventing cancer deaths?  My theory as to how we came to this place is three-fold. First, the public has difficulty understanding small probabilities. Sometimes, when presented with a scenario, they see a 1% risk as very high (my 40 year old friend got breast cancer and you are telling me not to worry? I have a ONE PERCENT risk!). Sometimes they see it as very low (sure I smoke, but of all the people who smoke NINETY NINE out of 100 don’t get lung cancer). As a consequence, Americans tend to participate in risky behaviors, spend personal money ineffectively on preventive services and don’t demand that we as a country spend money effectively in aggregate. Secondly, Americans want value for their health care dollar and believe they are getting it (but believe that others are being wasteful):

The mismatch between reality and voters’ perceptions is most acute when voters consider their own health care:
■ 65% of voters think that most or nearly all of the health care they receive is backed up by scientific evidence, with 26% thinking that half or less is backed up by science;
■ However, confidence diminishes when voters are asked about the health care that “most people” receive. Only a slim majority, 51%, believes that nearly all or most care is backed up by good science.

So, Americans believe their OWN health care decisions are good but every one else is being wasteful. Lastly, physicians have incentive to suggest the use of expensive technology when a less expensive one might do. From a study about prostate cancer:

We found that in the early period of IMRT [a very expensive treatment for aggressive prostate cancer] adoption (2001–03) men with high-risk disease were more likely to receive IMRT, whereas after IMRT’s initial dissemination (2004–07) men with low-risk disease [more folks but much less likely to benefit from such aggressive care] had fairly similar likelihoods of receiving IMRT as men with high-risk disease. This raises concerns about over treatment, as well as considerable health care costs, because treatment with IMRT costs $15,000–$20,000 more than other standard therapies.

So, changes in cancer detection and treatment leading to reducing “wasteful” care may not occur until the incentives change. Even to a doctor, $20,000 is a lot of money.

The US Preventive Services Task Force has for the last 20 years been making  sense out of small number probabilities and demonstrating where the value lies in for those of us caring for people who would prefer not to get cancer and  who are not yet sick. They have posted evidence on mammography for early breast cancer detection and PSA for prostate cancer detection that seem to be the opposite of the statement we all want hear about our cancer: “You are lucky, we found it just in time.”

Screening for cancer, it turns out, is an exact science when measured in aggregate but confusing on an individual level. I will try to clear up some of the confusion.

All screening discussions must include these truths:

  • The first is the fact that ultimately we all die. Dead with a cancer, whether we know about it or not, is dead.
  • The second is that some cancers will kill us or require aggressive therapy to stave off death ultimately no matter how early in the course it is detected. Living with a cancer that we otherwise wouldn’t have known about for 5 years does us no good if the treatment is the same, it just gives us 5 years longer to fret about it.
  • The third is that just because a cancer starts in a body part like the breast, doesn’t make it the same as your neighbor’s cancer with the same name. Some people with have cancer in their breasts for 20 years and die of old age but others with go from no detectable cancer to metastatic disease in 3 months.
  • The fourth is that all of our expensive testing has made it impossible to compare results today with results from 10 years ago. If we find a whole lot of non-aggressive types of cancer that start in the breast, it makes us look like we are better at treatment when all we are doing is counting cancers that wouldn’t have been counted 10 years ago.
  • The fifth is that there are behaviors (smoking, obesity) and some non-behaviors (family history) that make us prone to getting cancers, and if that is the case we ought to be watched a little more closely. Also we all ought to work on being healthier, as not getting the cancer in the first place is better than trying to beat it.
  • The sixth is that there are certain folks (older and sicker) who ought to worry about things other than having a cancer detected and we as doctors need to make them feel good about focusing on things other than early cancer detection

Upshot is that for folks OF AVERAGE RISK there is clear evidence that for certain cancers (breast, colon, cervical) at certain ages (over 50 and under 75 for breast and colon, over 21 and under 65 for cervical) early detection will make people live longer and feel better but the detection efforts don’t need to be very frequent (every other year for breast, every 3-5 years for cervical, and every 10 for colon screening with a colonoscopy). Outside of these age ranges there is some evidence for overtreatment (finding tumors when early treatment would not matter). There is also clear evidence for other cancers (ovarian, prostate) that early detection leads to overtreatment without people living longer or feeling better. Folks not of average risk include those with a strong family history (who may benefit from more intensive surveillance), folks who smoke (please quit!), and folks who are obese (exercise and weight loss are protective). In addition, if you have made it to 75, worry about something else.

I do a column for the University on a weekly basis (it doesn’t pay anything either). I am asked to analyze health related news items and determine whether the “lamestream media” headlines are justified in the body of the actual article. What I have found is that for the most part the headlines are sensationalized, the articles are retreads of press releases sent out by the journals, and the scientist quoted in these press releases tend to exaggerate their findings. This was particularly apparent in the article I chose for this week. The headline screamed “Stress Causes Brain  Injury.”  The headline didn’t mention that the subjects were rats,  the stress was rat bondage and to find the injury they had to kill the little buggers (no doubt extra stressful).

The topic is extremely timely, however. Recently, there has been some very interesting human data appearing regarding constant psychological stress (such as exposure to racism) and illness. Unfortunately, these studies are limited because defining stress in the world we live in today is very difficult. Also, sacrificing victims of racism to look for brain lesions would be, well, racist.

I proclaimed the real take home message to this study is “more work is needed.” I really believe that stress reduction cannot hurt and is almost certainly a good thing for one’s health. This site has a nice tool to allow you to measure and monitor your stress level. Immediate reduction techniques mentioned include specific exercises, affirmations, and visualization. As I told the University employees, their plan might include eating right and exercising regularly, taking regular breaks, making to-do lists, being mindful on a daily basis, and using relaxation techniques daily. I have yet to receive feedback from the University President about how he will implement this.

I went to look a some commercial property in downtown Mobile yesterday and was reminded of the Roger Miller song, “King of the Road.” The building, clearly built in the 1920s had gone through a tragedy of some sort. The second story was apparently removed and added onto the structure in the 1940s were about 20 8×8 rooms, each with a sink. There was a door labelled “Office.” There was a common bath for all of the rooms. The word was that it was a “hotel” although I suspect that was being euphemistic. The whole area had been sealed in the 1960s (judging from the papers on the floor) and had not been maintained since. The roof had many leaks, the boards were suffering from dry rot, and even the rats seem to have abandoned the space for fear of disease.

We were looking for potential investment property and this would certainly allow us to invest quite a bit of money (sort of like a sailboat). The truth is that with enough money, the building could be made into a showplace. An article in the New England Journal reminds us that the body does not work that way. In this article people’s blood pressure, cholesterol level, smoking status, and diabetes status looked at in various ways. The investigators found that of the people who were 55 and had everything well controlled, 85% were very likely to live beyond 80 years of age regardless of race or sex. Of people who had two or more of their risk factors uncontrolled or who smoked, 50% were likely to be dead of heart disease or a stroke before age 80.

To fix this building, we would likely have to tear out the entire interior and retrofit it with a modern building. We would end up with a 1920s facade in a 1920s neighborhood but would functionally have a 2010s building. Many of my patients would like to believe that if they let their insides go, I can retrofit them as well. A better approach for the building would have been ongoing maintenance over the past 90 years. It turns out that it is the only approach for the human body.

From the US Congress, 1837

Mr. L. insisted that the same reasons which had been urged by the gentleman from Louisiana (Mr. Johnson), in support of his amendment, applied with equal force to Mobile. That city was known to be increasing in population, wealth and business, with great rapidity. It was situated in a climate regarded as somewhat unhealthy at certain seasons, but its immense trade required the employment of seamen and boatmen at all seasons of the year, and if hospitals were to be provided for sick seamen and boatmen at the expense of the Government at any points, he regarded the southern cities as the places most entitled to notice. The amount he had proposed was small, and he hoped his amendment would not be rejected. The amendment prevailed without a division.

The last sentence seems sort of quaint today, doesn’t it. This was the discussion that ensued when the Marine Hospital in Mobile Alabama was funded in 1837. This bill funded hospitals in New Orleans, Mobile, Portland, Newport, and Wilmington, North Carolina, at a cost of $115,000 each.

Why were these hospitals needed? Most illness and death at the time was due to infectious disease. Most sick folks were treated in their homes;  physicians (or other healers) were in attendance, but the nursing was done by family members. In port cities, merchant seamen were necessary to transport goods  from America to Europe (here in Mobile, it was transporting cotton to Liverpool, England). To quote from the National Library of Medicine:

These seamen traveled widely, often became sick at sea, and then, away from their homes and families, could not find adequate health care in the port cities they visited or would overburden the meager public hospitals then in existence. Since they came from all the new states and former colonies, and could get sick anywhere, their health care became a national or Federal problem.

What began as a loose network of hospitals eventually became the US Public Health Service.

In the 1870s, when the Marine Hospital Service was federalized, the city of Mobile saw the need to provide these types of services for her citizens, and the Board of Health was created (by Alabama constitutional mandate). The duties included:

  • Examine all cases of malignant, pestilential, infectious, or epidemic disease
  • Exercise general supervision over sanitary regulation
  • Supervise all matters pertaining to quarantine
  • Supervise all measures of detention, disinfection, and purification of vessels from ports against which quarantine is proclaimed

The county health officer was employed by the Board to oversee the above. In addition, he was required to maintain vaccine and vaccinate all indigent people free of charge (that would be smallpox and rabies in 1873). He was also directed to maintain a dispensary where poor, sick people could receive care.

Fast forward to today. The traditional “health department” is performing roughly the same tasks as outlined in the 1870s, immunizations, control of infectious illnesses (in Mobile, mosquito control is a big part of this), and care of the  sick who happen to be poor. They are, it seems, victims of their own success. Malaria is unheard of in Mobile except when it arrives in a person who has traveled here with the parasite already incubating in his or her bloodstream. Vaccination has moved to the physician’s office with the Vaccines for Children program. Community Health Centers have taken over care of the poor sick. The public health focus needs to be on prevention and early detection of chronic illnesses. These account for 70% of American deaths and most of our disability. Many chronic illnesses are a consequence of tobacco use, poor diet, sedentary lifestyle, and risky behavior.

In Louisville, Kentucky, the “Board of Health” is now the Louisville Metro Department of Public Health and Wellness. Not only do they do they perform the traditional health department role but they

  • provide education regarding health behaviors that affect health, such as tobacco use
  • distribute condoms to prevent STIs
  • work to combat childhood obesity through physical activity
  • work to eliminate food deserts through food justice
  • sponsor a health equity speaker series

They do this in a belief that they can address the root causes of health disparities by supporting projects, policies and research working to change the correlation between health and longevity and socioeconomic status.

A far cry from running the quarantine station, is it not?

The Robert Wood Johnson Foundation and the University of Wisconsin have put together a web site which compares the health status of counties within states. Originally done by the University of Wisconsin for Wisconsinites, last year they expanded it to all (well, all but 115) counties in the United States. The local paper dutifully published an article, identifying Mobile County as a low performing county (#46, down from #43 last year) and the neighboring county of Baldwin as a high performing county (#3). The next day, the paper decided to get serious, publishing an editorial identifying what was measured

Social factors and health habits are taken into account in the health rankings, including obesity, smoking, high school graduation rates, air pollution, access to health care, access to exercise and life expectancy.

and pointed out that perhaps building a walking trail would solve all of our problems

From a health standpoint, trails offer cheap and easy opportunities for exercise. Families can walk together; those beginning an exercise program can try a one- or two-mile stretch of trail and improve.

In reality, being third in the 45th ranked state is nothing to brag about. Anyone who knows anything about who lives in cities as opposed to who lives in suburbs likely can make an educated guess as to why Baldwin (suburbs) has better health statistics than Mobile (city) and it has little to do with a 2 mile walking trail.

A more interesting comparison tool, found here, compares counties against others of similar demographics and economics. In this comparison Mobile County still doesn’t fare very well (average life expectancy 73.6 years, peers 73.5-77.8 years, every marker worse than peers except immunization rates and prenatal care access) but Baldwin is no great shakes either (average life expectancy 76.6 years, peers 75.5-78.2 years, worse than peers except in breast cancer survival, infant mortality, and suicide rates).

The purpose of the rankings is not, or so says the University of Wisconsin, to facilitate boosterism but in the hopes that communities will use this information to work towards improving the health of the citizens. I hope that the local paper (as well as the media outlet of any communities whose “rankings” were not what they would like) will look at this page where action steps are discussed. These action steps include working together as a community, finding programs and policies that work, implementing strategies, assessing needs and resources, evaluating efforts, and picking priorities. Additionally, they have targeted advice for community leaders, educators, health professionals, and government officials, and public health officials.

Here is the advice for the community leaders, in case anyone from the local paper is paying attention

  • Get the word out. Reach out to people you know and see every day about the County Health Rankings report, e.g., at a local Chamber of Commerce breakfast or at an urban planning meeting. Post information about the report on a listserv, website, or e-newsletter.
  • Organize. Meet with local leaders and community residents to discuss barriers to health and ways to overcome them. Host a town hall meeting or invite people to one.
  • Get policymakers to pay attention. Tell them about how their county or counties ranked and open a dialogue about ways to improve health in your community.
  • Be an advocate. Step out as a spokesperson about the rankings and the health issues you care about and rally other community leaders to take action.
  • Contact your local public health department about participating in a local task force or, if none exists, organize one to tackle these pressing issues in your community.
  • Ask your local or state health department about what they’re doing in response to the report to make sure you aren’t duplicating efforts.
  • Share your resources. Offer your time, staff, and/or funding with community partners. These are resources that can go toward community plans and programs aimed at tackling factors that affect health.
  • Communicate your message. Write an op-ed or talk to local media about the rankings and what needs to be done to improve the health of your community.
  • Start a conversation. Talk to your friends, colleagues, neighbors, and family members about the health of your community and what everyone collectively can do to make it healthier.

Now that the word is out in Mobile, I hope we’re able to make the rest happen here.

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