“The biggest predictor of health,” Dr. Frank Franklin declares, “is wealth.”
Franklin, professor emeritus of public health at the University of Alabama at Birmingham, is reflecting on the glaring social and economic disparities that have prevailed in Birmingham and Jefferson County for decades. He says the persistence of these disparities, coupled with the comparatively poor health of the community as a whole — for example, the Birmingham area has some of the nation’s highest rates of incidence for cardiovascular and respiratory disease, stroke, diabetes, obesity, teen pregnancy, infant mortality, and infection with HIV/AIDS and other sexually transmitted diseases — provide ample illustration of the irrefutable link between poverty and public health.
“There are clearly direct and indirect connections,” says Franklin. “It starts with access to and availability of healthcare. For instance, if you can’t get to the doctor to get your diabetes checked and get yourself on a proper course of treatment, you’re going to go on to kidney disease, blindness, amputations, all of the things that unmanaged diabetes does to the human body. But that’s only part of the equation.”
The conditions associated with poverty make it extremely difficult for low-income people to make their health a priority, Franklin points out. Poor education, limited job opportunities, lack of adequate transportation, substandard housing, abandoned buildings, unsafe neighborhoods, insufficient access to healthy food options, exposure to environmental degradation — these and other factors combine with low income to create what he terms a “feedback cycle” in which poverty and poor health reinforce and perpetuate each other.
“Self-help goes out the window when you have to deal constantly with crisis,” Franklin says. “You don’t have the money to pay the power bill. You live in a neighborhood that isn’t safe. Your car breaks down and it’s going to cost $1,000 to get it repaired. A lot of poor people experience those kinds of crises every day, and there’s no way a person can have effective executive decision making in that atmosphere. When you’re dealing with day-to-day crisis, it’s very easy to go for eating fast food, watching more television, not exercising. Really, you don’t have the opportunity to do otherwise.”
Dr. Mona Fouad is the director of UAB’s Division of Preventive Medicine. She also is the director of its Minority Health and Health Disparities Research Center, which provides education, research and community outreach aimed at eliminating health disparities.
“Poverty is not just, ‘I’m not making enough money,’” Fouad says. “We have to look at the social issues, and at the built environment as well. If we’re going to make a change in the level of poverty in Birmingham, we need to understand that it’s less important what is your DNA code — what matters is your ZIP code.”
Much more to be done
Over roughly the past 20 years, numerous studies and analyses have borne out the role that location, physical environment and other social determinants play in the overall health of individuals and communities. A 1993 study published in the Journal of the American Medical Association examining the non-genetic factors that contribute to death in the United States found that fully one-half of all deaths could be attributed to behavior and lifestyle; as for the rest, 20 percent were due to environmental exposure, 20 percent to biological determinants, and only 10 percent to healthcare.
A study published by the American Journal of Public Health in 2011 went farther in establishing the connection between social factors and mortality. That study highlighted risky health behaviors, inadequate access to healthcare, poor nutrition, housing conditions, work environment and social relationships.
Compiled by researchers from Columbia University and the University of Michigan, the study examined both what it called “individual-level” factors — education, health insurance status, employment status, social support, experience of racism or discrimination, housing conditions and early childhood stressors — and “area-level” factors, including income equality, built environment, racial segregation, crime and violence, social capital, and the availability of open or green spaces. The authors found that of the 2.8 million deaths in the United States in 2002, 9 percent were attributable to low education, 6 percent to racial segregation, 6 percent to lack of social support, 5 percent to individual-level poverty, 4 percent to income inequality, and 1 percent due to area-level poverty.
While the number of deaths directly attributed to individual or community poverty is comparatively low, all of the other factors examined by the Columbia/Michigan study are demonstrably more prevalent in poor neighborhoods. All told, then, 874,000 of the 2.8 million deaths in this country in 2002 — almost one-third of the total — were directly or indirectly connected to poverty. Almost certainly, that number has not trended downward over the ensuing decade-plus, as the current national poverty rate of 14.9 percent well exceeds the 12.1 percent reported in 2002, per the U.S. Census Bureau.
Such findings are especially poignant in Birmingham and Jefferson County. Here, a collective 17 percent of residents countywide live in poverty, and well over one-third of the county’s municipalities — including the city of Birmingham, with its 28.9 percent rate — have poverty rates that exceed Alabama’s statewide average of 18.1 percent.
In terms of health factors, the Place Matters report issued in September 2013 by the national nonprofit Joint Center for Political and Economic Studies in cooperation with UAB, the Jefferson County Department of Health and several local nonprofit partners, noted that Jefferson County “leads the nation in chronic diseases and conditions linked to premature death, disability, decreased productivity and high health care costs.” That same study identified numerous factors that underscore the predominant role that physical environment and other social determinants — including race — play in the overall health of individuals and communities, drawing a strong link between neighborhood conditions and “who is healthy, who is sick, and who lives longer.”
Jefferson County’s poor population also has been — and continues to be — impacted by the elimination by the Jefferson County Commission in January 2013 of emergency and inpatient services at Cooper Green Mercy Hospital, the county’s indigent care facility since 1965. A victim of the county’s declaration of bankruptcy in the fall of 2011, the hospital was the source of medical treatment and health services for at least 32,000 people, according to an estimate by the county commission.
In the wake of the closing, other local hospitals have accommodated a massive influx of former Cooper Green patients, in addition to other indigent patients who may or may not have relied on Cooper Green for their healthcare. Still, officials at two hospitals — UAB and Baptist Princeton — spoke to Weld in April about what one called the “serious challenges” created by the closure.
“Baptist Princeton has seen a double-digit increase in patient volume through our emergency department,” said Ross Mitchell, vice president of external and governmental affairs for Baptist Health System. “That volume has been steady, and it has had a significant impact on our operations.”
While stressing his belief that the county commission’s decision to close Cooper Green was “the right thing to do” under the circumstances, UAB Health System CEO Dr. Will Ferniany told Weld that the transition “has not gone smoothly at all,” and that “there is much more that needs to be done” to ensure that poor patients receive adequate care, case management and other services.
Baby steps in the right direction
Five months later, the county’s Chief Health Officer, Dr. Mark Wilson — CEO of the Jefferson County Department of Health — says that despite the setback of losing its inpatient and emergency room facilities, Cooper Green is “beginning to turn around” in terms of providing outpatient services. But, while not minimizing the loss of its primary indigent care facility and the ongoing issue of access to healthcare, Wilson says the real challenge for Birmingham and Jefferson County lies in addressing the factors that contribute to poor health, especially among low-income residents.
“It’s clear that poverty has a huge impact on people’s health,” Wilson says. “That is multi-factorial, and while access to healthcare has been a big factor, environmental factors are probably a bigger determinant. Even if everybody had perfect access to healthcare, we’d still have disparities. That’s where we have to focus if we’re going to address this long-term.”
Wilson’s statement represents a point of view that is heartily endorsed by Frank Franklin and Mona Fouad — along with, it is safe to say, virtually every other local public health expert. In recent years, driven in part by the research cited in this article and work from a host of other sources, there has been a significant shift of balance from emphasis on individual responsibility toward public responsibility for working to eliminate factors that contribute to poor health.
“We are trying to move from talking about individual poverty to talking about the poverty of the community,” Fouad says. “We have tended to blame health problems on individual lifestyles, telling people to stop smoking, lose weight, eat better, exercise more. But recently, we’ve seen promising signs from entities that provide funding for work in the area of public health — the Centers for Disease Control, the National Institutes of Health — putting their resources into addressing health disparities.
“It’s been in baby steps,” adds Fouad, “but now we’re looking at the importance of social determinants. We’re looking for ways to link systems and resources to build a healthy community. Over time, that changes things for the individual, too.”
Franklin likens the responsibility of individuals for their own health to pushing a boulder up a hill. The more external stresses come into play — the poorer the person and the community in which they live, for example — the steeper the hill, and the less likely the individual is to achieve good health outcomes.
“It is, or should be, the job of public health to lower the angle of the hill,” Franklin says. “Obviously, we want people to have responsibility for their own health and well-being, but we also want to make it easier for them to do that. There are some inspiring stories out there of people rising above their circumstances, but that’s not a common story. Experience shows us that almost no one will take care of their health first if they have daily stress bearing down on them.”
The value of holistic, community-oriented approaches to better public health is also being embraced by organizations that provide services to low-income and indigent populations, perhaps most especially in areas of health where the issues in play are less visible — or, to be more critical, less a matter of concern — to the general public.
Ryan Hankins is the executive director of M-Power Ministries, a faith-based social services agency headquartered in Birmingham’s Avondale neighborhood. In addition to operating a clinic that provides medical and healthcare services to more than 600 patients, M-Power also offers counseling and services for mental health, an area that presents its own challenges.
“Mental health is a huge piece of the public health picture, and to breaking the cycle of poverty,” says Hankins. “If you can’t find a job, can’t keep a job, can’t find the time or don’t have the capacity to help your kids with their homework — if you don’t have even a minimal level of physical health, that can lead to depression, which feeds a whole chain of mental health consequences. If we came in tomorrow and could give all of our patients a Blue Cross insurance card and a personal physician, we still might not see much change. From a community perspective, those things are not much good if you’re only treating symptoms. It’s more complicated than most folks recognize.”
The high number of HIV-infected people in the Birmingham area — though home to 13.6 percent of the total population of Alabama, Jefferson County accounts for about one-third of the state’s HIV cases, and a just-released report from the Centers for Disease Control ranks Birmingham 17th among the nation’s metro areas for the highest rate of HIV infection — is another area that, while of great concern to public health professionals, is not high on the list of issues that the general public associates with the health of the community at large. That lack of understanding only heightens the need for a more holistic approach to public health, according to Dafina Ward.
“The HIV/AIDS community, especially gay men and men of color, is not one that most people want to think about,” says Ward, the chief prevention officer for the Birmingham-based advocacy organization AIDS Alabama. “Most of the clients we serve come from areas of poverty, where there is a lack of both access and resources. There are so many issues related to that, from education to transportation to the fact that poverty results in so many HIV-infected people staying in situations that are unhealthy for them.
“In working with clients, we have to deal with those poverty-related issues before we can deal with their HIV,” Ward continues. “But I do see signs that we are finally starting to get it as a community. HIV is only a symptom. The real disease is poverty itself.”
Building social momentum
Like Ward, the other professionals interviewed for this article find cause for hope in the changing national and local landscape of healthcare in general, and public health in particular. The key, says Mona Fouad, is collaboration.
“Ultimately, the solutions have to come from the community itself,” Fouad acknowledges. “But we can help them with that, use our resources to help them prioritize. We can be facilitators of better health, provide technical assistance and expertise, work with the community and other partners to focus resources effectively. A lot of people have been doing good work for a lot of years — the medical and research community, the Health Department, our major foundations, various organizations — but we still see too many silos. We have to connect the dots, and we’re not there yet. But I see a lot of hope that wasn’t there before, and that in itself is success.”
And there are substantive successes on which to build, Mark Wilson points out. Among others, he points to the Jefferson County Health Action Partnership, a coalition of over 60 agencies that has worked since 2007 on various initiatives to improve public health, with a focus on tobacco prevention and healthy eating. He also praises the work of “big agencies” like the United Way of Central Alabama and its ongoing “Bold Goals” program, and the Community Foundation of Greater Birmingham, which in recent years has been successful, says Wilson, in directing local philanthropy toward health-related issues in an unprecedented way. In addition, he says, Birmingham Mayor William Bell is getting city government involved through his recent establishment of a public health task force.
Wilson also notes that in August, the JCDH completed an exhaustive community health assessment, including both hard data and extensive community input. The result is a five-year plan titled “Community Matters 20/20.” The plan will guide the health department’s work with a growing number of community partners in five key areas: reducing health disparities; promoting physical well-being through healthy lifestyles; optimizing the built environment, transportation system and public safety; optimizing healthcare access, availability and utilization; and improving mental health.
“There’s a lot of conversations going on, a lot of social momentum,” says Wilson. “It’s our challenge to figure out how to harness all of that. But I believe that we have the potential to make healthy living the norm in Birmingham. I’m optimistic that 10 years from now, we will have done what we need to do to reduce and eliminate the disparities we currently see in our poor neighborhoods.”
Frank Franklin is a little more skeptical, but no less hopeful. He readily acknowledges the conversations that Wilson references, but adds quickly that, “that’s been going on for years.” To reach the goal of eliminating disparities and improving public health in general, he says, will require the hard work of overcoming years of cynicism among people who are products of generational poverty and all of its root causes.
“There’s awareness, perhaps more than there has ever been,” Franklin says. “But there’s also an ingrained feeling that nothing can be done. There has been progress, but it has been pitifully slow. People have to be shown that there are things that work. As long as we keep seeing poverty and issues related to poverty as ‘we/they’ and ‘black/white,’ we’re not going to solve these problems.”