discussion board 1 11

In his article “We can do better – improving the health of the American people”¹ Mr.Schroeder aims to explain why American’s are spending more money for less effective health care than other countries in the world. He’s thinking is that just because there is better health care present and available it doesn’t linearly translate to better health to the public. Obtaining health requires a personal desire and often behavioral changes to occur as well, not just access to medical care. The second reason he points out is that a large portion of the population is unable to access this quality healthcare due to their inability to pay for it or because of the geometric location in relation to healthcare facilities. This is partly due to the vast country we inhabit and the lack of universal insurance coverage until age 65 (after which our rankings rise in the global list). As he rightly points out, people in the lower socio-economic groups have been unable to attract attention for a successful advocacy campaigns and there remains a systematic apathy to acknowledge the need to focus government resources to reduce the social disparities. An other reason for this disparity between high spending and poor rating could easily be the way medical procedures are billed. Up until very recently there has been no political will to look into how we as a country could decrease the amount it costs to provide medical services. In many European countries with universal health care reimbursements for services are based more on ‘value for increased health’ rather than ‘fee-for- service’ as in the US. This keeps health care spending proportional and in check.² There are too many instances where providers run unnecessary tests on patients in order to increase revenue in the US. However, it is encouraging that value-based reimbursement model is making headway here, although there remains many obstacles for the implementation.3

In comparing tobacco smoking and obesity Mr.Schroeder makes a point in saying that in many ways, these two conditions are similar in how they affect a person; they are both major risk factors for chronic disease (smoking for lungs, obesity for heart, liver, pancreas), the highest prevalence of both is found in the lower socio-economic classes, they both are difficult to prevent as they require behavioral changes and both get their start in early adolescence. On the other hand he goes on to explain that one’s obesity doesn’t effect people negatively around him like in smoking (second hand smoke). While smoking is completely unnecessary for humans, we do need to eat to survive. In order to combat smoking, a lot of different sub groups came together united. We have yet to see that kind of organization to combat (childhood) obesity. However, there are subtle signs that public is paying more attention to the risks associated with it as younger and younger children are developing diseases usually seen only in older population.⁴ Marketing and distribution of fast foods at schools and where mostly children occupy public spaces have been restricted since Mr. Schroeder’s article was written. There is also a growing awareness that prevention is better than cure when it comes to obesity.⁵

If the pie chart were to be redrawn to reflect only people living in poverty I would imagine it to look something like this:

Urban Rural

Social circumstances 35% 30%

Environmental exposure 10% 15%

Health care 15% 15%

Behavioral patterns 25% 25%

Genetic preposition 15% 15%

Urban poor population would have issues of poor living conditions, possible over crowdedness, inadequate sanitation systems, possibly no access to clean water or heat/air conditioning. There would also be the issue of air quality and noise pollution. While access to medical care is better than in rural areas, there would still be challenges in paying for medical bills and potential medications. Nutrient deprived foods are readily available in urban areas but access to healthy foods is often too expensive. There are fewer opportunities for physical activity as poor neighborhoods are often unsafe and lack recreational areas. Jobs for less educated are also often more dangerous in nature.⁶

In rural communities population is older and sicker. There are more accidental deaths (some from unsafe behaviors) than in urban areas. Living conditions for the poor are often lacking in preparedness to handle natural weather elements. Mental health is more fragile and access to quality health care is often limited. Insurance is not readily available and cost of medical care can prevent compliance. If one isn’t able to grown own foods, grocery stores can be a long way from home.⁷

In both of my models I believe that social circumstances are the main reasons why poor populations make unhealthy behavior choices. It has been shown that breaking free from cycle of poverty and theaccompanying social disadvantages is very difficult for any single person. Rather it demands an integrated approach by multiple agencies.⁸Healthy People 2020 is trying to address and alleviate some of these problems.⁹

While there are several social determinants of health that Church could be making a difference, one of the most obvious ones is the area of social and community context. The local church body can choose to be involved in building up and supporting the poorest members of their communities regardless of their religious beliefs. This can be done through support groups, weekly soup kitchens, helping to fill out forms for insurance and work, and by connecting people to each other outside of church. Jesus called us to be the light in the darkness – “in the same way, let your light shine before others, that they may see your good deeds and glorify your Father in heaven”¹⁰ – we do no good if we hide our light from the people who most need it.

References:

1. Schroeder, S. We can do better — improving the health of the American people. NEJM. Sep 2007; 357:12. Doi: 10.1056/NEJMsa073350.

2. Mason C. Public-private health care delivery becoming the norm in Sweden. CMAJ July 15, 2008 179 (2) 129-131. Doi: 10.1503/cmaj.080877
3. Putera I. Redefining health: implication for value-based healthcare reform. Cureus. 2017 Ma; 9(3): e1067. Doi: 10.7759/cureus.1067

4. Finkelstein EA,Kang Graham WC, Malhotra R. Lifetime direct medical costs of childhood obesity. Pediatrics. 2014; 133(5) DOI: 10.1542/peds.2014-0063

5.Pandita A, Sharma D, Pandita D, Pawar S, Tariq M, Kaul A. Childhood obesity: prevention is better than cure. Diabetes Metab Syndr Obes. 2016; 9: 83-39. DOI: 10.2147/DMSO.S90783

6. Anderson TJ, Saman DM, Lipsky MS, Lutfiyya NM. A cross-sectional study on health differenced between rural and non-rural U.S. counties using the county health rankings. BMC Health Services Research. 2015; 15:441. Doi: 10.1186/s12913-015-1053-3.

7. Moy E, Garcia MS, Bastian B, Rossen LM, Ingram DD, Faul M, Massetti GM, Thomas CC, Hong Y, Yoon PW, Iademarco MF. Leading causes of death in nonmetropolitan and metropolitan areas –United States, 1999-2014. Surveillance Summaries. CDC. 2017: Jan 13: 66(1); 1-8. https://www.cdc.gov/mmwr/volumes/66/ss/ss6601a1.htm?s_cid=ss6601a1 Accessed August 20, 2019.

8. Cheng TL, Johnson SB, Goodman E. Breaking the intergenerational cycle of disadvantage: the three generational approach. Pediatrics. 2016 Jun; 137(6): e20152467. Doi: 10.1542/peds.2015-2467

9. ODPHP. HealthyPeople.gov. Social determinants of health. https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health. Accessed August 20, 2019.

10. Matthew 5:16. The Holy Bible. English Standard Version.