Health vs. Healthcare: A Changing Paradigm
The Diabetes Association, reflecting on the past 50 years, notes improvements in diabetes drugs, equipment, tests – and, most importantly, in lifespan (http://www.diabetes.org/newsroom/press-releases/2015/50-years-of-diabetes-research-and-treatment.html). A diagnosis of Type I diabetes (sometimes termed juvenile diabetes) no longer means a shortened life. Unfortunately, both types of diabetes have been on the rise in recent decades. The Centers for Disease Control reports that the rate of diagnosed diabetes in individuals under 45 rose more than 200% in a span of less than 20 years (https://www.cdc.gov/diabetes/statistics/prev/national/figbyage.htm).
This is one reason that health communities are switching their focus from healthcare to the broader role of health. The medical community has ever better tools to manage disease, and people are living decades longer with serious illness. But some serious illnesses are striking at younger ages. Some are lifestyle-related while others – like Type 1 diabetes – may be the result of multiple environmental factors.
The medical community hasn’t been nearly as effective at adding healthy years to people’s lives as it has at adding years, at least when one looks at it from a population level. More years spent with more medications… and medical equipment… and surgeries. This is one reason healthcare – again, approached from a system-wide level –is growing unmanageable.
And it’s one reason the health industry needs innovation – at the population level as well as the patient care level.
Multiple Determinants of Health
Health is outside the scope of traditional healthcare. Even in those areas where we are seeing advances – fewer diagnoses – there is still a limit to what healthcare can do. There are times when prompt medical care is necessary to save lives. Some sources, though, put the impact of healthcare on health at as low as 10% (https://www.healthaffairs.org/do/10.1377/hpb20140821.404487/full/). Social determinants, health behaviors, and genes make up the rest.
Researchers from the University of California have summarized the many ways that education can affect health, from health literacy to social networks to work conditions and work-related benefits (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3863696/). They note that as MDs they believe in the power of medical care to heal conditions and save lives, but that there is a growing body of evidence that can’t be ignored: Social conditions matter.
Medical doctors and social workers alike are studying social determinants like Adverse Childhood Experiences. ACEs – everything from physical abuse to having a family member incarcerated — have been implicated in premature death. Some effects aren’t apparent until decades down the line; ACEs can affect the immune system as well as the developing brain.
In recent years, scientists have learned that even genes aren’t immutable. One’s experiences in infancy and even before affect their adult lives in ways that are difficult to explain. For example, babies who are breastfed are less likely to be obese as adults.
As for healthy behaviors, there are many: tobacco usage, activity level, healthy weight, fruit and vegetable consumption, adequate sleep, exposure to sunlight, exposure to toxins. Often health planners choose to focus on a few big ones like tobacco usage, obesity, and activity level.
Health Departments Rise to the Challenge
Among the many areas of focus are the following: that neighborhoods are safe for walking and biking, that buildings are free of mold, allergens, and lead, that people without cars have access to healthy and convenient foods, that homeless people find stable housing, that smokers have access to effective cessation programs, that preschoolers have access to high quality childcare, that their parents learn to manage the stresses in their lives. In short, health planners are trying to improve health by improving lives.
Many clinical healthcare workers are seeing their roles shift or expand. Doctors are working in teams with social workers or community health workers. Nurses are working as care coordinators. Paramedics are going out into the community to support high utilizers before they hit 9-1-1.
Much of the work, though, falls to population health experts. State health departments are forging partnerships with other governmental departments and with organizations in the private sector. What keeps their work from being “pie in the sky” is data collection and analysis, effect modeling, and sharing of best practices. Goals are often modest – for example, increasing or decreasing a data set by 10% over a period of ten years. Health departments may direct their attention to “winnable goals” where specific steps will lead quickly to measurable improvements in outcomes.
Many health departments are going through an intensive assessment and planning period as part of a national accreditation process supported by the Robert Wood Johnson Foundation and the Centers for Disease Control and Prevention. States also use health improvement planning to procure grant moneys.
Public health professionals are working as policy analysts, biostatistians and epidemiologists, and educators. They are working their way through volumes of health statistics: looking for patterns and hypothesizing about causes. It’s one thing to note that there are many factors related to poor health outcomes, another to tease out their relative importance or determine ways to solve them. There is a need for analytical skills as well as empathy in the world of public health.