Discussion Board 1

Read Schroeder’s article “We Can Do Better—Improving the Health of the American PeopleShattuck Lecture” NEJM, 2007 located in this link: for this module/week. Discuss the following points in your thread. Review the Discussion Board Instructions and grading rubric before posting your thread.  

Describe the 2 reasons Schroeder gives to explain why the US ranks poorly on many health measures in spite of spending more money than other countries on health care. What other single factor would you suggest that might also contribute to this paradox?

In what ways is the problem of obesity in America like the now decreasing problem of tobacco use? In what ways is it different?

The pie chart illustrating the 5 proportional categories contributing to premature death in the US are based on total US population mortality. How might these percentages change if the chart were to be redrawn to reflect populations living in poverty in inner cities? People living in poverty in rural areas? Suggest new percentages for each and explain why you think as you do.

• Social determinants of health are relatively new considerations as predictors of premature death, yet a growing body of research indicates their contribution is strong. Name a social determinant and describe a possible role for the Church in ameliorating it.
• Your thread is due by 11:59 p.m. (ET) on Thursday, and your replies are due by 11:59 p.m. (ET) on Sunday. 
• These are the replies that you need to respond to as well:
• Moriah Hough 

DB #1

This article startled me with how low the United States is ranked in health status compared to other countries of the world. Schroeder describes the reasons for this being:

           1) better health care does not equal better health, and 

           2) there are many Americans who do not receive quality care or receive no care at all.1

I would suggest that another factor that contributes to this paradox is a lack of education and information available to those living in poverty. Real change comes from adjusting behavioral patterns, as Schroeder notes in his article. But how can people change their behaviors if they are not taught why it is important to do so? There are organizations like Children’s Hunger Alliance and WIC (Women, Infants, and Children) that do this for healthy eating (therefore helping to treat obesity), but it needs to be done on a larger scale for overall health status in the United States to change.

Although obesity and smoking do share many of the same characteristics, treating obesity like smoking will probably not solve the rising obesity epidemic. Both conditions are large risk factors for chronic disease and are more prevalent in lower socioeconomic classes, not to mention the heavily influential promotions by their respective industries.1 However, everyone eats and is at risk for developing obesity, while not everyone smokes. Food is not addictive the way niotine is, and smoking is harmful to yourself and others at any dosage while eating food is not. For these reasons and more, tobacco control cannot be used as a complete model for treating obesity in America.

The five determinants of health contribute to premature death differently depending on the location of the population. For example, those living in poverty in inner cities might be more exposed to harmful environmental factors while those living in rural areas might have less access to health care. There could also be changes in behavioral patterns as the inner city population is more likely to be exposed to more advertisements for foods and medications. Below are my suggestions for how these percentages could change if considering location of population. 

Inner City

Rural Area

Genetic predisposition

25%

25%

Behavioral patterns

45%

40%

Social circumstances

15%

10%

Environmental exposure

10%

5%

Health care

5%

20%

The World Health Organization defines social determinants as “the conditions in which people are born, grow, live, work, and age”.2 Interestingly enough, the estimated number of deaths attributable to social factors in the United States is comparable to the number attributed to pathophysiological and behavioral causes.3 One of the most common and largely factoring social determinants is economic stability. In 2000, 133,?000 Americans died as the result of individual-level poverty, 119,?000 to income inequality, and 39.?000 to area-level poverty.3 I believe the Church has the responsibility to complete real actions based in love such as giving freely to the poor, caring for widows, taking in destitute orphans, visiting the sick, and caring for the dying. In regards to economic stability, this means giving generously of both our time and money. 

References

1. Schroeder S. We Can Do Better — Improving the Health of the American People. New England Journal of Medicine. Published 2007. Accessed August 19, 2019.

2. About social determinants of health. World Health Organization. Published 2019. Accessed August 19, 2019.

3. Galea S, Tracy M, Hoggatt K, DiMaggio C, Karpati A. Estimated Deaths Attributable to Social Factors in the United States. Am J Public Health. 2011;101(8):1456-1465. doi:10.2105/ajph.2010.300086

Second reply:

Hanna Burnett 

DB #1

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. 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. Accessed August 20, 2019. 

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