Americans will spend more than $4 trillion on health care this year, approximately twice as much per person as other wealthy countries. But we’re also a lot sicker — we die younger and we have more chronic disease.
Why aren’t we healthier? A lot of it has to do with social factors that affect our health. You can see the impact by just walking between two Charlotte neighborhoods.
It’s less than a mile from the upscale Mint Museum Randolph to the Grier Heights Community Center. But it's a lot further in terms of health. When you enter the Grier Heights neighborhood, life expectancy drops 12 years, according to U.S. Census Bureau data. Cancer and diabetes increase by 50%, while asthma goes up by 23%, according to Centers for Disease Control and Prevention estimates.
And as you enter Grier Heights, health insurance coverage drops by 17%. The Rev. Donnie Garris, pastor of Antioch Missionary Baptist Church in the neighborhood, said residents often have to make hard choices.
“Do I put bread on my table ... clothes on my children, making sure they’re taken care of when I’m not bringing in a lot of money?” Garris said. “Affording health care insurance could be a problem.”
That short walk between neighborhoods crosses the enormous social divide in the United States, one that’s far greater than in other wealthy countries. Median household income drops by 60% as you enter Grier Heights, and there’s a 40% increase in the number of people who are spending so much on rent they’re struggling to pay for things like food or clothing, census data show.
“If you are a parent, either unemployed or not making a lot of money, not only having to provide healthy meals, which is not accessible, transportation could be an issue,” Garris said.
Access to healthy foods, safe housing and transportation are called social drivers of health. And research shows as much as 80% of a person’s health is determined by these factors.
They’re so important that Charlotte’s largest medical system, Atrium Health, has developed a social determinant database using information from admissions records and health screenings. Kinneil Coltman, an Atrium executive who heads up community and external affairs, said Atrium uses the database to identify what’s called “public health priority ZIP codes.”
"It'sreally where we see a lot of higher rates of chronic disease, lower life expectancies, higher rates of poverty,” she said.
When COVID-19 hit, Atrium used that data to pinpoint areas most in need of testing and mobile vaccination units. And it screened people who were positive for the virus to make sure they had a place where they could isolate.
“While we were solving for these inequities in health and disease in our community around COVID, we also had to solve for those social determinant health inequities as well,” Coltman said.
Coltman said addressing patients’ social needs is less expensive than treating people who ultimately end up in the emergency room because of poor nutrition or inadequate housing. But access to healthy food, housing and transportation aren’t the only social determinants.
“Kids may come to school or come to church and say, ’Well, last night there was a shooter in the neighborhood and we were all in the streets and we just saw a body lying in the street,’” Garris said. “Now, they could talk about it as a common incident, but you know it has an effect on them.”
Adverse Childhood Experiences And Health
Research shows childhood trauma — including what doctors call “adverse childhood experiences,” or ACES — has a lifetime impact on health, said Shivani Mehta, an Atrium pediatrician.
“We know that people who have ACES have a 20-year discrepancy in life expectancy,” Mehta said.
And the more trauma kids experience — things like exposure to violence, substance abuse or mental illness in the home, even divorce — the higher their risk of heart disease, cancer and liver disease, according to the CDC. And a 2020 study in the Journal of the American Medical Association found kids who have experienced these traumas are more likely to develop dementia in later life.
The incidence of “adverse events” may be the same across wealthy and poor families, but Mehta says that the impact on kids in places like Grier Heights can be worse, especially if they don’t have access to treatment
“If you’re experiencing ACES, and then on top of that, you’re struggling with homelessness or there’s not enough food on the table,you’re compounding the effect of ACES,” Mehta said.
Stress itself causes biological changes, Mehta said. But the problem is complicated because those who’ve experienced ACES are also more likely to develop unhealthy habits. Grier Heights residents are twice as likely to smoke and 40% more likely to be obese.
“Do I put bread on my table ... clothes on my children, making sure they’re taken care of when I’m not bringing in a lot of money? Affording health care insurance could be a problem.”Donnie Garris, pastor at Antioch Missionary Baptist Church in Grier Heights
Stress Leads To Poor Choices
But be wary of blaming the patient, said Dr. Sandro Galea, dean of Boston University’s School of Public Health.
“There’s well-established science that shows we choose poorly when we’re under stress,” he said.
Galea said just focusing on social determinants — even adverse childhood events — misses the bigger picture. It’s sort of like saying lung cancer is caused by chemicals but ignoring that you may have picked up a cigarette.
“What’s the most important cause of death? Is it low education? Is it smoking? Or is it tars in your lungs? Galea said. “While the answer is all three of them, right? Limited investment in education results in the health behavior results which results in disease.”
In a seminal 2011 study, Galea took the same methodology used to study the health impact of smoking and applied it to social factors. He found the number of deaths from things like low education, racial segregation and poverty is equal to those from biological and behavioral causes. And he said other wealthy countries do a better job of addressing those social inequities.
“What they have is a much stronger safety net,” Galea said. “They have much stronger investment from government to actually shore up these ill effects of these forces as needed.”
That’s why many public health experts now believe many Americans could be healthier if we spent less on medical care and more on social programs.
Next week, we look at what effect education has on health and health care.
