But the reality is that most of us are going to die after spending the last three to 10 years of our lives suffering from increasing frailty and dementia—and America is totally unprepared for the number of people who will go through this in the next few decades as the baby boomers age.

“We haven’t thought about the medical care we need, or the medical care that we prefer—which isn’t often the kind of care we receive,” said Brownlee. This is true for the nation broadly and also for individuals and families.

Take a patient Brownlee called “Helen T.” Helen was admitted to Boston’s Massachusetts General Hospital emergency room with a broken hip; she was suffering from advanced Alzheimer’s and had an advance directive indicating that she didn’t want intubation or CPR. But her daughters were told by a surgeon that unless their mother was operated on, she would be in a lot of pain—and although the operation required intubation, the surgeon said that the advance directive could be reversed temporarily. Her daughters agreed to the surgery, beginning a two-month-long odyssey in which Helen was shuttled back and forth from her nursing home to the ICU to receive many different treatments beyond simply repairing her hip, including a catheterization, a cardiac stent, multiple intubations, treatment for pneumonia and a urinary tract infection, and a tracheostomy to insert breathing and feeding tubes.

Ultimately, a palliative care team was brought in, and Helen’s daughters agreed that her mother wouldn’t want any of this treatment; she died peacefully in hospice surrounded by her children and grandchildren.

“Every person involved in Helen’s care wanted what was best for her” and were aware of her advance directives, said Brownlee. But there were many points along the way where different decisions could have been made. Cases like these, she said, are about communication and denial.

Doctors present families and patients with choices that seem stark: death or treatment. But they aren’t upfront in letting people know when treatment won’t improve a patient’s quality of life. Nor do they normally present another option: to make the patient as comfortable as possible as he or she dies. The problem is compounded by various specialists who don’t see the patient as a whole person but instead see individual issues that can be resolved.

Nobody, said Brownlee, told Helen’s daughters, “‘We can make her comfortable without surgery’—nobody said that.”

“Why do people find themselves on this train that leads toward more and more and more [care], even if they sign an advance directive?” she said.

People think more is better when it comes to medicine—more drugs, more time in the hospital, more treatments. So part of it is patient preference. But a great deal depends on where you live, and what hospital you’re admitted to. Within California, there are huge differences between how patients are cared for at the end of their lives in the northern and southern parts of the state, Brownlee said.

According to Brownlee, in 2007 chronically ill patients at UCLA Medical Center spent an average of 14 days in the ICU in the last six months of their lives—more than three times longer than patients at UCSF Medical Center, and longer, too, than patients at Cedars-Sinai, who spend an average of 9.6 days in the ICU.

The use of palliative and hospice care has risen over the past decade, and fewer people are dying in hospitals, said Brownlee, but there remains a tremendous gap between the care patients want and the care they receive.

In 2003, 33.8 percent of patients in California died in the hospital. In 2007, that number dropped to 31 percent. But the average in the rest of the country is 28 percent. And in the Los Angeles area you are significantly more likely to die in the hospital or after spending time in the ICU than you are in other areas of the state.

It’s counterintuitive, but this regional variation is a result of greater availability of ICU beds and hospital beds. In areas where there are more beds per capita, more people are admitted to the hospital, and are thus more likely to die in the hospital. As a result of a post-World War II building boom, California (and Southern California in particular) has many small hospitals. Los Angeles has more doctors per capita than any other place in the country, said Brownlee.

And because of the economics of our healthcare system, hospitals, much like hotels, don’t make money with empty beds.

So how can we move toward a system that gives people the care they want, rather than the care determined by the region where they live or the number of beds in the nearest hospital?

“In my ideal world I imagine a health system in which patients no longer feel like widgets, and doctors no longer feel like factory workers,” said Brownlee. She wants to see “a world where doctors really talk to their patients,” where care shifts away from hospitals and into the home, and where primary care doctors have more time to treat their patients.

She also thinks we need more trust between doctors and patients. Doctors, she said, “see you as a walking lawsuit waiting to happen”—and you can’t trust someone you think wants to sue you.

Every time you go to the hospital or a doctor’s office, she advised the audience, you should think, “No decision about me without me.”

She also said that a fundamental shift is needed in how patients evaluate the care they receive; we tend to think that the doctor who gives the most tests and uses the most technology cares the most.

At stake isn’t just our health and comfort but also the economic future of the nation, said Brownlee—which is why we all need to start talking and thinking about death now, before it’s too late.

In the question-and-answer session, audience members shared their experiences with terminally ill and elderly family members and asked Brownlee where to go for more information on regional variations in end-of-life care.

Brownlee said that she is preparing reports for the California HealthCare Foundation on end-of-life care, cancer care, and variation rates of certain types of procedures all over the state; these will be available on the foundation’s website early next year.

Is there any financial incentive for hospitals not to offer palliative care? “Hospitals are paid for offering more care, not better care,” said Brownlee, adding that the Affordable Care Act will change that to some degree—but that patient demand is what will ultimately force hospitals to offer more palliative care.

Brownlee believes that change can come to America’s end-of-life healthcare. “It’s going to take a lot of patient voices, and a lot of leader physician voices,” she said.

The post You Might Wanna Die Elsewhere appeared first on Zócalo Public Square.

In some parts of California, you’re likely to have all sorts of medical treatments at the end of your life and die in a hospital. In other parts of California, you’re likelier to die at home with less intervention. Such disparities can be found across the country, and they are not indicative, as a rule, of patient preferences. They’re indicative of differences in mindsets and habits among healthcare providers. For most of us, “good” end-of-life care means the kind of care you want, but it can be hard to know if you live in a part of the country where that’s what you’re likely to get. In advance of the Zócalo event “Does Where You Live Determine How You Die?” we asked several healthcare scholars for tips: how do you know if you live in a place that offers good end-of-life care?

You can’t know for sure, but there are important indicators

No matter where you live, if you have been diagnosed with an illness such as stage III or IV cancer, emphysema, heart failure, kidney failure, or dementia–or if your loved one is in the ICU with a life-threatening illness requiring a breathing machine for more than four days–the message you should be hearing from your doctors is “Hope for the best; prepare for the worst.” Beware when you hear them say, “We are doing everything we can.” That’s often doctor-speak for “S/he’s likely to die no matter what we do.”

Your health system should encourage early referral to palliative care if you or your loved one has a serious chronic illness. “Early” means “at the same time you have been diagnosed,” not “after curative treatment has failed.” Palliative care providers, typically a team including doctors, nurses, social workers, chaplains, and other professionals, can work together with your other doctors to address key domains of care often forgotten by the others–symptom management, tailoring treatment to meet your own personal goals, and spiritual support–while you are receiving treatment aimed at prolonging your life.

If you are interested in your region’s track record for hospice use and ICU use for patient who died–types of care trajectories that are on opposite sides of the spectrum–check out the Dartmouth Atlas data tools at www.dartmouthatlas.org. Although this will not tell you anything about the quality of your providers, it’s important to know that simply by dint of living in Los Angeles you may be more likely to die hooked to machines than if you live in San Francisco.

Amber E. Barnato M.D., M.P.H., M.S., is associate professor of Medicine, Clinical and Translational Science, and Health Policy and Management at the University of Pittsburgh.

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Forget what the regional norm might be–the key is to make your preferences abundantly clear

Patients near the end of life have many treatment possibilities–from aggressive medical interventions to comfort care. But in some areas of the country, the choice to receive less aggressive care is not always a clear option. We have known for a long time that there is marked geographic variation in the delivery of aggressive versus palliative measures. Patient preferences do not seem to drive this variation. For example, surveys find that many more patients prefer to receive palliative care than actually receive it.

In a nationally representative study of 3,000 deaths, we found that patients who lived in regions of the country with aggressive end-of-life practice styles were less likely to die in the hospital and more likely to receive hospice care if they had prepared a written advance directive. Patients can prepare living wills to document preferences for the use or avoidance of life-sustaining treatments such as feeding tube placement and CPR so that physicians and family members can make decisions that reflect patient preferences when the patient is no longer competent to make these decisions.

Our results suggest that advance directives are most effective when one prefers treatment that is different from the local norms. By preparing an advance directive and discussing treatment preferences with family members, friends, or physicians, patients can help to ensure that they receive the type of end-of-life care that they prefer, regardless of the prevailing practices of the region where they live.

Lauren Hersch Nicholas, Ph.D. is a health economist at the Institute for Social Research, University of Michigan and a research affiliate of the UM Center for Healthcare Outcomes and Policy.

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There are clues–and we can all help to change the culture of end-of-life care

Good end-of-life care for me means at least two things. First, I don’t want to spend my last days in unnecessary pain. I also don’t want to go through a vicious cycle of hospitalization and ICU stays. That means I would need to live in a place where the indispensable value of palliative and hospice care is recognized and infused throughout the overall healthcare culture and system. Second, I want to be cared for by healthcare professionals who respect my autonomy. I don’t want them to make assumptions about what I want or think based on my race, ethnicity, gender, wealth, education, or religion. Instead, I want doctors, nurses, and social workers to take time to listen to me, talk to me as a person and not just another dying patient, and try their best to respect my wishes. This means I would need to live in a place where thoughtful end-of-life care conversations take place on an ongoing basis.

Where I live, Milwaukee, Wisconsin, is considered average in terms of access to hospice care and intensity of aggressive procedures performed at hospitals in the U.S. I know this because there are very helpful resources such as the Dartmouth Atlas Project, which has documented quality and utilization of healthcare resources available in every region of the U.S. The Atlas shows the powerful effect of where we live on the types of care we receive at the end of life. I also know that a new statewide initiative, Honoring Choices Wisconsin, is being launched to promote advance care planning that is modeled after the successful initiative in La Cross, Wisconsin. Although it takes a lot of effort and time to change the culture and system of end-of-life care, I believe that many changes are occurring across the nation and likely to change the face of the end of life care within the next decade.

Jung Kwak is assistant professor at the University of Wisconsin-Milwaukee. Her research and teaching interests include cultural diversity and surrogate decision-making at the end of life.

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For now, we have indicators, but for tomorrow, we must have a responsive patient-centered system

Why is it that, in some U.S. states, 40 percent of nursing home residents with severe functional impairment get transferred from one healthcare setting to another (such as to a hospital) during their last 90 days of life, while, in other states, only 3 percent of dying nursing home residents are forced to undergo such treatment? Why should we be concerned with this variation? Because transitions of dying patients from one setting to another are associated with poor quality of care and unnecessary suffering.

Why such disparities? It is not patient preferences. It is not that patients are sicker in one state compared to another. The important determinants are the culture of decision-making and how we pay for healthcare. Let me give you an example. Some states pay for a nursing home to keep a “bed”–a space–available for a patient while that patient is in the hospital, so that if the patient returns to the nursing home afterward, there’s space for him or her. In the past, this was important in order safeguard access to nursing-home care. But there is an unintended consequence: it gives nursing homes an incentive to send away people to the hospital. The nursing home gets paid for the bed anyway, and, if a resident returns after a three-day stay in the hospital, then she qualifies for Medicare skilled services, for which the home can charge a much higher rate. Incentives matter.

In a recent study, Dr. Amber Barnato of the University of Pittsburgh and colleagues found that decision-making processes in an ICU with an aggressive pattern of care differ significantly from those in an ICU with a less aggressive pattern of care. Healthcare providers in the lower intensity ICU worked with the patient and family to arrive at a decision that respects patient’s choice. The key to good end-of-life care is patient-centered care–a process of communication and shared decision-making that allows the dying patient and family to set goals and arrive at medical care that respects those goals.

How can you know whether you live in a region of country that has high quality end-of-life care–one in which your symptoms are controlled as you like, your treatment wishes are honored, you are treated with respect, and emotional support is provided? Unfortunately, we don’t have publicly reported data on that. The Dartmouth Atlas of Health Care has some useful information concerning ICU utilization, hospice referral, and other measures to examine hospital performance at the close of life. But the key data that is missing is whether medical care respected a patient’s values and goals, whether a patient received her desired level of symptom control, and how much emotional support the patient and family received. Such information would require speaking with the patient or the proxy decision-maker for that patient. And it’s time we did. As consumers, we must demand that hospitals, nursing homes, and healthcare providers promote patient-centered care.

Joan M. Teno, M.D., M.S. is professor of health services, policy, and practice at the Warren Alpert School of Medicine at Brown University.

The post Does Fresno Mean Feeding Tube? appeared first on Zócalo Public Square.

“How many of you have had an elective surgery?” she asked a full house at an event co-sponsored by Zócalo Public Square and the California HealthCare Foundation, prompting about a third of the crowd to raise their hands.

Brownlee, the acting director of the health policy program at the New America Foundation, defined elective procedures as any in which the patient has a choice. Prostate tests and mammograms are elective, she said, as are many bypass surgeries and joint replacement procedures. And too often, she argued, patients don’t have the information they need to make the right decision for themselves.

The Prostate Puzzle

Brownlee opened her address by discussing the prostate-specific antigen, or PSA, test, which is recommended for men over 50 to test for early-stage prostate cancer. As the lead medical writer for U.S. News & World Report in the 1990s, she discovered some troubling statistics about the success of the PSA test.

One-third of men who received the test weren’t informed that it was happening until after the fact, she found. And two-thirds of men who subsequently received treatment for prostate cancer – a procedure that can have major side effects including incontinence and impotence – said they didn’t receive enough information to make a good decision for themselves.

Most importantly, she said, “there wasn’t any evidence that giving men a PSA test actually reduced their risk of dying prematurely.”

Furthermore, the recommendations patients receive from their doctors are dictated by where they live. Residents of San Luis Obispo undergo treatment for prostate cancer at 10 times the rate of many other communities, she said, citing data from the renowned Dartmouth Health Atlas.

Yet despite the verified disparities and concerns about the procedure, the majority of doctors still give routine PSA tests without discussing other options, and most patients still don’t have the information they need to decide. But, Brownlee said, “a revolution is coming.”

The History of Tonsil Removal

Brownlee spent a few moments tracing the evolution of how the medical community treats sore throats in children. The majority of adults over 50, she said, had their tonsils removed as children.

A study conducted in England demonstrated that far too many children were undergoing tonsillectomies, she said. A group of students were examined by a doctor, who concluded about 40 percent of them needed their tonsils removed. The school then sent the students deemed healthy to another doctor, who determined that 40 percent of the remaining group needed their tonsils removed. When a third doctor examined the remaining students, he concluded that 40 percent needed tonsillectomies.

“The expectation by physicians was that about 40 percent of them needed their tonsils out, and so that’s what they found,” Brownlee said. “It gives new meaning to the phrase ‘No child left behind.’”

Today, very few children have their tonsils removed, as more and more doctors conclude that there are other, less risky options to treat chronic sore throats. But meanwhile, other similarly unnecessary treatments have become more popular than ever. For example, mammograms are now recommended every year for women over 40, but Brownlee said the data does not show the procedure routinely prevents an early death.

Replacing Informed Consent

Before undergoing any elective procedure, patients must sign a legal notice of “informed consent,” which states that they understand their options and have made an educated decision to take a particular path. But those documents are filled with legal jargon and don’t represent a true agreement between doctors and patients, Brownlee said.

And since elective procedures for Medicare patients cost U.S. taxpayers many billions of dollars a year, it’s crucial that those procedures are what patients really want.

The evidence shows that “when [patients] are informed, they often make different choices,” she said. “Doctors are often not very good at explaining things in a way we can understand.”

The “revolution” that Brownlee spoke of is the medical community slowly turning away from the informed consent model and toward what she calls shared decision-making. That requires work from both doctors and patients, she said.

For patients, Brownlee recommended a variety of steps. She emphasized the importance of soliciting second opinions, as well as asking for a patient decision aid, a brochure that walks through all a patient’s options and what they mean.

All patients should ask three questions before they undergo an elective test or procedure, she concluded: What are my options? Is doing nothing one of my options? What are the risks of each of the options, and what are the possible benefits?

In other words, she said, “Trust, but verify.”

For event photos, please click here.
For full video, please click here.
To read Anthony Iton’s essay on how zip code can determine lifespan, click here.
For four experts’ opinions on how to be better patients, please click here.
To read Brownlee’s essay on how health care can be more harm than help, click here.
Read Brownlee’s “In The Green Room” interview here.

*Photos by Aaron Salcido.

The post The Danger of Too Much Health Care appeared first on Zócalo Public Square.

I often say to people, “Give me your address and I’ll tell you how long you are going to live.” The statement typically elicits a burst of startled laughter. We Americans are socialized to believe that control of our fate lies squarely in our own hands. But the truth is that our zip code is often more important than our genetic code in shaping our likelihood of premature death.

How do I know this? Death certificates. From 2003 to 2009, when I was the health officer for Alameda County, Calif., I was also the official Registrar of Deaths. Death certificates tell you not only when a person died, but also where the person lived. From looking at over 400,000 death certificates over a 45-year period, we were able to calculate the average life expectancies of residents of more than 150 neighborhoods in Alameda County.

What we found were shocking patterns of disparity. The people in the neighborhoods with the highest life expectancy statistics were living over 85 years on average. The people in neighborhoods with the lowest life-expectancy statistics were living only 65 years on average. That’s a 20-year difference! A life expectancy of 65 years is on par with Pakistan or Tajikistan. A life expectancy of over 85 years exceeds that of Japan, the country with the longest life expectancy in the world.

In other words, within one county, population 1.51 million, we found the ecological equivalents of Tajikistan and Japan, and everything in between.

With this analysis in hand, we could tell anybody whether he or she lived in the ecological equivalent of Japan, Iran, Honduras or Peru. We also looked at numbers in many other American cities, including Philadelphia, Cleveland, Seattle, Baltimore and Los Angeles. In every case, we found disparities of a similar magnitude.

Many people react dismissively to such findings. “This doesn’t apply to me,” they say. “I work out. I eat healthily.” We all like to believe that we are somehow immune to these larger forces that influence our lives. And, to be sure, avoiding smoking, being physically active and eating healthy food are good habits that offer us some protection from premature death. But even for those of us with the healthiest behaviors, geography often plays a big, if hidden, role.

Good neighborhoods provide access to good schools, to parks and open space, to transportation, to decent employment and to healthy food. Good neighborhoods support social connectedness through religious institutions, fraternal societies, community centers and other social gathering places. Bad neighborhoods, by contrast, fail on all of these fronts. In bad neighborhoods, health risks are abundant and resources scarce. Schools are poor, parks are few, jobs are scarce and crime is high.

The differences between good and bad neighborhoods also create differences in levels of stress. In good neighborhoods, stress is low and manageable. In bad neighborhoods, stress is high and unrelenting. People in bad neighborhoods must contend with inadequate services, unpleasant surroundings and fear of crime. This sort of stress has demonstrable physiologic consequences. Chronic stress lowers our immunity and contributes to tissue and organ damage. It “weathers” us, wearing us down and, ultimately, shortening our lives.

The good news, however, is that none of this is in any way inevitable. As much as place of address and life expectancy correlate with one another in the United States today, they do so less than in many other countries. Also, historically, the correlations in the United States used to be much lower.

The conditions that we witness in low-income neighborhoods are man-made, the result of flawed policies. They can be “unmade” through the actions of an informed and motivated citizenry. A deep and sustained investment in policies that focus on early childhood experiences (e.g. high-quality preschool), heighten educational attainment, improve access to health care, promote more mixed-income neighborhoods and encourage living wages will help de-couple the tight relationship between address and life expectancy. Growing up in a low-income neighborhood need not produce such dramatic health problems. In 21st-century America, our charge is to create the political will to undo some of the legacy of our 20th-century mistakes. I look forward to the day when you can tell me your address and I, looking at the numbers, will have nothing special to predict.

Anthony Iton is senior vice president for healthy communities at The California Endowment. He participated in a Zócalo panel on health inequality.

*Photo courtesy of Dottie Mae.

The post This Neighborhood is Killing Me appeared first on Zócalo Public Square.

Los Angeles doctors are plentiful, and Angelenos have some of the highest rates of visits to doctors and specialists in the nation. So you’d expect Angelenos to get the very best health care. But do they really?

Look at the numbers, and you might notice that Angelenos are getting a lot of health care, but they aren’t necessarily getting a whole lot of health. The Dartmouth Atlas of Health Care offers a snapshot of the care Medicare beneficiaries receive across the country. The statistics on who’s getting what are very different from place to place. Take the example of back surgery. For those suffering from all-too-common lower back pain, surgery isn’t always a good option. In fact, recent research suggests that other, more conservative options, such as physical therapy, are often much better for relief. Yet Medicare beneficiaries in Los Angeles are 40 percent more likely to undergo back surgery than residents of Fresno. And they are almost two and a half times as likely to have back surgery as residents of Honolulu, Hawaii.

We see similar numbers when it comes to the treatment of an enlarged prostate. This is a common condition among older men and may be treated by transurethral resection or removal of the prostate (TURP). But other options for treatment exist, and while TURP may provide the greatest chance for relief of symptoms associated with an enlarged prostate, it also carries a greater chance of complications and side effects like incontinence and sexual impairment. In treatment-happy Los Angeles, men are almost twice as likely to undergo TURP for for an enlarged prostrate as men in Alameda, Calif. And they’re two and a half times more likely to undergo the surgery as men in Ogden, Utah.

Does that mean Angelenos are reliably over-treated? Actually, no. Many who might benefit from hip replacements, for instance, aren’t getting them. Clinical trials have shown that about 90 percent of patients report being happy with their new hips and feeling better overall. Yet residents of Napa are 50 percent more likely to receive hip replacements than residents of Los Angeles.

The “right” rate of any procedure is going the one that is aligned with the preferences of well-informed patients. Often, patients just don’t know enough to make a sound decision. Los Angeles residents experience some of the highest rates of aggressive end-of-life care in the country, but is that really what they want? Medicare beneficiaries in their last six months of life who were treated at UCLA Medical Center saw an average of 11 different physicians and had 48 individual physician visits. Forty-four percent of those patients died while in the hospital. The cost to Medicare for the last two years of each of these patients’ lives totaled almost $100,000. The national average was just over $60,000.

Certainly, Medicare beneficiaries in Los Angeles appear to have little grounds for complaining about stinginess of treatment. But what’s less clear is whether they really wanted such aggressive medical attention. Were they given other options? And were patients undergoing back surgery or TURP informed about the potential risks as well as the possible benefits of these treatments? When looking at statistics for end-of-life care, how many patients really want to spend their last days of life in the ICU, tethered to machines? How many really want to see an endless stream of physicians? Asking what it is that patients want is particularly critical when it comes to questions about medical decisions that have obvious tradeoffs – those tradeoffs may be weighed very differently by different patients.

Patients deserve choices they understand and treatment they really want. That means we need to do a better job of helping patients get the information they need, when they need it. It also means doctors and patients should be sharing important medical decisions. Patients should be able to get the treatment they need, and no less. But they should also get only the treatment they want, and no more.

Shannon Brownlee is acting director of the Health Policy Program at the New America Foundation and the author of Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer.

*Photo courtesy of Tammra McCauley.

The post Health Care Can Make You Sick appeared first on Zócalo Public Square.

The issue is “not just that the rich on average will live more than six years longer in the United States than the poor,” he said. “Even middle-class white folks like me can expect to die two to three years sooner than the affluent. So this is about all of us, not just about the poor.”

That’s significant, Adelman said, because people need to focus on solving health inequality not just as charity, but because it affects their own lives. Adelman joined public health expert Tony Iton and urban planner Ryan Snyder on a panel moderated by KQED health reporter Sarah Varney to discuss the challenges posed by health disparities, as well as possible solutions to the problems.

The Scope of the Problem

All three panelists at the event, which was co-sponsored by UCLA’s Luskin School of Public Affairs, referred to statistics about the breadth of health inequalities that stunned some audience members. Iton, senior vice president for the California Endowment, said the problem is particularly visible in Oakland, where he once served as director of the county health department.

“A child growing up in west Oakland, an African-American child, can expect to live 15 years less long – 15 years – than a white child in the Oakland hills, just two or three miles away,” he said.

Varney opened the panel by asking Adelman to describe the famous Whitehall Study, which catalogued health disparities in Britain. Study participants were civil servants from all pay grades. The study, which is featured in Adelman’s documentary Unnatural Causes, showed a direct correlation between pay grade and health.

“When this began, this study, most of us [would have assumed] the people were dropping dead of heart attacks were high-powered executives” with high stress levels, he said. “Whitehall showed that not only was that not the case, the executives were living far longer than anyone.”

In Los Angeles, too, health disparities are dramatic, Snyder said, using the example of childhood obesity. In Manhattan Beach, one of the wealthiest areas of Southern California, about four percent of children are obese. In Maywood, a tiny working-class city in Los Angeles County, that figure is 37 percent.

Numerous Causes

Too often, Adelman said, a person’s health problems are assumed to be solely their own fault.

“People always say ‘Oh, some people are healthy because they eat right, they exercise, they don’t smoke, and others … are making wrong choices,’” he said. But “the choices we make are constrained by the choices we have. If you live downwind from a toxic dump, that’s not about your choice. If you don’t have a place to get those 5 to 7 vegetables per day in your neighborhood, that’s not a choice.”

The outside forces governing individuals’ health involve every issue of life, panelists said. Iton described the California Endowment’s work in 14 communities that face major public health challenges, saying despite their differences, the areas have many similar issues.

“The schools don’t work, they’re on the wrong side of the freeway, there’s no public transportation, there may even be environmental issues,” he said.

Snyder, who runs an urban planning consulting firm, said structural issues are a large part of the problem. He has consulted with over 100 cities to try to make communities healthier through access to transportation, bike lanes, walkable sidewalks and the like.

Snyder said that often, poor residents’ only choice for a place to live are communities that are not built in a healthy way.

“Skyrocketing rates of obesity are closely tied in with the built environment,” he said. For example, “access to park space is dramatically different in higher income neighborhoods versus lower income neighborhoods.”

One unifying element of the many factors that make people die earlier is the stress involved in being poor, Adelman said, invoking the “fight or flight response” that is common to all animals.

“What happens if you’re constantly on alert, constantly in a world that’s uncertain?” he said. “If your 401k might disappear, if you’re worried about whether your kid is safe at night … it actually wears down your organs.”

Implementing Solutions

Although none of the panelists claimed to have all the answers to solving health inequalities, they all proposed partial solutions. Varney commended the California Endowment’s Healthy Communities initiative for addressing root causes rather than simply the surface issues.

Much of Snyder’s work involves creating plans for communities to make them more walkable and bikeable, a major factor separating healthy, affluent neighborhoods from struggling poor ones.

“The public health folks are really leading the charge, not the planners, on these health issues,” he said.

Iton said that the public health community has only recently begun to put enough issue on preventative, rather than reactive, medicine. Education, he said, is a prime way to combat health problems that plague too many people.

“We’ve started to realize that health is really opportunity, the ability to get an education, to get a job, to really access the levers of opportunity of our society,” he said.

And all three panelists agreed that people looking to create healthier communities should look to the actual community members for answers. Snyder said that when he holds town hall meetings in poor neighborhoods, people turn out in droves, eager to share excellent ideas for how to improve their communities.

“Change is not going to start from the top down,” Adelman concluded. “It’s got to come from people demanding it from the ground up.”

For event photos, please click here.
For full video, please click here.

*Photos by Aaron Salcido

The post Unequal Pay Means Unequal Health appeared first on Zócalo Public Square.