By Mandi Bishop
Shifting the Paradigm: Moving Beyond Medical to Socio-Ecological Healthcare
As I write this, the US is amidst a series of catastrophic natural disasters, with millions of Americans facing unprecedented flooding from Hurricane Harvey & Irma and its remnant rainfall. These circumstances are devastating. But, as impactful as they are to the health and wellbeing of the individuals living in affected areas, storms are not “social determinants of health”. Right? They are forces of nature, blind to disparities between people or populations in their destruction, with the only outcome determinant being the luck of the draw.
The Centers for Disease Control (CDC) defines social determinants of health as: “Conditions in the places where people live, learn, work, and play affect a wide range of health risks and outcomes.” These conditions are broad: culture and beliefs; demographics – and how those demographics compare or contrast to others in the area; socioeconomic status – and whether that status is generational or due to recent events; access to healthy food; available transportation; education level; housing stability – and quality. How might these conditions become variables impacting health during and after a flood?
First, consider the decision to ride out the storm, or to evacuate (whether or not orders are issued). That choice is made based on a complex set of factors, many of which align to social determinants of health. Culturally, Gulf Coast Texans, much like native Floridians and other coastal dwellers in the southeast, are inclined to stay in their homes. Previous disaster experience, especially when one has survived without significant personal loss, can provide a false sense of invincibility; conversely, a lack of previous disaster experience for residents new to the area can be a detractor to heeding warnings. Many cannot afford to leave their residence, get far enough out of harm’s way, and pay for housing for an indefinite period of time. According to Brian Resnick’s recent article in Vox, “Why some people never evacuate during a hurricane, according to a psychologist”, other groups who are often less inclined to leave include: elderly and/or disabled, without adequate help to assist in an evacuation effort; those who are not digitally engaged and may not know about the extent of the impending danger; pet owners; those who fear the threat of post-storm property crime more than the weather.
There are more situational nuances contributing to decision factors, as well. According to Jennifer Horney, an Associate Professor of Epidemiology and Biostatistics at Texas A&M University, in her article, “Why Don’t More People Evacuate Before Hurricanes,” the rate of population growth amongst the socially vulnerable in the South correlates with the collective ability to respond to storm warnings or evacuation orders and prevent adverse health outcomes. For example, for the significant portion of the population working in low-wage service-industry positions, is the storm expected on a day of the week when the evacuee would normally be working – and could they afford to miss a day, if not? Has there been enough time between the last storm and the imminent one approaching for an individual or household’s risk perception to be adjusted? And, in a perverse twist on the typically positive health benefits of strong human connection: does a strong sense of social responsibility to one’s neighbors and community become the deciding factor to stay?
For those on public assistance, the evacuation decision becomes even more complicated. When Hurricane Katrina hit New Orleans on August 29, 2005, it presented a “perfect storm” of household economics: it was the end of the month, the time in which welfare dependents are least likely to have even the most meager funds available. School had just started, meaning any available funds for the month in households with children were likely to have been exhausted on supplies. Many recipients do not have bank accounts (according to the FDIC, the South still had 10% of all households without bank accounts as of 2011 – higher than any other region – with the percentage of public assistance recipients without bank accounts being substantially higher than the regional average), and they believed they would not have ready access to first-of-the-month funds if they left their homes and mailboxes. These households represent a disproportionately high number of those who chose to stay put versus flee.
Assuming the decision is made to stay in one’s home during the storm, how that home is built and where it’s located become key indicators for its occupants’ health outcomes. Newer construction is likely to be sturdier, perhaps even having storm shutters or other protections, and built to withstand the flooding appropriate for its zone, having complied with stringent building codes designed to prevent property devastation. As newer contruction typically costs more; it’s likely these occupants have some financial means, as well as homeowner’s or renter’s insurance. On the opposite end of the housing safety spectrum, we have mobile homes, which are notorious for decimation during storm season in the South, and whose occupants rarely have the same structural or financial protections afforded their new construction neighbors.
The lack of storm-resistant housing, alone, can be deadly; even more so when compounded with other social determinant factors of the inhabitants, such as age, transportation, and disabilities. Approximately 1,836 people lost their lives during Katrina and its immediate aftermath (with the number of missing and presumed dead still over 700), more than half of them senior citizens, many of them living in houses built on flood plains or in trailers. The majority of those deaths were due to drowning. For those who survive the storm, but whose houses are damaged or destroyed, the health impacts are widespread and long-lasting.
Katrina destroyed 75% of all available housing units in New Orleans, and one million people lost their homes across Louisiana and Mississippi. 140,000 temporary housing units were supplied by FEMA to Gulf Coast evacuees who could not afford the cost of ongoing displacement or rebuilding. Unfortunately, this expedited relief effort for the needy came at a severe health cost to inhabitants. Over the course of the two years following their deployment, these trailers were later found to have dangerously high formaldehyde levels, and more than 11,000 health complaints related to formaldehyde inhalation were reported. Eventually, more than 55,000 residents of the Gulf Coast region won a multi-million dollar class action lawsuit against FEMA-contracted mobile home manufacturers relating to the health risks posed by the use of substandard materials.
Beyond the housing instability exacerbated by the storm’s effects, and the physical health concerns presented by dangerous debris, floodwaters, and toxic temporary housing, there may be considerable secondary health challenges for survivors. With school closures comes a lack of free or reduced-price food; for some students, these meals are the primary source of nutrition. In Harris County, TX, which includes Houston, 63% of the school-aged population are economically disadvantaged, according to the most recent statistics from the Kids Count Data Center. Impassable roadways make the logistics of food and supply distribution difficult, and grocery and convenience store shelves remain empty even for those stores that are open. Pharmacy and medical center closings mean many patients will go without prescribed medication for days or weeks. Stress from the storm’s impact to one’s living situation and community increases the risk of heart and asthma attacks, in addition to being the basis for the development of post traumatic stress disorder (PTSD). Depression is common amongst survivors, in particular in those who were permanently displaced, unable to return to their communities even years after the storm due to economic factors.
Returning to our original series of questions regarding elements you would consider as components of health management after this exploration of the primary and secondary health impacts of a hurricane, it is clear: by virtue of its impact on living conditions, a storm – or any kind of disaster, natural or otherwise – could be considered a social determinant. The healthcare system can help reduce the effects of these occurrences by embracing a socio-ecological approach to care.
What is a socio-ecological approach to care?
Figure 1: Socio-Ecological vs Medical Model of Health Management, Dr. Rex Archer, Kansas City Department of Health
In the US, the education and practice of medicine is geared towards diagnosis and prescriptive treatment of a particular health condition, and the gulf between public health and commercial healthcare research and services appears wide. The epidemiological approach in public health takes a community-level view of disease control and contributing factors, including social and environmental influences. The medical approach takes an individual and often disease-specific view, typically without the benefit of evidence-based interventions to identify and address the patient’s complex needs.
For the storm scenarios presented, epidemiologists, like Jennifer Horney, may study the collective decision points – the “isms” and power structures - guiding evacuees and stalwart home-stayers in order to derive models that could inform policy regarding the most effective ways to communicate with at-risk residents regarding dangers and options. Clinicians in a commercial healthcare setting treat the presenting health conditions for the patients in their care, and may study the short and long-term clinical outcomes of those cohorts to establish correlative and causal relationships between variables within their purview. When these two fields converge, the opportunity for positive impact in prevention, treatment, and outcomes are optimal: with an increased understanding of the social determinants, individuals and the public can be better positioned to manage their health.
Figure 2: Population Health Optimized by Social Determinants, via Andy Gardner of Lifely Insights
This convergence is increasingly happening, thanks to value-based care reimbursement models that close the gap between public health, population health, and individual medical approaches through integrated care delivery. The success of these care models relies upon a comprehensive understanding of a patient’s socio-ecological circumstances that would enable or prohibit their adherence to the prescribed care plan: their stability, access to care, and availability of health resources.
The evidence basis for this combined clinical-social approach is growing, and is being curated and accelerated by initiatives like All In Data for Community Health. Prominent examples of work to integrate socio-ecological data points into clinical decision frameworks include: the Protocol for Responding and Assessing Patient’s Assets, Risks, and Experiences (PRAPARE), which integrates a screening tool and subsequent action plan into the healthcare provider’s EHR; the Duke-Durham Collaborative Community Health Indicators project, which aims to democratize the data and expose correlative relationships between community and health indicators; the Camden Coalition of Healthcare Providers’ Healthcare Hotspotting project, which uses data to reallocate resources to high-cost, high-needs patients.
In order to bring integrated care full circle for the patient, and bolster the body of evidence supporting the efficacy of these care models, the patients’ social needs must be met, and their outcomes across all vectors tracked. Organizations such as Unite Us do this via technology-enabled local community service collaboration, referral management, and case management for each patient identified as needing assistance.
The results of this converged community-clinical, socio-ecological approach to healthcare can be astonishing. In one example, by housing homeless super-utilizers of its affiliated county hospital, in a partnership with a local Housing First organization, the Camden Coalition of Healthcare Providers was able to reduce admissions in the cohort by 60% over the first six months of the program, according to preliminary data cited by Dr. Shabnam Salih. Similar results have been reported by Dr. Ram Raju at Northwell Health in aligning partnerships with food banks and delivery services to address hunger.
Incorporating social determinants of health into the fabric of healthcare system design and care delivery provides tangible value to all constituencies involved in the system: patients, providers, caregivers, families, communities, businesses, and public service agencies. The knowledge, tools, and technologies exist to accelerate the adoption of integrated care inclusive of clinical and community components, and bend the unsustainable cost curve that has been the hallmark of US healthcare for decades. Although there are policy, practice, and funding barriers, these challenges are not insurmountable, and overcoming them is an economic and moral imperative. Future generations are depending upon us to rethink health and care.
We cannot prevent the next disaster. However, adopting a socio-ecological approach to healthcare can help our citizens be better prepared to make informed choices through an applied understanding of their motivations, help our policymakers better understand at-risk populations in order to develop more effective response plans, help emergency responders triage their resources according to comprehensive risk assessment, and help healthcare workers predict the likely impact of these scenarios on their patient volume and staffing needs.
Unite Us Networks across the country are following this socio-ecological model to addressing population health and have found success by integrating the social determinants of health across the country. For more information on our coordinated networks of care please fill out your information below.