Income, ZIP code, education are good indicators of health

Jesse and his mother
Jesse Alvarado, 5, and his mother Natividad Sarinan visited Children's Hospitals and Clinics in St. Paul, Minn., on Oct. 5, 2009, after Jesse started having symptoms of the flu.
MPR Photo/Lorna Benson

Access to health care is regarded as the backbone of good health. If you have decent insurance, you will likely live a longer, healthier life than people who are uninsured. The U.S. health reform debate reinforces this idea.

But as critical as the insurance debate is, public health researchers will tell you that there are several others factors that have an even bigger effect on your health. And many of them seem to have little to do with health - factors like where you live and where you shop.

They even go a long way in explaining why there are disparities in health between people who are white and people of color, and there are signs they could be playing out in the current influenza pandemic.

In public health circles, these factors are referred to as the social determinants of health. Chances are you haven't heard much about this view of health. But the social determinants movement is gaining momentum.

What is a social determinant?

There's no doubt that our behaviors shape our health. If you eat too many fatty foods you'll become obese. If you smoke, you increase your risk of cancer. But your opportunities to go to college? Can that affect your health?

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"If you live in certain zip codes in the Twin Cities you will live five, seven or eight years less."

"There are tremendous differences in every single health outcome you look at whether it's an infectious disease, whether it's heart disease, whether it's cancer, whatever, education is a tremendous predictor of health outcomes."

Camara Jones, research director on social determinants of health and equity at the Centers for Disease Control and Prevention in Atlanta, said researchers don't know exactly why education levels affect health.

But no matter the reason, the link to better health is so powerful that it can't be chalked up to chance. So is the link to income.

"For every single outcome that you look at in terms of income, the higher your income the better your health outcomes are," Jones said.

The reason for the link is difficult to translate, but it is easier to measure disparities in education and income than differences in housing and diet. Jones thinks money and education are important health indicators because they improve your odds of living in a good neighborhood, and where we live matters a great deal to our health and even our life span.

Obesity and diabetes in adults in Hennepin County
This graphic shows the change in percentage of adults in Hennepin County that are obese and those with diabetes from 2002 to 2006.
MPR Graphic/Steve Mullis

"If you live in certain ZIP codes in the Twin Cities you will live five, seven or eight years less," said Paul Mattessich, executive director of Wilder Research in St. Paul. "Or say it more dramatically, you will die five, seven or eight years sooner than people who live in other zip codes because of the different community factors."

The community factors he's talking about are social determinants of health -- things like crime, pollution, the quality of housing, access to full-service grocery stores, jobs and recreation. The presence or absence of any of these conditions can have an enormous effect on health behaviors in a neighborhood.

Wilder Research recently used ZIP codes to collect health data in the Twin Cities. Mattessich's colleague Craig Helmstetter is still analyzing the results, but Helmstetter said the preliminary findings show that people who live in wealthier neighborhoods live longer. It might be that they have more advantages.

"Places like Minnetonka, like Eden Prairie, like Edina have lower rates of mortality, longer life expectancies than places like North Minneapolis, the Phillips neighborhood, Frogtown here in St. Paul," Helmstetter said.

Social determinants and the flu

Research shows that health disparities are the greatest in poor neighborhoods populated with people of color. These groups have the highest levels of chronic disease and many other conditions.

The current H1N1 (swine) influenza outbreak could be a perfect example of how these disparities are playing out.

At Children's Hospitals and Clinics of Minnesota five-year-old Jesse Alvarado sits quietly on a hospital bed clutching his belly. His mother, Natividad Sarinan, said she brought him to the hospital because he was very pale and his lips were turning yellow. All of his other symptoms indicated influenza.

"Yesterday he started vomiting. He started having belly aches and a sore throat," Sarinan said through a translator.

Jesse's doctor decides it's too soon to admit him to the hospital just yet.

Jesse and his mother are Hispanic. According to the hospital, from April through the end of June, 81 percent of 700 flu patients at Children's have been non-white. Boris Kalanj, who directs the Office of Health Care Equity at the hospital, said usually the hospital and clinic system treats an even 50-50 split between white and non-white patients.

"We don't know the true answers for why we are seeing these differences," Kalanj said. "We are intrigued."

It's entirely possible that the social determinants of housing, access to health care and transportation are playing a role in the spread of H1N1. Kalanj puts it this way:

"Being exposed to crowded conditions, whether in the homes where there tend to be more people living, or people using public transportation, or people using the emergency room for primary care where the waiting room is full and perhaps they get more exposure to viruses there."

It's also possible that people who work in low-income jobs are less likely to take time off from work if they're sick. The illness could then spread more easily to their co-workers and their co-workers' families.

Kalanj said it's important to try to figure out the cause of these exposure differences to see if any changes can be made to prevent disparities with future disease outbreaks. He said if it's true that some people don't feel like they can take off work when they're sick, one solution might be to create a pool of money that employers could tap to to pay workers to stay home when they're ill.

Community groups take action

Solving health disparities related to social determinants of health can seem overwhelming, but a group of residents in the Payne-Phalen neighborhood on St. Paul's east side is chipping away at them one issue at a time. Atum Azzahir, the leader of a Powderhorn/Phillips neighborhood health center, sits with a group of six other African-American women in a 'healing circle'. Several of the women are overweight and dealing with health problems.

Azzahir and James
Atum Azzahir, left, leads a healing circle with Pam James and five other women in St. Paul, Minn. Azzahir is Executive Director of the Cultural Wellness Center.
MPR Photo/Lorna Benson

"And if there's anybody who's implicated it's African-American women," she says. "We are all implicated in this discussion."

One woman in this group has dangerously high blood pressure. Another struggled with debilitating asthma attacks that sent her to the emergency room nearly every week.

They are all on the path to better health thanks in part to their participation in this healing circle. This is a place where they can talk about their struggles. Some of the women say they feel isolated from society. Others discuss how their tight finances limit their ability to find safe housing.

Jessie Jackson said money problems can be overwhelming at times and that leads to her unhealthy behaviors.

"Crisis make you indulge in starches and sweets," Jackson said.

Azzahir adds: "And every one of us does it." The women nod in agreement.

"So it seems like that's another experience with food that we have to really examine because our health is implicated if we don't," Azzahir said.

Azzahir speaks from personal experience. Her son died earlier this year of a heart attack. He was only 47. She didn't even know he had heart disease.

"A very humbling experience:

Overcoming these health disparities will be hard work. It's even challenging for a major health care provider that has $5 million dollars to throw at the problem.

Just ask Ellie Zuehlke, who works for Allina Hospitals and Clinics.

"It's been a very humbling experience," she said.

For more than a year, Zuehlke has overseen Allina's Backyard Project on the other side of the metro. The hospital and clinic system set out last May to improve the health of residents in the Powderhorn, Phillips, Central and Corcoran neighborhoods of Minneapolis.

Two of Allina's hospitals are located in the neighborhoods and yet Allina officials knew that many of the area residents were uninsured and often didn't get adequate care.

Allina set out to provide things like blood pressure and cholesterol services, but the residents weren't interested in having their cholesterol checked. Many of the health issues were things that were out of their individual control and the residents wanted help fixing them.

"We hear a lot about jobs, we hear about housing, we hear about school, we hear about safe environments for kids to be able to play, about having access to and being able to afford healthy foods, stress, just a lot of the challenges of daily life that really do have a profound impact on a person's health," Zuehlke said.

So Allina revised its approach. The health provider is now attempting to measure the social determinants of health affecting the neighborhoods. They're gathering the information directly from residents, who are being asked to participate in listening circles and door-to-door health surveys.

Dona Evans is a resident who agreed to organize a listening circle in her neighborhood. Marcus Ford, also a resident, answers her question during a training session.

"My first question of you is how do you keep yourself and your family healthy?" Evans asked.

Said Ford: "One thing I've noticed is since I've been trying to eat healthy it cost more to eat healthier than it does to go to McDonalds and get a burger for 99 cents."

Answers like these will be challenging to sort out, but Zuehlke hopes solutions will become apparent as the information flows in from the neighborhoods.

"But I'm not really sure that we know what to do about it," Zuehlke said. "And I think a lot of what we're doing in the backyard is working together in a new way to figure out 'What do you do about it' and 'How do you change this?'"

For some of these neighborhoods the social determinants of their health clearly pose monumental challenges. It would be easy to say that we can't change the conditions where some people live and work.

But there's a lot to be gained even through small changes. And over time, those changes can alter a person's odds of dying an unnecessary, early death to one that favors a long, healthy life.