“The Moral Determinants of Healthcare”

I recently wrote about my and others’ concerns about the current state and direction of Vermont’s healthcare systems. But we must also ask, what have our political leaders done to mitigate the social, environmental, and economic drivers of Vermonters’ deteriorating mental and physical health?

I expressed support for the philosophy behind OneCare Vermont, along with my doubts about the success, pace, and cost of its implementation. The idea of moving away from “fee-for-service” healthcare towards investing upstream in prevention, education, and chronic disease management or “population health” makes eminent sense —Ben Franklin (1776) “An ounce of prevention…”

But the burden of providing “population health” extends far beyond the healthcare system. We ourselves are the number one determinant of our own well-being through our daily choices: do we smoke, exercise, eat healthy food in moderation, wear seatbelts, get vaccinated, maintain positive relationships, practice empathy etc.

Atul Gawande’s piece last month in the New Yorker explaining why Costa Ricans outlive Americans goes a long way to clarifying why prioritizing public health —measures to improve the health of the population as a whole — must be central to the delivery of medical care.

Meanwhile last year, Donald Berwick MD, published in the Journal of American Medicine (JAMA) a widely distributed paper entitled The Moral Determinants of Health.

I’d like every legislator to read both pieces.

No scientific doubt exists that, mostly, circumstances outside health care nurture or impair health. Except for a few clinical preventive services, most hospitals and physician offices are repair shops, trying to correct the damage of causes collectively denoted “social determinants of health.” Marmot1 has summarized these in 6 categories: conditions of birth and early childhood, education, work, the social circumstances of elders, a collection of elements of community resilience (such as transportation, housing, security, and a sense of community self-efficacy), and, cross-cutting all, what he calls “fairness,” which generally amounts to a sufficient redistribution of wealth and income to ensure social and economic security and basic equity. Galea2 has cataloged social determinants at a somewhat finer grain, calling out, for example, gun violence, loneliness, environmental toxins, and a dozen more causes. The power of these societal factors is enormous compared with the power of health care to counteract them.”

“How do humans invest in their own vitality and longevity? The answer seems illogical. In wealthy nations, science points to social causes, but most economic investments are nowhere near those causes. Vast, expensive repair shops (such as medical centers and emergency services) are hard at work, but minimal facilities are available to prevent the damage. In the US at the moment, 40 million people are hungry, almost 600 000 are homeless, 2.3 million are in prisons and jails with minimal health services (70% of whom experience mental illness or substance abuse), 40 million live in poverty, 40% of elders live in loneliness, and public transport in cities is decaying.

Decades of research on the true causes of ill health, a long series of pedigreed reports, and voices of public health advocacy have not changed this underinvestment in actual human well-being.”from the Moral Determinants of Health, Donald Berwick M.D.

Although the healthcare community can and must do better to improve access and reduce cost, our governor and legislators must look seriously at their role in improving the determinants of population health, one of which is to drive change that reduces the levels of stress that underlies much illness affecting so many Vermonters.

What are the external determinants of population health?

  1. a secure place to live that one can afford (25-35% of income)
  2. adequate, affordable, nutritious food
  3. positive childhood influences, free of abuse, neglect, addiction etc.
  4. free or affordable education from birth through all of life’s passages
  5. access to free or affordable healthcare
  6. employment opportunities that pay a livable wage
  7. a non-toxic living environment
  8. a just, restorative, and non-punitive criminal justice system
  9. interpersonal and technical connectivity
  10. secure family and community infrastructure and public transport

If these ten elements drive the overall population health of Vermonters, the role of healthcare, though critical, is but one of the determinants of well-being. The rest are the purview of the Governor’s leadership and legislative action. We must ask ourselves what have our political leaders done to mitigate the social, environmental, and economic drivers of deteriorating mental and physical health.

Housing is in a crisis stage. According to a recent report by the National Low-Income Housing Coalition, a full-time Vermont worker needs $23.68 an hour, or $49,258 annually, to afford a typical two-bedroom apartment here. The average Vermont renter earns about $13.83 an hour. As of 2020, there were 1110 homeless Vermonters. The U.S. Dept. of Education reports an almost identical number (1008) of homeless public-school students. Among all U.S. states, Vermont has the ninth highest rate of homelessness.

Food insecurity is on the rise in Vermont. A recent UVM study indicates that nearly a quarter of Vermonters are food insecure, some 70,000 adults and 16,000 children.

21% of Vermont children have experienced three or more “adverse family experiences:” — parents divorced, separated, dead, in jail, abusive, mentally ill, or addicted to alcohol or drugs. As few as three such adverse family experiences can impair how a child succeeds in school, their longevity, and their physical and mental health.

Public education is available for all Vermonters between the ages of three (pre-K) up to senior high level. But there is no fully funded program for childcare in Vermont and some 13,000 children under the age of three need childcare for adult family members to work. And our school students and teachers are suffering from the impacts of the toxic stresses caused by declines in social and economic security.

As of 2018, under 4% of Vermonters were uninsured for healthcare, but being insured and having access or being able to afford copays and the increasing array of procedures and visits that are not covered is preventing many Vermonters from getting the care they need. 26,000 Vermonters remain uninsured. Vermont’s average premiums run $669/month. Young Vermonters (25-34) are three times more likely to be uninsured than the average Vermonter.

Although the Vermont Department of Labor (DOL) reports unemployment at three percent, the Gund Institute at the University of Vermont found that nearly 40% of households faced job disruptions (25% lost jobs, 35% reduced income, 20% furloughed). Of households with job disruptions, almost 40% also experienced food insecurity.

Vermont is generally a healthy place to live, but toxic algae blooms caused in part by agricultural runoff from dairy-driven countries like Addison and Franklin that abut the Lake are on the increase rather than decline. Monocropping of corn and other feed crops require chemical fertilizers and weedkillers that damage life in our soils and waterways. The recent PFA findings in places of learning is deeply concerning as some 200 million Americans have been found to have PFAs in their blood.

Vermont has an incarceration rate of 288 per 100,000 people (including prisons, jails, immigration detention, and juvenile justice facilities), meaning that it locks up a higher percentage of its people than almost any democracy on earth. There have been improvements, but Vermont still has one of the higher rates nationally for family child removals (termination-of-parental-rights).

About 85% of Vermonters have high speed Internet access with up to 10 Mbps download speeds, making the Green Mountain State one of the worst in terms of broadband accessibility (47th). 18% have fiber to the home. During the Pandemic, tele-medicine, -commuting, and -learning highlighted the critical nature of broadband access to Vermonters.

A rural state with declining downtowns and expanding urban areas is slowly improving its public transportation infrastructure. But about 250,000 Vermonters are still heavily dependent on car ownership for travel to and from work. And most toxic air pollutants in Vermont come from mobile sources—such as cars, trucks, and other motorized vehicles.

Our collective report card is not great.

If some 80% of our health is determined by the social determinants and 20% is determined by the healthcare system, what have our political leaders done to mitigate the social, environmental, and economic drivers of deteriorating mental and physical health? We need a vision and a formal legislative plan to address this fundamental question. But who will lead?

Add the spike in mental health crises and reports of self-harm besetting our schools and emergency rooms and the increase in suicides and the call to action becomes imperative.

Action will lower the cost of remedial healthcare.

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