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Peter Beilenson: Population Health

Peter Beilenson: Population Health Program Transcript [MUSIC PLAYING] PETER BEILENSON: Your zip code that you live in makes more difference in your health and well-being than the genetic code that you're born with. [MUSIC PLAYING] The bottom line that we use all the time "is place matters." The place that you grow up matters hugely. And if there's a four-legged stool of things that supports, that allow for people to grow healthfully and into decent social-economic wellness, if you will, it's access to health care, it's access to decent education, to decent, safe housing, and probably most importantly access to a livable wage paying jobs. It's those four things that if you do have them, you're going to turn out much, much better in general than if you don't have them. I can give a perfect example of this in real life. A neighborhood in Baltimore called the Oliver neighborhood, which is a particularly decimated, vulnerable, underserved left-behind neighborhood. It used to be where a working class African-American, It's now a drug-infested area. There's dilapidated housing with lead-poisoned kids. There's housing that has fallen down. The broken window theory of once a couple of houses have broken windows, the neighborhood tends to go downhill because it looks like things aren't being taken care of. And so more crime occurs. So it's heavily crime-infested. There are a lot of uninsured adults who don't get their health care taken care of. So there's a lot of chronic disease-- diabetes, high blood pressure, strokes, et cetera. So there's lack of decent housing, lack of health access. The schools that serve this neighborhood, Oliver, are particularly poor. And lastly, not only is it a food desert in terms of not having good produce and fresh foods available because there are no supermarkets in the neighborhood, it's literally a wage desert. I can't think of any business in the Oliver neighborhood that pays a livable wage job. So that's a perfect crystallization of having nothing of the four-legged stool of social determinants of health. Compare that with Howard County, Maryland, 12 miles away, maybe three or four zip codes away, where the vast majority of the population has access to great recreation facilities, excellent housing. There's been one lead-poisoned kid in the entire county of 300,000 people in the last couple of years, total. The percentage of folks who are uninsured in that county is about 7% to 8%, 9%, compared to 30% of the adults in this neighborhood in Baltimore.

Peter Beilenson: Population Health

The school system is ranked the best in the state, probably one of the top 10 in the country. And there are innumerable living wage jobs. And, not surprisingly, the healthiest county in the state of Maryland is Howard County. And the poorest- - the least healthy county in the city/county in the State of Maryland is Baltimore. [MUSIC PLAYING] So the paradigm that the Institute of Medicine put out-- probably now it's 15, 18 years ago-- but it's looking at health problems and health policy with a three-step process. And epidemiology is particularly important in the first and third steps. The first step is doing a needs assessment of whatever population you're serving. You assess the needs of the population that you're serving. And that's where epidemiology comes in-- statistics, data, et cetera-- depending on what issue you want to deal with. And when we picked priority areas when I was in Baltimore City, the Baltimore City Health Commissioner, we looked at areas that had large numbers of years of productive lives lost. Basically means if the average life expectancy is, let's say, 75 in the community, and something tends to kill people in their 30s, like AIDS did several years ago, that's 40-something years of productive life lost. And so that's an important thing to focus on similarly. Infant mortality, that's 75 years of productive lives lost. So the paradigm needs assessment can be done in looking at years or productive lives lost. It can also be in a specific policy area, like immunization. The needs assessment might be what part of your population is particularly unimmunized, and then go after that. And then the second phase of this paradigm is policy development. So you assess the needs of your population. And to deal with them, you come up with policy. It can be legislation to address the issues that you've found. It can be a program that you start up. It can be advocating for a change in a certain area to get that need addressed. And the third component is assurance, which is basically evaluation. We almost always in my work-- whatever initiative that we launch, we always build in an evaluation tool at the end so you can see if what you did, the policy you developed, met the need that you assessed. There are three classic examples that I've worked on in the last 15 years or so that highlight the use of this paradigm the Institute of Medicine uses in terms of looking at ways to look at public health problems of needs assessment, policy development, and assurance. And the first is an immunization issue.

Peter Beilenson: Population Health

In the mid- to late 1990s-- 1996, '97, to be exact-- we had worked with the Agency for International Development. And at that time, Vice President Al Gore wanted to choose an American city to show that the lessons that were learned outside our borders by the AID COULD be brought to bear on third-world parts of the United States. And we were chosen first here in Baltimore. So the Vice President came along with the mayor and myself, and we went around about the vulnerable areas. And he was talking about some of the success stories that AID had had internationally. And one of them was that the immunization rate in several impoverished developing countries, including Kenya, were significantly better than the immunization rates we had in our schools here in Baltimore. Even though there is a law that requires kids to be fully immunized before they go to school, it just wasn't being enforced. Only 62% of kids in the school system were fully immunized or had records there of. So the policy that we developed was multi-pronged, one of which was to do a lot of public relations communication to parents saying, hey, we're going to be dealing with this. We're going to start holding you responsible. We had huge clinics in the school system buildings prior to school starting in the '96-'97 school year where we had thousands and thousands of kids coming in to get immunized. And by the way, at the same time, not just school-aged kids, but their little siblings. So we hoped it would make a difference for kids coming up. So we instituted these two policies. And again, this is something we could do ourselves. It was both communications-based as well as offering services. And we went from 62% of kids at the beginning of that school year to 99.8% immunized within three months. And because we enforced this-- so we went from something like 40,000 of the 100,000 kids unimmunized at the beginning to about 200. And as far as we could tell from a lot of heavy work, most of those 200 actually moved out of-- they just were incorrect information that the school system had about them. They actually weren't even in the school system anymore. So we basically went from one of the worst immunized cities in the country to one of the very best. And it stayed that way for the last 12, 14 years because the enforcement tools have been kept in place. So needs assessment in this case, pretty simple. You just look at the data from the school system that show we were very under immunized. Policy development, communications, legal ramifications, and offering clinics to immunize kids. And assurance, following up to make sure that the law was enforced, that the rules were enforced at the school system level, and keeping track of the kids going forward that were immunized. So a good public health success story and a little bit unusual in that most public health problems from AIDS to chronic disease take decades to develop and

Peter Beilenson: Population Health

usually take a while to fix. In this case, it took a decade to develop. But it took three months to fix. Early in 1998, the CDC, the Center for Disease Control and Prevention, comes out with their national rankings on syphilis. And Baltimore not only ranks first in the country, but we have one out of every 20 cases in the entire United States in Baltimore City. You've got to assess what's the epidemiology behind this outbreak. And it was very interesting. We actually, by the way, had hit the trifecta of being number one in the country not only in syphilis, but gonorrhea and chlamydia, too. Obviously you would think somewhat related, but in reality not. And that was because gonorrhea and chlamydia were tending to hit 13- to 25- year-olds if you looked at the data. Serially monogamous, which many nurses know having taken care of it, especially if you've taken care of teens, serially monogamous means basically you're talking to the teenager, how many partners do you have? One. How many partners in the last seven weeks? Five. Well, you've been serially monogamous. But they tend to know their partner. And so it's easy enough to do contact tracing and to get the partners notified and medicated so that you can deal with the gonorrhea/chlamydia outbreak. And so that was being done a lot through the school system and through our family planning clinics for teens. Syphilis, when you looked at the data, was very, very different. It was 25 or older, more like 30- to 50-year-olds who were involved in drug for sex, particularly crack, and were in crack houses, and barely knew the person's first name, if that. And so it was much harder to track, and much harder to deal with. And looking at the epidemiology of it, it actually looked like it was dispersed around the city, which was surprising. But if you followed Baltimore's history, you knew that the year before a lot of the high rises that were disastrous, that concentrated a lot of impoverished drug-using population, were torn down. And so they shredded the populace and placed them all over the place. And so that was actually, we think, part of the reason for the spread because there was more-- it wasn't concentrated in one, or two, or three, or four places. But it was all over the place. And so your chances of coming in contact with someone with syphilis was greater. And once enough of the population, particularly the drug-using population of that age, were infected, then you reach a tipping point where by which you're more likely to come in contact with someone who's infected and therefore get infected yourself. So the policy we developed was multi-pronged again. Partly it was communication. So we wanted patients, or individual citizens, as well as

Peter Beilenson: Population Health

providers, docs and nurses, to know the signs and symptoms of syphilis because it was actually relatively rare before. And so we were seeing a lot of patients coming in from emergency rooms who had been treated for a fungus when actually they didn't have a fungal infection, they clearly had syphilis. But the doc or nurse practitioner had not seen a syphilis patient ever. And so they were misdiagnosing. And so we actually encouraged people to send folks with genital lesions to our STD clinics because just as with heart bypass, the more you do, the more you know. And the more you see, the better you are treating it. So we did that. We actually trained our disease trackers in blood drawing and sent them out. We didn't do this terribly much, but we sent them out to crack houses to draw blood. Why? Because that's where you do syphilis testing. And then we would come back and either shoot people up with penicillin there or bring them back to our clinics. And then the third thing we did, which was actually the biggest yield, was, if you think about it, because they're involved in the sex-for-drugs trade, a significant portion of this population is going to some way get arrested during a given year, either for possession charges, or distribution charges, or prostitution charges, or whatever. And so we did stat testing for syphilis at the central booking center, which is where everybody comes in who gets arrested in Baltimore. And we had a huge yield of syphilis-positive individuals. And so they were at least-- although, you're supposed to get three shots of penicillin, they at least got one before they were released within a day, or two, or three. And then we tried to follow-up with many of them. But one shot at least makes a difference. So within a year, we had an 82.4% drop in our syphilis cases from 660 to something like 100-- low 100s, mid 100s. And it has stayed at or below that level virtually the entire time since because we've done a lot of outreach and are making sure that people who are in vulnerable populations are tested. We're still too high. But we dropped out of the trifecta. And we are no longer number one in gonorrhea, chlamydia, or syphilis. And so it's a significant success story. Although certainly, we did not eliminate syphilis. [MUSIC PLAYING]

Peter Beilenson: Population Health

Peter Beilenson: Population Health Additional Content Attribution Trowell‐Harris, I. (n.d.). Various Photographs [Photograph]. Used with permission of Irene Trowell-Harris. Wakefield, M. (n.d.). [Photograph]. Used with permission og Mary Wakefield WAL_NURS6050_NIH-SenatorDanielInouye Official White House Photo by Pete Souza