Social Determinants of Health

[SeaConquest]

I originally wrote this as a Facebook post on my wall, but I thought it might make an interesting chat board discussion topic. We focus on a lot of these topics as separate issues, but it's only within the past decade or so that researchers, physicians, nurses, social workers, and policymakers are beginning to understand this subject as a unified whole in a field called the social determinants of health. 
https://health.gov/healthypeople/objectives-and-data/social-determinants-health

I raised the issue because of a NYT article today about how Mississippi was uniquely susceptible to the pandemic. I am including my original Facebook post and the NYT article below. 

During my community health rotation in nursing school, I took an interest in a subject called the social determinants of health. Mississippi is a case study in how all of these social determinants coalesce into the lowest life expectancy in the United States. And that was before the pandemic.

1) Poor or nonexistent prenatal care during pregnancy ensures that babies in MS start their life with the highest rate of infant mortality in the United States (more than twice the rate of California's). Not to mention the "pro-life" policies that reduce access to contraception and abortion that force women to have these pregnancies in the first place, which in part explains why MS has the second highest rate of teen pregnancy in the US (which also contributes to much riskier health outcomes for both mother and child).
 

2) If you make it past infancy, MS ranks as the second least educated state in the nation, behind WV. Without an education, people often turn to crime. Not surprisingly, MS, has the second highest imprisonment rate, behind LA. People also tend not to do very well financially. As a result, MS has the highest rate of poverty in the US. And when you are poor, you probably are pretty far down on Maslow's hierarchy of needs -- thinking mostly about survival -- so you probably aren't spending too much time worrying about civic engagement and voting. Thus, MS ranks as the 6th worst state for voter turnout.

3) When you are poor, you also don't have a lot of money to eat healthy foods because it's cheaper to grab a burger from the $1 menu at McDonalds or a cheap bag of Doritos from the liquor store (both of which take your EBT card) than to buy fresh fruits and veggies from a farmers market (which may not). In CA, we are spoiled by having cheap and plentiful access to high-quality fruits and veggies nearly year-round, but travel to many parts of this country and you will be shocked by the high prices and limited selection of options. Not surprisingly, MS has the second highest rate of childhood obesity and the highest rate of adult obesity in the US. A diet filled with cheap foods that are high in sugar also leads to cavities and tooth decay. MS ranks the worst in the nation for dental health.

4) As we all know, obesity leads to a host of other major health conditions. Thus, it is no shock that MS leads the nation in rates of heart disease and stroke, and has the second highest rate of diabetes. But, no worries, certainly insurance will pay for these conditions. Not in MS, where they rank among the top 5 states in the US for both uninsured children and adults. That adds up to a lot of medical debt. In June 2021, MS had the 5th highest rate of personal bankruptcy in the US. Shocking. The article goes on to talk about the state of the healthcare system in MS and why it is collapsing, but I wanted to give fuller context on how these issues are connected and have collided to create a perfect storm during the pandemic across much of the South.

https://www.nytimes.com/2021/08/29/us/when-the-new-covid-surge-struck-mississippi-was-uniquely-unprepared.html

 

When the New Covid Surge Struck, Mississippi Was Uniquely Unprepared

Poverty and politics have left the state with fewer doctors and nurses than it needs and hospitals on the brink of shutdown.

 

 

The field hospital set up inside a parking garage next to the University of Mississippi Medical Center is equipped with five intensive care beds and 27 acute care beds.Credit...Emily Kask for The New York Times

By Richard Fausset

Aug. 29, 2021, 5:00 a.m. ET

JACKSON, Miss. — On the ground floor of a parking garage at the University of Mississippi Medical Center, there are coronavirus patients where the cars should be — about 20 of them on any given day, laid up in air-conditioned tents and cared for by a team of medical personnel from a Christian charity group. Another garage nearby has been transformed into a staging area for a monoclonal antibody clinic for Covid-19 patients.

These scenes, unfolding in the heart of Mississippi’s capital city, are a clear indication that the health care system in the nation’s poorest state is close to buckling under the latest avalanche of cases triggered by the highly contagious Delta variant of the virus.

“We have reached a failure point,” LouAnn Woodward, the medical center’s top executive, said late last week. “The demand has exceeded our resources.”

The current coronavirus spike has hit the South hard, but a combination of poverty and politics made Mississippi uniquely unprepared to handle what is now the worst coronavirus outbreak in the nation. The state has fewer active physicians per capita than any other. Five rural hospitals have closed in the past decade, and 35 more are at imminent risk of closing, according to an assessment from a nonprofit health care quality agency. There are 2,000 fewer nurses in Mississippi today than there were at the beginning of the year, according to the state hospital association.

“If you look around, the state’s hospitals were in bad shape before there was such a thing as Covid,” said Marty Wiseman, an emeritus political science professor at Mississippi State University. “It was not a good time to layer a pandemic on top of that.”

 

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Neshoba General Hospital in Philadelphia, Miss., has been overwhelmed with patients during the most recent surge in the virus. Credit...Emily Kask for The New York Times

Mississippi has waged decades of political battles over health care policy that can run almost as hot as the fights over the symbols of the old Confederacy. Most crucially, the state rejected a proposal to expand Medicaid, the federally subsidized health insurance program for low-income residents, a decision that critics say has deprived Mississippi of a much-needed infusion of federal money that might have strengthened small hospitals on the brink of failure and allowed them to recruit and retain doctors and nurses. That debate is being revisited by advocates who hope the pandemic will force a new reckoning.

What Mississippi has been left with, after years of infighting, is a system believed to be the weakest in the nation. According to a 2020 report from the Commonwealth Fund, a New York nonprofit group, Mississippi ranks at or near the bottom among states on key health care measurements, including infant mortality, childhood and adult obesity, and adults who have gone without care because they could not afford it.

The hospitals that have shut down in recent years cited the same factors plaguing many of those still operating in the state: not enough money from patients with private insurance, not enough government help to care for the poor. Money is also at the root of the health care personnel shortage: Doctors and nurses can often make significantly more money elsewhere.

 

The hospital closures have meant real challenges for local communities. Quitman County Hospital, in a sparsely populated corner of northwest Mississippi, was the only hospital in a 25-mile radius when it closed, creating a particular hardship in medical emergencies. In Newton, a small community about 65 miles east of the capital, the shutdown of Pioneer Community Hospital meant the loss of 150 jobs.

And across the state, a shortage of health care workers has shrunk access to high-quality care. The dearth of physicians is so acute in some areas that in 2019, before the pandemic, legislators considered exempting newly licensed doctors from paying income taxes for 10 years if they agreed to work in underserved communities.

 

 

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An ambulance brought a patient to the field hospital in the parking garage at University of Mississippi Medical Center in Jackson, Miss.Credit...Emily Kask for The New York Times

Mississippi, as of Friday, was averaging 108 new cases per 100,000 residents over a seven-day period — a crisis fueled by a dismal statewide vaccination rate of 37 percent and made worse by a shortage of professionals to care for the sick. Memorial Hospital in Gulfport has canceled brain and heart surgeries due to a lack of available intensive care unit beds. Most days, Dr. Woodward’s hospital, the largest in the state, has upward of two dozen patients waiting in the emergency ward and other parts of the hospital for intensive care beds to free up. State officials are even trying to outsource some of the state’s sickest patients; Kentucky’s public health commissioner, Steven J. Stack, said this week said that hospitals in his state had fielded requests from Mississippi officials who were hoping to send them “I.C.U.-level-care patients.”

But as Mississippi opens its new war on the virus, it can sometimes seem like a state at war with itself.

Gov. Tate Reeves, a first-term Republican, recently declined to call a special session of the Legislature, a move supported by legislative leaders who had hoped to quickly allocate $1.8 billion in federal relief money to state health workers.

The Reeves administration announced this week that it was signing up more than 1,000 contract health care workers to address the hospital labor shortage, at a cost of $10 million per week — a cost that will eventually be borne by the federal government. The news was at once welcomed by beleaguered frontline health workers and derided as hypocritical by critics of Mr. Reeves, who declared in his first State of the State address that “big government intervention creates as many problems as it solves.”

“The big government that some in the state are critical of has basically come here to save our collapsing health care system,” said Derrick T. Simmons, a Democrat and the State Senate minority leader.

Though Mr. Reeves has encouraged vaccinations and mask wearing to combat the virus, he has also sent mixed messages, calling the latest guidance from the Centers for Disease Control and Prevention on indoor mask wearing “foolish.” He recently upbraided a reporter for wearing a mask at an indoor news conference, calling it an act of virtue signaling.

Still, persuading people to get the vaccine has become a top priority. Archie Manning, the former University of Mississippi football star, recently recorded a radio spot in which he encouraged residents to get a shot. “We know the vaccine works,” Mr. Manning says in the ad, “but only if you get it.”

 

 

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Workers at Neshoba General Hospital conducting drive-through Covid testing.Credit...Emily Kask for The New York Times

The message hasn’t reached everyone. Last week, the state government warned that increasing numbers of Mississippians were calling the state poison control center after ingesting a drug often used for livestock deworming, which some erroneously believe can protect against the virus.

That same day on WMPR 90.1 FM, a community radio station in Jackson, listeners heard a fiery sermon by a pastor who argued that Covid precautions were unnecessary for those who enjoyed God’s protection.

Those interested in improving health care in the state have long faced daunting odds. A succession of conservative governors have decried the cost of Medicaid, which is shared by the federal and state governments. Former Governor Haley Barbour, a Republican who served from 2004 to 2012, backed steep cuts to the program, including a divisive plan, eventually blocked by a judge, to remove 65,000 older adults and disabled people from the Medicaid rolls. He also suggested that people were gaming the system.

“Forgive me if I think people who work two or three jobs to pay for health care for their families shouldn’t be forced to pay for health care for people who can work, but choose not to,” he said in 2011.

Mr. Barbour’s successor, Phil Bryant, torpedoed a state health insurance exchange meant to be a component of President Barack Obama’s Affordable Care Act. Mr. Bryant said at the time that he did not want to support Obamacare, as the act is known, because he feared it would saddle the state with oppressive debts related to Medicaid.

Mr. Reeves and the Mississippi Legislature — like the legislative bodies in a dozen states with Republican-controlled statehouses — continue to oppose Medicaid expansion, despite a renewed push for the program from state health care advocates who insist that money from the program might have helped Mississippi better weather the pandemic.

Mississippi’s hospitals have even proposed a plan that would cover the state government’s share of the cost with a tax on the hospitals themselves and small monthly premiums for those who would sign up.

In Hattiesburg, Phyllis Chambers-Berry, the chief nursing officer at Forrest General Hospital, said she believed that expanding Medicaid before the pandemic would have left her hospital in a stronger position to deal with the Delta variant. Now, with her hospital’s 50 intensive care beds full, she said she was hoping the state would send 26 contract workers who would allow the hospital to open 10 more beds.

Those workers would represent just a fraction of what Forrest General actually needs. The hospital has 240 nursing jobs that are unfilled, Dr. Chambers-Berry said. Of those who remain, she said, “I could tell you from the looks on their faces — they’re exhausted.”

 

Edited August 29, 2021 by SeaConquest

[Dmmetler]

Reeves also, in earlier surges, had this annoying tendency to attribute ICU beds over state lines as available to MS. And that is true-except that MS can’t use the entire capacity of, say, Memphis, because we are also the primary ICU/critical care for a big chunk of west TN and Eastern AR, and sometimes even gets cases from MO. One major reason why Memphis set up overflow COVID units early on was in recognition that we needed to accommodate surges from neighboring states as well. 
 

We haven’t yet, mostly due to the fact that staffing is a limitation more than beds and equipment. But one reason why the health department put a mask mandate back in was directly related not to numbers locally, although they’re bad enough, but because we know we will be getting the worst cases from the neighboring states, too. Especially since we are the major pediatric ICU facility for the region. 

Edited August 29, 2021 by Dmmetler

[KungFuPanda]

Oh man, all WV had going for it was at least it beat out MS in education.  Now they don't even have that.  It's so sad.  Their early vax rollout was stellar and the seniors were mostly vaccinated early on, but I don't think the general population has broken 40% yet.   These seniors, my mom included vividly remember the polio epidemic so they needed very little convincing.  The state declined quickly in just a few recent generations.  Politics changed, most people with an education had to find work in other states and the opioid epidemic has just destroyed the WV. It's so beautiful in so many places and this just hurts my heart.  Growing up, most people had at least a small garden since the population is largely rural and not THAT far removed from ancestors who could live off the land.  There wasn't a lot of money in the community, but it was unusual to know a family that didn't know how to hunt, fish, and grow and preserve food.  (People knew how to play instruments and sing too, so there was always food and music.)  It seemed that even people who didn't have time or the physical ability to grow a "real" garden still grew tomatoes, cucumbers, and some kind of salad greens.