What’s your social rank? Status can influence welcome into a doctor’s office

by Suzanne Bohan

February 27, 2013

Dr. Stephen Hwang is a general internal medicine physician at St. Michael’s Hospital and researcher in its Centre for Research on Inner City Health. He wrote a new study assessing discrimination in doctors’ offices on socioeconomic status.

Family physicians’ offices in Toronto more frequently rebuffed people of low socio-economic status seeking first appointments, even when there is no economic incentive to do so, a new study found. All Canadians have universal, publicly-funded health insurance.

In 2011, researchers called nearly 400 family practice offices seeking a first appointment,

posing as either a newly-transferred bank employee or a welfare recipient. In both cases, the researchers told the receptionists that they had either no health problems or that they had diabetes or low back pain. The pseudo-bank workers were able to secure an appointment 23 percent of the time, compared with 14 percent for the lower-status pseudo-welfare recipient – 50 percent better odds of getting in for the higher status caller.

“This impairs access to primary care, and we don’t think this is acceptable,” said Dr. Stephen Hwang, a physician with St. Michael’s Hospital in Toronto in a statement.

The study was published online Monday in the Canadian Medical Association Journal.

In a Feb. 27 article in the Toronto Star by Theresa Boyle, Hwang was quoted as saying, “The most likely explanation is that people working in doctors’ offices may be unconsciously biased against people of low socioeconomic status.” He added that it was the physicians’ staff that demonstrated a reluctance to schedule lower-status patients, not the physician. So it could have reflected staff bias, or could have been due to the physician providing direction to staff on new patient acceptance, Hwang said.

“I’ve always been struck by the fact that many of my patients who are marginalized say that they have been treated poorly by health-care providers in the past, simply because of their position in society,” Hwang said in the article.

I’m posting this news on a Canadian study to cultivate more empathy for what happens to people lower on the socioeconomic ladder in the United States, where the reimbursements for their care is almost always lower than for wealthier patients given the hodgepodge of medical coverage options. I’ve heard first-hand peoples’ reluctance to schedule a visit to a doctor, because they fear being treated disrespectfully.

TAKEAWAY: This study is a wake-up call for doctors (and patients) to remain vigilant for hidden biases – which compromises treatment.

—

Boyle, Theresa. “Doctors appear more likely to take on wealthier patients, study finds,” Toronto Star, Feb. 27, 2013.

Health, Health disparities

Poor housing endangers health

by Suzanne Bohan

February 27, 2013

We had to laugh when we saw this offering on a mountain roadway in the Klamath Mountains in Del Norte County in Northern California. I was with Melissa Darnell, a community organizer working with a major privately-funded initiative to vastly improve the health of county residents over a decade.

This one is a serious fixer-upper that’s probably beyond a cost-effective restoration, but it’s emblematic. A couple of days earlier we’d visited a woman in another Del Norte community with major decay in the doublewide mobile home where she and her family lived. Holes in the floor were covered with plywood, and the home had other obvious signs of major damage.

Many live in mobile homes in the region. For that reason and others, unsafe, unhealthy housing is a significant issue. Annual rainfall is around 75 inches, and mold and fungi – both asthma triggers – grow readily in leaky homes.

In Del Norte County:

26.8% of low-income residents report mold in the home₁
45% of children reported suffering an asthma attack₂
35.7% of adults reported suffering an asthma attack₃

Another challenge in the region is there’s no homeless shelter for displaced individuals or families in this cold, wet climate, in part because of strong community resistance.

The initiative that Darnell is working for is on a quest to raise the health of Del Norte residents, especially children, by improving myriad social and living conditions. And housing is among them.

Among the solutions:

Creating a housing collaboration among public, private and nonprofit entities to offer financial literacy, credit counseling, pooling of resources and the assessment of policies that hinder home ownership.
Strengthening or developing offerings for home health assessments.
Promoting understanding about homelessness and alleviating fears about sheltering homeless families, with the aim of establishing a temporary shelter during inclement weather.

TAKEAWAY: Costly and common illnesses such as asthma are strongly linked to substandard housing.

—

California Center for Rural Policy; “Rural Poverty and its Health Impacts: A Look at Poverty in the Redwood Coast Region.” Rural Health Information Survey, 2006
California Department of Public Health; “Asthma in Children and Adolescents in California Counties, 2003”
California Department of Public Health; “Asthma in Adults in California Counties, 2003”

Health, Health disparities

Hmong garden quickly thrives in Crescent City

by Suzanne Bohan

February 26, 2013

A one-acre garden in Crescent City tended by the local Hmong residents.

This garden was a delightful site in Crescent City in Del Norte County, especially when the back story emerged. In the spring of 2011, it was an empty one-acre lot. But someone lent the land so the small Hmong population in Crescent City could grow a community garden they’d long wanted. About 600 Hmong live in Crescent City.

Several months later it was a thriving oasis.

Another view of the garden.

All it took was the land along with some supplies and a new fence, and the Hmong residents took over. By August it was yielding plants important to Hmong culture for foods and medicinal uses. A local company, the Hambro Group, lent the land and provided water and fertilizer, and the California Endowment’s Building Healthy Communities initiative covered other costs, such as the fence.

The gardeners planted mustard, cilantro, cabbage, beets, corn and much more on 24 plots. They also grew many medicinal plants, such as those used to help women regain energy after delivering a child. ₁

It was a wonderful example of giving people the resources, and they’ll quickly take the initiative to create something outstanding. And given the difficult history of the Hmong, this kind of asset creates one more element around which to form a real community. Since August 2012, when I took these photos, the garden relocated to another lot, and I’m told it was tilled and planted just as quickly. I’m waiting for photos to the new site to add to this post.

The Hmong, who aided American forces during the Vietnam War, paid a high price. Many died, and when the war ended the survivors and their families were driven from their homes in the Laotian mountain villages into Thai refugee camps. There they often waited years to immigrate, with most yearning to come to America.₂

—

1. Atherton, Kelley. “Growing their Greens,” Sept. 30, 2011. The Triplicate.
www.triplicate.com/News/Local-News/Growing-their-greens

2. Magagnini, Stephen. “Special Report: The Forgotten People.” Sept. 12, 2004, Sacramento Bee.

Health, Health disparities

Youth outlooks brighten in Del Norte County

by Suzanne Bohan

February 26, 2013

Makenzy Williams inside the Youth News Network studio in Crescent City. The program changes her thinking about the challenged community.

Makenzy Williams, 17, felt like many youth in scenic but economically depressed Del Norte County.

“I wanted to get out and stay out,” she said of the Northern California county, which includes Crescent City.

The Triplicate, the local paper, even recently mentioned the common sentiment. “. . . Del Norte youth carry a common motif of not liking Crescent City and wanting to move away — ASAP,” a July 30, 2012 article stated, quoting a camp counselor at a new youth leadership academy aimed at turning around that mindset.

The Klamath River flows through Del Norte County.

Roosevelt elk rest on a coastal bluff in Del Norte County.

Del Norte, which borders Oregon, is stunning country. Pristine rivers crisscross the land, lakes abound, and its western edge faces the Pacific Ocean. It’s filled with towering redwood and fir forests, many of them now state and federal parks. The area draws many sports fishers as well as kayakers, campers, hikers and other outdoor enthusiasts.

But job opportunities are now few — although several decades ago the once-thriving logging and fishing industries promised good-paying, lifetime work for able-bodied workers. Currently, a job at the unionized Safeway is among the better positions around, one local said.

“It is sad how much it lacks in opportunity for those who live here,” Makenzy wrote in a recent email. “There are a lot of extremely talented young people here, but they have no way to express it.”

Del Norte had been heading on a downward trend since the sharp decline in timber and fishing industry jobs — with youth fleeing and the economy struggling and along with its schools. Substance abuse is a major issue, and many disease rates are higher than average for California, as is depression. Unemployment is also above average.

The county leaders for years have worked hard to reverse the tide. So they were thrilled when they learned that the California Endowment, a Los Angeles nonprofit, decided to invite them to join an ambitious, 10-year, $1 billion initiative to transform ailing communities into ones headed toward a far better, healthier future. (The initiative is described in here.)

A poster describing the youth leadership and news training programs.

Cultivating youth leadership is essential to its success, as they’re the ones with the energy, enthusiasm and long-term stakes to push for lasting change. So the Endowment largely funded a two-week Y.O.U.T.H. Academy in Del Norte last summer, with contributions from several other organizations as well. And the Endowment fully funded the subsequent 8-week Youth News Network program, which taught youth news-production skills such as interviewing, videotaping and editing. Participants also earned an $800 stipend.

Teaching communication skills was a key goal of the news production training, in addition to instructing them in practical skills that could expand job options while creating also important stories about the community.

“If you can’t communicate effectively, you’re not part of the decision-making process,” said Ron Gastineau, a newly-elected city councilman in Crescent City who oversaw the youth leadership and news production programs. “That’s what happened to a lot of them. It opened up their eyes and increased their confidence.”

It changed Makenzy’s life, and did develop her confidence in taking a leadership role. “By the end of the summer, I found myself directing my group, making decisions, and seeing them come to me for guidance,” she said. “That is something I had never thought I’d be capable of doing, but I loved it.

“I also learned that nothing is impossible,” Makenzy said. “With work, and sometimes it can be a lot of work, anything can be accomplished.

Last summer, when I first met her while she was in the program, she also said, “It’s good to meet people who are serious about what they’re doing, people who want to make a difference in their community. I thought they just didn’t care.”

She’s not the only one inspired by the changes the initiative is bringing. Other youth expressed similar sentiments.

Makenzy has decided to pursue a military career, and in June hopes to leave for the United States Air Force Academy. Part of her would like to stay, though, and help develop a youth center, something modeled after the acclaimed Youth Uprising center in Oakland which she visited during the summer program.

“I love Crescent City, I really do,” Makenzy said. “But I also think leaving and coming back is the best thing to do for myself, and perhaps I can bring back my new experiences and ideas to the community.”

TAKEWAY: In economically distressed areas, quality youth leadership training is key to creating a new future.

Health, Health disparities

Health disparities – and solutions – examined in depth

by Suzanne Bohan

February 26, 2013

In June 2012, I embarked on research to examine the wide disparities in health and longevity between neighborhoods just miles apart. It’s not unusual, especially in urban areas, to find that people living 10 or so miles from each other will have up to a 20-year gap in life expectancy.

I reported on this topic as a science and health writer with the Bay Area News Group (Contra Costa Times, San Jose Mercury News and Oakland Tribune) including this four-part series called “Shortened Lives.”

And poorer communities are on the losing end of this gap, coping for with more heart disease, diabetes, cancer, asthma and other diseases, as well as mental challenges. Deprivation and stress account for much of the disease burden. And the term “deprivation” covers a lot of issues – lack of access to good food and safe places to exercise, limited job and educational opportunities, lacking a feeling of security in one’s neighborhood and financial strain, to name a few.

But my research goes far beyond just examining this crisis. It’s focusing on what’s being done to shrink this gap. The problem is well known, but what far fewer know about are promising interventions that are making a difference.

Many advocates rightly point to this wide gap in health and life span as unfinished business of the Civil Rights Movement, as it largely affects blacks and Hispanics in the United States. (But not exclusively: Poor whites in the United States, largely in rural areas, also suffers similar gaps compared to wealthier whites.)

I’ll be examining a few major initiatives around the nation, especially the largest privately-funded one run by the California Endowment. It’s called “Building Healthy Communities,” and I spent much of the summer reporting on it. This current crop of blog posts come from that reporting. Rather than explaining the healthy communities’ campaign with each post, I’ll summarize it here and provide a link in all blog posts that reference it.

It came about because Dr. Robert Ross, the CEO of the California Endowment, grew disillusioned with the limits of what medicine could heal after working in a Camden, NJ community clinic as the crack epidemic broke out in the early 1980s. He realized his Ivy League medical education hadn’t given him the tools to deal with healing the social ills that create so many medical emergencies and chronic sicknesses. So he turned his attention to healing communities, not just individual patients. From that pivot in his career, the Endowment’s “Building Healthy Communities” initiative was ultimately born.

The California Endowment is the state’s largest private foundation, with some $3.7 billion in assets. In 2010, Ross and the board of directors launched the “Building Healthy Communities” campaign, and committed most of the organization’s grantmaking to it – $1 billion over 10 years. The nonprofit thoroughly researched the most distressed communities in the state, and found ones with the organizing strength and resiliency to create a better future – with some outside assistance. In exchange for hard work and inspired thinking on the part of the 14 communities, the Endowment committed to leaving them on a trajectory toward far better health and well-being, especially for the community’s children, when the initiative winds down in 2020.

These are the 14 communities participating in the campaign: Del Norte County, a rural area on the Oregon border; neighborhoods in Sacramento, Oakland, Richmond, Long Beach, Santa Ana and San Diego, near the Mexican border; two in Los Angeles – South Los Angeles and Boyle Heights; five rural or semi-rural communities – Salinas, Coachella Valley, South Kern, Fresno and Merced.

The initiative is deploying the best strategies known to bring about social change at the community-wide level, based upon examining several decades of successes and failures. In short, it rests on local leaders and community-based organizations engaging residents and local politicians to tackle major challenges stymieing progress and growth in the area. It’s all about organization, community enthusiasm, rigorous research and measuring results along the way. The initiative is strongly focused on improving schools, because health is so strongly linked to educational status and the critical thinking that education instills. And prevention is the mantra, as it’s so much more cost-effective and humane than coping with illnesses after they emerge.

And the campaign works with the nonprofits that the Endowment funds, meeting regularly and agreeing upon long-term outcomes to improve the community. The nonprofits still operate independently, but expand their mission to include the broader shared mission. The results can be exciting, as I describe in this post.

The initiative, however, goes beyond community level work by leaders, nonprofits and residents, as they alone don’t have the resources to completely turn things around – not after decades of deprivation. It takes broader policy changes and new infrastructure to secure lasting change, and that can only come from regional, state or federal policy shifts.

To that end, the initiative also deploys a statewide team to educate citizens and lawmakers about important policy decisions in the works.

This is a thumbnail sketch, and you can find more information here. I can attest that there are inspiring and exciting developments underway in these communities, with scores of smart, dedicated people determined to create real change. And there are some fantastic stories that never made the press. Some of these blog posts aim to partially fill that gap.

Health, Health disparities

Oscar winners may gain years in life, along with prized gold statuette

by Suzanne Bohan

February 23, 2013

Katharine Hepburn’s four Best Actress Academy Awards (Morning Glory, 1933; Guess Who’s Coming to Dinner, 1967; The Lion in Winter, 1968; On Golden Pond, 1981) on permanent display at the Smithsonian’s National Portrait Gallery in Washington, D.C.

Academy Award winners this Sunday may not realize it, but they have another reason to

clutch their newly-won Oscars so tightly: That 13-inch gold statuette can actually add years to their lives.

Movie stars who have won an Oscar live on average four years longer than stars nominated but not selected. Katharine Hepburn won a record four Oscars and lived to age 96. Anthony Quinn, the winner of two Academy Awards, won two and lived to 86. But Richard Burton, who was nominated seven times but never won, died at 58.

That research came from the University of Toronto, and the scientists behind it had wondered if the award’s boost to status and self-esteem were enough to increase lifespan. So they compared the length of life for those who won Best Actor or Best Actress awards with those who were nominated for the prize but didn’t win.

The answer was a decided yes, with a four-year life increase in longevity for those winning the prize over those nominated.₁

That’s a stunning advantage, wrote Sir Michael Marmot in his book, The Status Syndrome: How Social Standing Affects Our Health and Longevity. It’s equivalent to wiping out the mortality rates from heart disease. Marmot was knighted in 2000 by the Queen Elizabeth for his pioneering work studying the differences in health along the socioeconomic ladder.

“Winning an Oscar is like reducing your chance of dying from a heart attack from about average to zero,” wrote Marmot. “Not bad.”

That’s not the only study connecting social status and self esteem to longevity. Nobel Prize-winning scientists lived an average of two years longer than scientists nominated but who didn’t win.₂ Another famous study found that among British white-collar workers, executives and managers enjoyed a longer life span than those in mid-level management, while blue-collar workers had the shortest lives.₃

It’s long been accepted that low socioeconomic status predisposes people to health problems and shortened life spans, but it was usually attributed to limited access to health care along with poor lifestyles and diets. But the recent crop of studies show something else is at work, since movie stars, distinguished scientists and white collar workers have similar access to medical care and certainly have incomes sufficient to ensure adequate diets.

And there’s a lesson for everyone.

Donald Redelmeier, MD, one of the scientists conducting the study, which was published in the Annals of Internal Medicine, says the results suggest that the enhanced self-esteem gained by winning a prestigious award exerts a powerful effect in improving health, even in those who already had many advantages in life.

“Once you’ve got a major accomplishment that nobody can take away from you, that gives you a sense of self-esteem and makes you much more resilient to all of the other stressors in life,” he said in a radio interview.₄

That, in turn, could lower levels of stress hormones linked to cardiovascular disease and other health problems, as well as improved immune system function. Oscar winners, he wrote in the study, are also more likely to “preserve their image by continually avoiding disgraceful behaviors and maintaining exemplary conduct.” Low self esteem, in contrast, leads to depression, which weakens motivation to maintain good behaviors.

Obviously, few people will ever win an Oscar, but bioethicist Arthur Caplan, PhD, in an email exchange I had with him a few years ago, said that the Oscar study “does at least suggest that money isn’t everything in life. Achievement and social recognition count too.”

Achieving distinction – such as earning salesperson of the year award, winning an athletic event or an important recognition for your community work – can instill a sense of lasting accomplishment and boost to self-esteem. Achievement also promotes positive thinking, another attribute strongly linked to lowered stress and the practice of protective health behaviors.

To help others, you can also use your knowledge of self-esteem’s link to health to boost other peoples’ well being as well. As Caplan said, “Parents, teachers, politicians, and the media who have the power to honor and acknowledge worth might keep this in mind.”

TAKEAWAY: While a good diet and an active lifestyle are critical underpinnings of a healthy life, social factors such as status and recognition also play an important role.

—

1. Redelmeier, DA, Singh, SM. 2001. Survival in Academy Award-winning actors and actresses. Annals of Internal Medicine 15; 134 (10):955-962.

2. University of Warwick (2007, January 18). Oswald A. and Rablen, M. “Mortality and Immortality.”

3. Marmot, MG, Smith GD, Stansfeld, S, et al. 1991.Health inequalities among British civil servants: the Whitehall II study. Lancet 337(8754):1387-93.

4. Redelmeier, DA. Interview on CBS Radio One by Mary Lou Finlay, May 14, 2001.

Health, Health disparities

Street vendors furtively do business in Los Angeles

by Suzanne Bohan

February 16, 2013

He’s showing us the sherberts he sells, pedaling through neighborhoods. He keeps them cold with dry ice.

We first saw this street vendor standing next to his cart in South Los Angeles one hot afternoon last summer. Someone was purchasing one of the frozen desserts he sold from his bike/street cart, keeping it cold with dry ice.

He was leery, though, when Rudy Espinoza and I approached him, but still lifted a lid to show us the colorful frozen food.

Street vending is illegal in Los Angeles, so this vendor had every reason to worry. These solo entrepreneurs tell of their equipment and products being seized by law enforcement officials, and getting slapped with fines.

Rudy Espinoza, a program officer with the Community Financial Resource Center in South Los Angeles, is working to help street vendors operate legally.

But Espinoza was there to help, and he handed the young man his business card. He’s part of an effort to legalize street vending in Los Angeles, and to steer the vendors toward offering healthy fare in areas with few grocery stores or restaurants. These vendors often serve up foods such as quesadillas and tostadas, for as little as $2 or $3. Espinoza, a senior program officer with the Community Financial Resource Center in South Los Angeles, helps promotes business in the low-income neighborhood with microloans and business development support. He’s leading his organization’s Healthy Food Cart & Street Vendor Initiative, which began in 2011.

South LA, like many inner city neighborhoods, has few grocery stores and residents typically drive long distances or take time-consuming bus rides to shop for groceries. Many don’t have a car or the time, so instead pick up meals at fast-food restaurants or get something from a corner liquor store – often high-fat, high-calorie processed foods. This lack of easy access to affordable, healthful food is blamed as one factor behind the higher obesity rates in poor neighborhoods. One-third of adults in South LA are obese, compared with less than one-quarter overall in Los Angeles County.₁

Espinoza’s organization, in partnership with other groups including the East Los Angeles Community Corporation, is pushing City Hall to legalize street vending, particularly in neighborhoods called “food deserts” given their lack of access to quality food. They’re supported by funding from foundations to promote healthful living and economic revitalization.

The first step in the quest is permitting the street carts to sell at farmers’ markets, after they pass health inspections and other regulatory steps. That’s beginning to happen, but it’s still not the solution. Cart owners say they can’t survive just selling at farmer’s market, which are held once a week and for a few hours. They need daily access to their markets.

In the mid-90s, Los Angeles lawmakers attempted to legalize street vending, but the process was so complicated it sputtered out. And city officials have to factor in the concerns of bricks-and-mortar restaurants and food stores, who pay rent and don’t welcome low-cost competition outside their doors.

But with pressure from vendors and organizations like Espinoza’s, Los Angeles is taking another look. Mayor Antonio Villaraigosa’s spokesman said that the city is re-examining the prospect of legalizing street food vending, according to a Los Angeles Business Times article.₂And this time with an eye toward easing restrictions. To keep the pressure up, on Feb. 28 the East LA Community Corporation is hosting a panel discussion called “Make Good Food Legal.”

Other cities are far ahead of Los Angeles on the issue. New York City, for example, in 2008 started its “Green Cart” initiative, which authorized up to 1,000 licenses for street vendors to sell fresh produce in certain areas. Business blossomed after the law passed, and some 500 carts operate today, run largely by immigrants who work long hours to achieve their dream of financial independence. ₃

That’s the other boon from the legalization of street carts. It gives motivated people a chance to earn a living wage, in their community and with no fear of being fired. And while selling popular, inexpensive items conveniently near peoples’ homes.

But the street vendor Espinoza and I talked with quickly packed up his cart onto the back of his truck and drove away, clearly anxious over our encounter. That ended his prospects for sales that afternoon in that neighborhood.

TAKEAWAY: Street vending, which is popular in many other countries, could play a significant role in increasing access to locally-made, quality foods in areas with few grocery stores. But laws need changing to support it.

—

1. Los Angeles County Department of Public Health, “Trends in Obesity: Adult Obesity Continues to Rise,” September 2012.

2. Los Angeles Business Journal, “Street vendors cook up challenge to sidewalk sales ban: legalization effort turns up heat on Los Angeles City Council,”Oct. 8, 2012. (Not available free online.)

3. New York Times, Opinion Page, “Conquering Food Deserts With Green Carts,” by David Bornstein, April 18, 2012.

What’s your social rank? Status can influence welcome into a doctor’s office

Poor housing endangers health

Hmong garden quickly thrives in Crescent City

Youth outlooks brighten in Del Norte County

Health disparities – and solutions – examined in depth

Street vendors furtively do business in Los Angeles

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