INTRO COMMENTS: Hello and welcome to Modern Healthcare’s Next Up, the podcast for emerging healthcare leaders. My name is Kadesha Smith. I'm your host. I’m also the CEO of CareContent, a digital strategy agency for healthcare organizations.
Today, we are talking about social determinants of health. Where a person is born, where they live, where they learn, where they work, play, worship, where they grow old. The fact is that access to quality healthcare; community resources; and clean water, food, and air — all play a role in how healthy we are.
Now, none of this is new, but COVID has laid bare the stark reality that low income Black and Hispanic Americans in struggling communities are more likely to die of the virus.
Now more than ever, healthcare organizations have become responsible for mitigating these social determinants.
Today, we are talking to Dr. Brian Castrucci, an award-winning epidemiologist with 10 years of experience working in state and local health departments. He’s also President and CEO of the de Beaumont Foundation. The Foundation’s mission is to improve health at the community level. They work to advance policy, build partnerships, and strengthen public health by creating communities that provide people with the opportunity to achieve their best possible health.
We will be discussing how healthcare leaders can use social determinants of health to promote health equity, especially those that have been major drivers of inequities revealed during the COVID-19 pandemic.
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MODERN HEALTHCARE: Now, let’s dive into our conversation with Dr. Brain Castrucci.
MODERN HEALTHCARE: Hello, Dr. Brian Castrucci. How are you doing?
DR. BRIAN CASTRUCCI: I'm doing well. How are you?
MODERN HEALTHCARE: I am good. Thank you so much for making the time. I just want to share some data points to kind of give a lay of the land related to social determinants of health and what's been going on in our current healthcare landscape.
So first, in US counties with the highest poverty rates, we know that the pandemic, the COVID-19 pandemic, has caused 19.3 deaths per 1000 people, but up to 11.1 deaths per 1000 people in higher income counties. So there's a huge income disparity and how COVID-19 fatality is playing out.
We also see this in different racial groups, so in the US, black people are dying at 2.1 times the rate of white people.
And then we also know that costs of COVID — the treatment can exceed $8,000, for an individual and 68% of adults in the US say these costs would be somewhat or very important in deciding where they seek care. So, COVID-19 has kind of created this backdrop for us to have a really robust discussion about social determinants of health.
My first question is that, you know, because COVID-19 has revealed a wide array of social inequities driven by social determinants. We typically think of race, income level education level, but are there any social determinants that we are not considering?
DR. BRIAN CASTRUCCI: I don't know that COVID has revealed these, I think COVID has finally forced us to confront what we've been ignoring for a very long time. Definitely race, income education, but also housing security, food security, gender disparities. We have known about these disparities, we have not done anything to really address them. And now we're paying a very high price.
Take something as simple as, you know, salary inequities. We had 121 consecutive months of economic growth through the end of 2019. But we didn't increase the federal minimum wage. And so as inflation has gone up, the federal minimum wage has stayed the same. Housing has gone up, but we just have remained stagnant. And it just created this kind of perfect storm for COVID-19.
And when people ask, you know, what's the difference between the US and other countries? Part of it is, in our country, COVID was the match, but we've provided decades of kindling with neglectful social policy. So take again, something like housing: We don't have rent control, we're not doing proactive rental inspection. We're not doing the things that we could to ensure that everyone has their chance to achieve their optimal health.
MODERN HEALTHCARE: And so when, in talking with healthcare leaders, this has typically not been a realm where physicians and healthcare administrators have taken the helm.
What are the social determinants that healthcare leaders can have the biggest impact on and then, which ones are sort of out of their wheelhouse?
DR. BRIAN CASTRUCCI: So, it depends how you define healthcare leaders. I would argue that a practicing physician working with his or her patients, ultimately, will have very little impact on the social determinants of health. They can 100% impact that patient's social needs. The social needs are those things that are unique to that patient, and that may be exacerbating their physical condition. And so that is having a food pantry at the hospital, that's providing a night in a hotel, it's doing something that helps that patient get through an acute crisis.
When you think about social determinants, those are impacting everyone simultaneously. So, it's not about a specific health system. It's not about a panel of patients. It's about the community at large.
And so what we really need is not to lean on healthcare for their medical knowledge when it comes to social determinants of health. We need to lean on healthcare for their power, for their ability to possibly put low-interest loans on the street.
You know, take something like asthma, and you have kids who are coming into the ER with asthma, and they're having to be admitted. Ultimately, if the reason they're coming in is because of something in the apartment building that they live in, then there's no clinical remedy to that. You have to actually change the environment. Well, maybe the reason that these kids are all having asthma in one particular apartment complex, could be because the HVAC system is old, but the property owner doesn't have the resources to change it out. So, there is a real argument for healthcare putting low-interest loans on, you know, on the street, to that property owner, so they can change out the HVAC. The hospital makes its money back on the loan, and all of a sudden, we resolve the issue that was driving the children into the ER with asthma. And that's social determinants, right? That's what's doing that.
It's nothing that any one clinician can do. The only thing we can do clinically, is impact social needs. And that's much more of a band-aid than it is a solution.
MODERN HEALTHCARE: In the example you just gave, knowing that a certain group of kids lives in a building that's contributing to their asthma — that requires the clinicians and that hospital or health system to be really close to the ground, really in touch with the needs and challenges of their population. But healthcare leaders are sometimes seen as these like elusive, ivory tower types. They go to their big office in their suit, they're out of touch with the real-world problems like affordable housing and racial bias and things like that.
If you're an aspiring leader, meaning you have your eye on becoming a senior leader in a healthcare organization, how do you keep a pulse on what's happening with the folks outside your circle?
DR. BRIAN CASTRUCCI: I think we gave healthcare an amazing tool with the transition to the electronic medical record. And the data are there. And the data scientists are there. And it's really taking the data that are collected — and hopefully implementing some sort of extended assessment, so that you are assessing not just the physical characteristics of the patient but also their social characteristics. When you take the social characteristics across many patients, you aggregate that data, you geocode it, you'll be able to see in your community where there are hotspots and what the issues are.
I mean, taking that example, with the children who have asthma, I mean, healthcare has that information. Right? Healthcare has the address of every single patient and can look at that information. Now, any one healthcare system's data are incomplete because they don't have the other healthcare systems, you know, in the community. But what a real aspiring leader is going to do in healthcare, and some places have started to do this — how do you aggregate data across healthcare systems, so that you can get a full and complete picture of the community? And then, you know, work with government to actually impact some of the social determinants through policy?
One of the big challenges here is we've kind of conned healthcare into taking on issues that are really not in their wheelhouse. They're not in their purview. Government came to healthcare and said, "Hey, people who have housing issues, they're sicker, and you deal with sick people. So, housing is your issue now." And healthcare went, "Oh, yeah, you're right. It's our issue." No. That was an opportunity for healthcare to push back and go, "Wait a second. It is impacting us, but it's not solely our challenge to take on." This is an issue for local government to take on.
Healthcare needs to start pushing back and saying, you know, we are happy to engage with local governments to develop plans and strategies. But food insecurity is not something that's going to be solved by a healthcare system. Housing insecurity is not going to be solved by a healthcare system. Racism, not going to be solved by just a healthcare system. These are deeply entrenched societal problems that will require a thoughtful societal response.
And so if we continue to look to healthcare to solve these problems, we will ultimately be unsatisfied with our progress.
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MODERN HEALTHCARE: And now, here are more thoughts from Dr. Brian Castrucci.
MODERN HEALTHCARE: So you've argued that a national program supporting paid sick leave is sort of one of the critical factors for fighting COVID-19, you know, just an example of one of the social policies that could be helpful.
What other national policies do you see as being key to surviving this virus, and any others that may come our way in the future?
DR. BRIAN CASTRUCCI: Well, I think first and foremost, we need to fund public health. This was all preventable, and let's remember that. If we had had an infrastructure in place, in governmental public health, we could have avoided some of the consequences that we've seen from the virus. But we have starved the public health system for resources for decades. We knew this was coming. We knew it was a "when." It was never an "if."
We made some really bad decisions. When you think about the fact that we spend about $700 billion every year on defense. But I don't know any foreign nation that has taken a quarter million American lives on American soil. And yet, we pour money into the military every year while we cut public health. We are actually cutting public health workers in some jurisdictions right now at the height of this pandemic. Because the cities don't have the tax base that they previously had. So, number one is, fund public health.
And then we need to be very thoughtful about how we construct our society, so that everyone has a chance to achieve their optimal health. And that's, that is thinking about a livable wage, that's thinking about access to housing. Rent control, policies that don't allow you to increase rent more than the increasing cost of living. There are things we can do to make the playing field more fair. We've just chosen not to do it. We've prioritized profit over people. And as long as that continues, we're not getting healthy.
MODERN HEALTHCARE: So, who do you think is doing this? Like if you look at a health system, a community, a public health department that you think is really putting in the best effort, really seeing some positive results, who would you point to as an example?
DR. BRIAN CASTRUCCI: I have to tip my hat to Kaiser Permanente. I think that with Bechara Choucair's arrival at KP, they have really been thoughtful and engaging with policy. We partner with them on our City Health Initiative, which is a program that identifies nine policies and rates the 40 largest cities as to the number and quality of those policies. And we've been able to change about 59 policies and just the past two years.
And Kaiser's partnership there is because they understand that health does not solely occur inside a clinician’s office. That health is about where you live, and where you work and where you're playing. You know, take, for example, the $200 million that they've invested in low-interest loans for housing development. And so that's not just for Kaiser patients, that's in the Kaiser, you know, footprint. But it's just building housing stock so that everyone in a particular community can be housed and can have security in their home. And ultimately, what Kaiser knows, what they've figured out, is that ultimately, they will see returns on that as a health system. Because if people are housed, they are healthier.
You know, Humana has done similar work with their Bold Goal initiative, trying to improve healthy days lived amongst their footprint. And again, not thinking through that clinical lens, thinking through the social lens.
And that's how we have to change our thinking. It's not about patients. It's about populations, it's about policy. When you want to talk about health and the conversation turns to pills and procedures, we’ve got to turn it back to policies and partnerships. Because that's the path to better health in our nation.
MODERN HEALTHCARE: You know, when I was studying Public Health at Tufts University, I often felt like public health was this really important field that was still trying to find its identity in the mainstream. Do you get that sense that this is sort of a blind spot for even people going into healthcare leadership? It's just not being aware of, sort of, the impact public health can have, their role in it? Or would you say that more healthcare leaders are embracing this?
DR. BRIAN CASTRUCCI: I think it's hard for people to understand the value of preventing something that hasn't happened. And that's a huge challenge for public health.
We also don't have a brain architecture to understand public health. So, if I say to you, "After this podcast, let's you and I go get a pizza." Now, what you're expecting is dough, kind of pressed out thin, with sauce and cheese, because we have a brain architecture that says pizza is this. What we don't have is what is the brain architecture for what is public health. And it doesn't exist. And so some people think it's healthcare for the poor, other people think it's those folks who give shots.
And ultimately, public health works against some of the basic ethos of Americana, of, you know, everything is individual. It's me pulling myself up by the bootstraps, and I will forge everything myself. And that's just, it's not realistic when you live in a society.
And so what we have to help people understand is that public health is like the foundation of your house. It's not something you think about all that often until it cracks. And right now, with COVID, we're seeing all the cracks. I don't know of anything short of the virus that has brought the US economy to a screeching halt, which it did earlier in this pandemic.
When that foundation fails, you have to make some choices. Because if you want to, if you want to have good test scores in school, you need to be healthy. If you want people to do their best job at work, they need to be healthy. If you want people to show up to church on Sunday, they’ve got to be healthy. There's nothing that you can do in our society if you are not healthy. And so we have to not talk to ourselves about public health, but talk to other leaders and help them understand the value and importance of public health.
And I think right now is a prime opportunity to leverage what's happened with COVID. We have to help people understand that if we don't correct the public health system, the vulnerabilities that existed for COVID will continue to perpetuate. And let's be super clear, the mortality rate for COVID, while not inconsequential, has been low. Now, think about this with a 10% mortality rate, or a 15% mortality rate.
We have to invest in public health. And we have to make sure that our frontline, which is that public health frontline — they're the frontline workers, even before the healthcare frontline workers. We need to make sure that that system is there. We would never send soldiers into a battle without the tools they needed to win. But that's precisely what we've done with COVID and our healthcare, and our public health workforce.
MODERN HEALTHCARE: Frontline workers before the frontline workers — give me some ideas of who you're specifically talking about.
DR. BRIAN CASTRUCCI: I'm talking about your state and local governmental health departments, people who make the infrastructure of protection and health promotion throughout our nation. When the planes from Wuhan came to the US, and we had to get Americans off those planes into isolation and quarantine, that was done by the health department. The health department was there to do the surveillance, and to do the testing, and to do the contact tracing. But we had weakened that system, we had starved that system for resources. And so they threw everything they had at trying to prevent the disaster that we have now with COVID. We just didn't give them enough to throw.
MODERN HEALTHCARE: We had a conversation with Emily Brown, who was the former director of the Rio Grande County Public Health Department in Colorado, who talked about this very same issue. Her job became pretty much impossible, especially on top of sort of the politicizing of COVID-19. And then that exacerbated with, you know, the cuts to staffing and resources to be able to track and do proper surveillance — and do the enforcement that public health departments are supposed to be able to do.
Let's talk about what's needed, then.
You know, in a recent episode, also, we talked with CEO of Northwell Health, Michael Dowling, and he said the next generation of healthcare leaders has to be committed to addressing health disparities and addressing social determinants of health.
If you could put together the roster of skills, personality traits for future leaders who want to have this baked into how they approach healthcare, what skills should they have? What traits should they have?
DR. BRIAN CASTRUCCI: I think a good future leader needs to be humble, right off the bat. Many sectors are competing for whose responsibility it is to address the social determinants of health. And it's all of our responsibilities. And so it's really that skill set of how do you play in the band? Not necessarily all do competing, simultaneous solos. So, I think that's about humility.
It's about community engagement and community development. We can no longer design policies, programs, and interventions without a real voice of the community. And not, you know, a task force, but really, at the board level, right? Making sure that the community that the hospital is serving is represented at all levels of the institution and that, you know, there is no "about us without us." And I think that's something that leaders have to embrace. And they have to be able to communicate that throughout the healthcare system, so that they can be strong champions for the community.
I think, additionally, it's really taking a very broad understanding of what healthcare is. I mean, in many, many cities throughout the US, your hospital is your largest employer. And how to mobilize that power. I've worked in government and public health for a decade before joining the de Beaumont Foundation. And I was in many legislative chambers, you know, with colleagues telling everybody that we need more funding in public health. But, of course, we say that. We're the public health people. What I need is, I need the three largest employers in the county to go to the county commission and say, "We, the largest employers in this county, want you to fund public health. Because it's in our best interest."
Right now, the greatest threat to continued prosperity in this country is the fact that our public health system is in shambles. And until, you know, we have leaders who can understand that and view what healthcare's role is comprehensively, I don't think we're moving forward — it’s understanding that. But, on the other side of that, we don't necessarily need healthcare leading in housing and food security, and other issues that aren't necessarily in the expertise of healthcare.
So, it's about how healthcare can lead when appropriate, and then see that leadership when it's appropriate in other areas.
MODERN HEALTHCARE: Thank you so much for just setting the record straight. And I think we'll probably be talking with you again, as the Biden-Harris administration takes a different approach to public health. I'd love to have you back on to sort of hear your thoughts and some of the policies they're pursuing.
BRIAN CASTRUCCI: Anytime. I'd be happy to do it.
MODERN HEALTHCARE: Awesome. Thank you so much.
DR. BRIAN CASTRUCCI: Thank you.
OUTRO COMMENTS: Thank you so much, Dr. Castrucci. Social determinants of health will continue to threaten the lives of countless Americans, but healthcare leaders like Dr. Brain Castrucci will keep promoting public health to address healthcare inequities.
We’d also again like to thank our episode’s sponsor, Masimo.
We invite you to keep checking Modern Healthcare for more articles about the future of healthcare in the US, especially throughout the COVID-19 crisis. We also encourage you to attend Modern Healthcare’s virtual event on Dec. 8 to harness the knowledge and tools needed to address the social determinants of health. For more information, register at ModernHealthcare.com/SDH
Again, I’m your host, Kadesha Smith, CEO of CareContent. We help health systems reach their growth goals through digital strategy and content.
Look for more episodes of Next Up at modernhealthcare.com/podcasts, or subscribe at Apple podcasts or your preferred podcatcher. Thank you again for listening.