Drug abuse, obesity, maternal health among key findings
Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.
Rates of obesity and drug use and maternal health are identified as top local health issues in the most recent community health assessment and improvement plan put together by the Onondaga County Health Department.
Here to talk about that assessment and plan is Dr. Katie Anderson. She's the commissioner of health for Onondaga County, and she remains an associate professor of microbiology and immunology, and medicine, at Upstate.
Welcome back to "The Informed Patient," Dr. Anderson.
Katie Anderson, MD, PhD: Thanks for having me.
Host Amber Smith: Your term as health commissioner began in November, so most of this assessment was probably finished before you arrived.
Did anything in the report surprise you?
Katie Anderson, MD, PhD: Well, first, I encourage everyone who's listening to review the Community Health Assessment report. It's available on our website for the Onondaga County Health Department (http://www.ongov.net/health/documents/OnondagaCountyCHA-CHIP.pdf), and it's really an incredible resource, and it summarizes how our community's doing with respect to an array of health metrics, so there's lots of data.
And then it also went out into the community and assessed subjective perspectives on how our community thinks we're doing and what they're concerned about, and then, finally, reviews some of our assets in terms of environment and resources.
So for me, this was my first opportunity to review the Community Health Assessment as health commissioner. And the thing that struck me most wasn't necessarily a surprise, but it was really impactful and sobering, and that was that as we look through the report, and for just about every metric, from gestation to death, we see that the health outcomes for residents of our community who are residents of color, most notably black residents of Syracuse, that they experience worse health outcomes than white residents of the county.
And this isn't a problem that's limited to Onondaga County. It's a national problem, and it's not a new problem. It's unfortunately longstanding, but it's undeniable, and it should be unacceptable, and it should be a call to action.
Host Amber Smith: And it's throughout the report. The disparities kind of show up in many different ways.
Now, health isn't just the absence of disease, and the report describes five social determinants of health. Can you kind of give us a synopsis of how our community is doing with regard to these five? We'll start with education.
Katie Anderson, MD, PhD: Sure. So this is one area where our county is fortunate to have a lot of resources, actually, in the area of education.
We have a large number and variety of post-secondary educational institutions, including those for advanced degrees as well as community colleges, with over 36,000 students. At the same time, even though we have lots of opportunities for education, we've got significant challenges.
If we look overall across the county, our high school graduation rate is on par with the state. But for economically disadvantaged students, their graduation rates are 20 points lower than non-economically disadvantaged students at 77% versus 95%. So there is lots of room for improvement.
Host Amber Smith: What about economic stability?
Katie Anderson, MD, PhD: This was another concerning statistic that came out of the community health assessment, for me, so looking at census data through 2020, we see that about one in three Syracuse residents lives below the federal poverty level, and that's compared to about 14% of county residents as a whole. So, underscoring these disparities for individuals who live in Syracuse, specifically.
And then, hidden in that statistic about the poverty line is that there's 27% of households in the county who live just above the federal poverty line, but don't have enough to cover their basic resources to live and continue to struggle.
And then finally, we see that the poverty rate amongst children in Syracuse is particularly significant, with one in two children of those under 18 living in poverty.
So these are significant problems, and they impact wide aspects of health, including access to fresh, healthy foods, opportunities to engage in physical activity, access to education and employment, and all sorts of other metrics that compound in an individual's health.
Host Amber Smith: What is the social and community context that's listed?
Katie Anderson, MD, PhD: So this is a really important one as well, and this is one of the more indirect ways that an individual's life experience can impact their health. But we know that strong relationships with others, family members, a strong community, can help protect individuals against mental, emotional, physical health impacts.
And one metric that's mentioned in the report is trauma and adverse childhood experiences. And that sounds like somewhat of an abstract concept, but these adverse childhood experiences are traumatic events that occur in childhood and can include violence, abuse, growing up in a family with mental health or substance abuse problems, and the stress from this experienced in childhood can change brain development and impact how the body responds to future stress.
So what you experience as a child impacts your future health. And this in turn impacts things like alcohol, substance abuse in adults, chronic diseases, suicide attempts, mental health. And concerningly, the report lays out that about 40% of Onondaga County adults report they've experienced two or more adverse childhood experiences.
So there's significant trauma for many of our community members.
Host Amber Smith: You know, as we talk about these social determinants of health, it's occurring to me: A lot of this stuff is out of our control, it sounds like where you're born and how you're raised.
Katie Anderson, MD, PhD: That's where it can get really difficult to wrap your head around "How do we tackle these problems?" Because it's all so interwoven and complex.
But at the same time, I feel like the directive is clear as we look at these data. So from preconception to even gestation, some residents of our county are set up to be disadvantaged and to have adverse health outcomes, and that to me is a clear signal that we need to start working on this, and we have some clear direction for where we need to start working.
Host Amber Smith: Now, what about neighborhoods and built environments? That's listed in there as well.
Katie Anderson, MD, PhD: So this is another area where our county has a lot of things going for it in terms of the natural environment, parks, green spaces, we're increasing bike lanes and sidewalks and things like that. And then we also have some plans that will hopefully improve our built environment in Onondaga County, including some urban renovation efforts.
But there's also, again, some significant challenges in Syracuse. So for example, 90% of our homes in the city were built in 1989 or earlier, and one of the main problems with that is, that that places them at higher risk for still having lead paint, for rodent infestations, for mold. And 60% of our homes in Syracuse are also rental units, which can decrease the likelihood that an individual can have ownership and properly maintain those properties.
Host Amber Smith: Now, the last social determinant of health is listed as health care access and quality.
Katie Anderson, MD, PhD: This is another area where our county is doing quite well in some ways and has a lot of room for improvement.
Fortunately, 98% of kids in our county have health insurance and a similarly high percentage of adults.
We have lots of medical resources in our county, with four health systems, a multitude of private practices and specialty services, but, and laid out in the health assessment, despite this apparent abundance of medical resources, there are issues with access and delays. So one in two adults who answered the survey reported long wait times to get appointments. And then, in our county, similar to the rest of the country, we're challenged by medical staffing levels and availability of primary care and other appointments.
Host Amber Smith: The assessment points out that 23% of county residents die before reaching the age of 65, but the premature death rate is much higher for black residents at 48% and Hispanic residents at 41%. What are the reasons for the disparities?
Katie Anderson, MD, PhD: So this is a really troubling statistic, and I think it reflects the cumulative impact of many factors and disparities that are experienced over the course of a lifetime by some residents of our county from the time that they are gestating, or in the womb, to the time that they die.
So we know that residents of color in our county are more likely to experience preterm birth, so, to be born before a due date, be born early, and to have higher rates of infant mortality. They're more likely to experience childhood obesity, and they're more likely to experience violence and other factors that drive childhood trauma and to impact mental health.
Lastly, they're also more likely, this is just another metric of many, to experience higher mortality rates related to cancer. This is also in the report.
So this twofold higher rate of early mortality for residents of color in our community is absolutely terrible. But it's also important to underscore that this is not an innate difference.
Everybody should be likely to experience the same long, healthy life. These disparities underscore the critical need for improved health equity in our region.
Host Amber Smith: So the disparities at the end of life. There's also disparities at the beginning, or before birth, with racial and ethnic disparities in maternal and infant health. The preterm birth rate among black moms is 11%, among Hispanic moms it's 12%, compared with just 8% among white mothers. Are the reasons for this the same as the reasons for the death rate at the end of life?
Katie Anderson, MD, PhD: They're likely similar and somewhat related to the concerning differences in mortality rates.
The differences in preterm birth rates across residents of color versus white residents of Onondaga County are possibly due to things like higher rates of teenage pregnancy, as well as access to quality prenatal care.
And, terribly, these same disparities are also likely reflected in the higher rates of infant mortality that are observed among residents of color in Onondaga County.
Host Amber Smith: Should these numbers be similar among the races? Should it all be equal?
Katie Anderson, MD, PhD: That's an important question, and I would say these numbers should be similar among the races or equally optimized, across residents of different colors. There's likely, and it's important to say, there's likely room for improvement across the board, but there are no inherently biological reasons driving these racial disparities. They derive from a combination of social, economic and features of our system that cumulatively come together to impact the potential for some of our residents to achieve their maximum health.
Host Amber Smith: So what is health equity? And do you think it's achievable?
Katie Anderson, MD, PhD: It's maybe most helpful to contrast the term "health equity" with "equality," and equality means that we go about providing the same resources, the same approach to different groups and to different members of our community. It doesn't take too much thought to recognize that while this is somewhat easier and more straightforward, things don't work the same for everybody.
Health equity is a more complex but more optimal state, where everybody has a fair and just opportunity to attain their highest health. But it's harder. It means that we need to consider social determinants of health. We need to talk about and recognize disparities, and it's not comfortable always. We need to acknowledge and address things like racism as a threat to public health.
So it's not easy, but it has to be our primary goal.
Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.
I'm talking with Dr. Katie Anderson. She's the Onondaga County health commissioner. Now, the report says the county's rate of preventable hospitalizations is 144 per 10,000, and that's higher than the state, excluding New York City, which is 120 per 10,000.
What are preventable hospitalizations, and why do we have so many more of them?
Katie Anderson, MD, PhD: The term "preventable hospitalizations" can cover a wide variety of clinical conditions, but maybe the most relevant ones for this discussion and for our county are related to issues of health care access, and these would be conditions that represent worsenings of chronic medical conditions that typically and should be managed well outside of the hospital. So this could include asthma, heart failure, high blood pressure, conditions which optimally would be managed by an individual and their primary care doctor.
So my guess is, and we need to look into this further, that our higher numbers reflect issues with access to preventive care and primary care and also wait times for appointments.
But this is something we need to delve into further.
Host Amber Smith: Now, obesity is also addressed, with 34% of public school kids and 60% of adults in Onondaga County being overweight or obese. What are the public health implications of this?
Katie Anderson, MD, PhD: I think that this is really important, again, thinking about how early health can impact later health, because childhood obesity is tied to higher rates of diabetes, heart disease, other serious chronic medical conditions, and it's a real cause for concern, and there are disparities in rates of obesity as well.
Our high rates of obesity are likely tied to economic and environmental determinants of health, so things like: Can individuals access healthy food, fresh fruits and vegetables, both in terms of the cost as well as transportation and thinking about food deserts (areas where it is difficult to buy affordable fresh food) as well as healthy spaces for physical activity.
We already have programs in place, both the county and many people out in the community, to increase physical activity and nutrition in schools, but these need to continue to be prioritized.
Host Amber Smith: I know this report focuses on Onondaga County. Do you have any idea, does it apply, do we see the same sorts of things, do you think, in the counties bordering Onondaga?
They're more rural, so I know there'll be some variants there, but do you suspect that obesity might be an issue in our adjacent counties as well?
Katie Anderson, MD, PhD: I think that it likely is. I think that obesity and issues with access to proper nutrition are things that go along with being economically disadvantaged, which certainly rural communities as well as city communities can experience, and I'm guessing that's an issue everywhere.
Host Amber Smith: The suicide rate in Onondaga County is 11 per 100,000 population, which compares with eight per 100,000 population for the rest of the state, so that seems pretty significantly higher. What are the reasons that the suicide rates might be higher here?
Katie Anderson, MD, PhD: It's difficult to pin down exactly why our suicide rates are higher than other areas or higher in some groups.
But it could be driven by things like higher rates of substance use, financial issues, mental health, lack of community supports or social supports. And easy access to lethal means, like guns or drugs, can place some groups at higher risk for suicide.
Host Amber Smith: Are there things that public health can do to try to reverse this trend?
Katie Anderson, MD, PhD: Our health department is maintaining a high focus on trying to better understand the drivers of the suicide rate in our area and to address it. So some of our programs, again, in collaboration with folks in the community are to promote resilience training in schools, to try to address social determinants of health through a wide variety of our programs, and then we also complete a suicide fatality case review of everyone who dies by suicide in our county so that we can start to identify trends and themes and try to find ways to act.
Host Amber Smith: Now, in looking at substance abuse, the report notes that emergency department visits for opioid overdoses is 59 per 100,000 population compared with 55 per 100,000 population for the rest of the state.
What are your thoughts on those numbers?
Katie Anderson, MD, PhD: First, and again, I refer folks back to look at the Community Health Assessment, because this is one figure that is very dramatic, in terms of looking at the number of, in this case, opioid-related fatalities from 2012 to 2021, and the dramatic rise.
So substance use has been on the rise in our area, as have overdoses, and this largely relates to an influx of fentanyl. But the opioid overdose, emergency department visit data, is likely driven by two things. One, a true and high level of substance use and overdose in our area. But also, and this is maybe a little bit counterintuitive, we have been, and others have been, really trying to get naloxone, which is a lifesaving drug reversal, that can be administered to individuals who are overdosing. And it's possible that as Narcan (a commercial brand of naloxone) -- there's thousands and thousands of doses in our community -- actually has a beneficial effect, more people may survive to get to the emergency department.
Host Amber Smith: Let me ask you about your assessment for how the pandemic affected our community. We've just passed the third-year anniversary. Are there any public health lessons that were learned in the past three years?
Katie Anderson, MD, PhD: I think there have to be. It's amazing to think that it was three years. So when I reflect on the pandemic now, especially in my new role with the health department, my perception and my experience was that our county and our community really rose to the challenge of the pandemic admirably.
And it brought groups together to think creatively and collaborate and respond quickly across sectors, community-based organizations, academia and education, clinical groups, in the county, and I hope, and I intend, that we continue to strengthen these partnerships and we continue to collaborate and now to address some of these larger, I don't want to say day-to-day because it shouldn't be day-to-day, but the health assessment really underscores the fact that we need to continue to work together, and we also need to be continuing to prepare for the next health emergency, because there will be others.
Host Amber Smith: Well, Dr. Anderson, I thank you very much for making time for this interview.
Katie Anderson, MD, PhD: Thank you.
Host Amber Smith: My guest has been Onondaga County Health Commissioner, and Upstate associate professor of microbiology and immunology, and medicine, Dr. Katie Anderson.
"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.
Find our archive of previous episodes at upstate.edu/informed.
This is your host, Amber Smith, thanking you for listening.