Urban Health: Public Health Lessons from Los Angeles

1. Urban Health:Public Health Lessons from Los Angeles Wharton School of Business October 18, 2007 Jonathan E. Fielding, M.D., M.P.H., M.B.A Director of Public Health and Health Officer L.A. County Department of Public Health

2. Los Angeles County – Background • 4,300 square miles • 89 incorporated cities and 2 islands • 9.9 million residents (more than 42 States) • 46% Latino, 32% White, 13% Asian/Pacific Islander, 10% African American, 0.3% American Indian • Over 100 different languages spoken by significant size populations • 15% living in poverty (14% of families & 24% <18) • 22% of adults & 8% of children have no health insurance

3. Why Should We Care About Urban Health? • Urbanization represents a major demographic shift in human history • At beginning of 19th century 5% of people lived in urban areas • At end of 19th century 45% of people were living in urban areas • Today almost 400 cities have pops. > 1 million • Studying urban health requires us to investigate the relation between the urban context and the distribution of health and disease within an urban population Source: Galea & Vlahov. “Urban Health: Evidence, Challenges, and Directions.” Annual Review of PH, 2005 (26).

4. Determinants of Health in Urban Areas • Characteristics of the urban environment that affect population health • Access to health and social services • Physical environment • Land use and community design • Pollution • Housing • Water • Social environment • Poverty • Social cohesion • Education opportunities Source: Galea & Vlahov. “Urban Health: Evidence, Challenges, and Directions.” Annual Review of PH, 2005 (26).

5. South Los Angeles: Poor residents Crowded but much lower density than mid-West and each coast cities Fewer community resources (such as greenspace, food outlets, ERs/trauma centers) Los Angeles suburbs: Higher income residents Housing density lower than inner city More community resources (parks, grocery stores & restaurants, hospitals) What Is Urban Health? Urban area is often characterized by dense inner city surrounded by less dense suburbs

6. Leading Causes of Death Based on Crude Mortality, Los Angeles County, 2004

7. Leading Causes of Premature Death (Before age 75) - Los Angeles County, 2004

8. Leading Causes of Disability-Adjusted Life Years (DALYs) in Los Angeles County, 1998

9. Leading Causes of Death & Premature Death For Males in LA County, 2004

10. Leading Causes of Death & Premature Death For Females in LA County, 2004

11. How We Can Approach Disease • Level 1 – Treating disease condition • e.g. enhancing disease management for diabetes • Level 2 – Reducing risk factors for disease • e.g. improve nutrition and increase physical activity to prevent diabetes • Level 3 – Focus on underlying determinants of disease • e.g. ensure opportunities for people to achieve optimal health by • Supporting anti-poverty programs so people can afford to eat healthfully • Supporting the development of greenspaces and parks so people can be physically active

12. How We Can Reduce the Overall Disease and Injury Burden • Level 1 – Treating disease conditions • Pros: • No substitute for non-preventable conditions • Applying good disease management can reduce burden of many diseases • New medical advances can further reduce burden • Cons: • Usually costly and less cost-effective than working on other levels • For people without regular access to care, the benefits of medical advances are minimized

13. Effectiveness of Chronic Disease Self-Management Programs • Of 780 studies screened, 53 studies contributed data to the random-effects meta-analysis • Data on diabetes, osteoarthritis and hypertension: Self-management interventions led to a statistically and clinically significant pooled effect size of: 1) -0.36 (95% CI, -0.52 to -0.21) for hemoglobin A1c, equivalent to a reduction in HgbA1c level of about 0.81%. 2) Decreased systolic blood pressure by 5 mm Hg (effect size, -0.39 [CI, -0.51 to -0.28]). 3) Decreased diastolic blood pressure by 4.3 mm Hg (effect size, -0.51 [CI, -0.73 to -0.30]). 4) Data on osteoarthritis statistically significant but clinically trivial for pain and function outcomes. Chodosh et al. Meta-analysis: chronic disease self-management programs for older adults. Ann Intern Med. 2005;143:427-438.

14. ROI From Changes in Employee Health Risks on A Company’s Health Care Costs • Estimate of the impact of corporate health-management and risk-reduction programs for The Dow Chemical Company using a prospective return-on-investment (ROI) model • Methods: risk and expenditure estimates derived from multiple regression analyses • Results: “Break-even” scenario would require company o reduce each of 10 population health risks by 0.17% points per year over course of 10 years • Conclusion: results support continued investments in health improvement programs to achieve risk reduction and cost savings Goetzel et al. Estimating the Return-on-Investment from changes in employee health risks on the Dow Chemical Company’s Health Care Costs. J Occup Environ Med. 2005;47:759-768.

15. Level 1 – Treating the Disease:Healthcare Spending • Financial outlay: • 16% (~$2 trillion) of U.S. GDP spent on health care in 20051 • Projected to increase to 20% by 20152 • U.S. has highest health care spending per capita ($6,700 in 2005), more than twice as high as the median OECD country3 • ROI: • U.S. healthcare system performance ranked #37 in world (out of 191 countries)4 • U.S. ranked #38th in world in life expectancy5 1 (Catlin et al. 2007, Health Affairs); 2 (Borger et al. 2006, Health Affairs); 3 (Anderson et al. 2007, Health Affairs), (OECD) Organization for Economic Cooperation and Development; 4 (World Health Report 2000); 5 (United Nations: World Population Prospects: 2006 revision)

17. Level 1 – Treating the Disease:U.S. Healthcare Expenditures, 1970-2004 Source: Smith, et.al., Health Affairs, 2006

18. Level 1 – Treating the Disease:Efficacy of Disease Management • 23% of adults in LAC report being diagnosed with hypertension (2005) • percent of adults taking medication to lower blood pressure has increased from 65% in 1999 to 73% in 2005 • 24% of adults in LAC report being diagnosed with high cholesterol (2005) • only 52% taking medication to lower cholesterol

19. PFP Report – High Impact, Low Cost Clinical Preventive Services Source: Dr. Eduardo Sanchez, PFP (2007)

20. PFP Report – High Impact, Low Cost Clinical Preventive Services Source: Dr. Eduardo Sanchez, PFP (2007)

21. Actual Causes of Death in the United States in 2000 Deaths Estimated Percentage of Cause No. Total Deaths Tobacco 435,000 18 Diet/activity patterns 365,000 15 Alcohol 85,000 4 Microbial agents 75,000 3 Toxic agents 55,000 2 Motor vehicles 43,000 2 Firearms 29,000 1 Sexual behavior 20,000 1 Illicit use of drugs 17,000 <1 Total 1,124,000 47 Sources: Mokdad, Marks, Stroup & Gerberding, JAMA 2004 Mokdad, Marks, Stroup & Gerberding, JAMA 2005

22. How We Can Approach Disease • Level 2 – Addressing the behavioral risk factors for diseases • Pros: • Relatively few risk factors heavily impact incidence of various diseases • Each risk factor affects multiple diseases • Preventing disease often has much better ROI than treating and managing disease • Cons: • Must address both prevention (to reduce incidence) and risk-reduction (to reduce prevalence) • Variable evidence of effectiveness of interventions by behavior • Very large disparities still exist between various demographic groups even after effective intervetions

24. Percent of Adults who Smoke Cigarettes by Gender - LA County, 1997-2005

25. Level 2 – Addressing Risk Factors:Effect of Smoking Reduction Efforts • About 50% of decline in heart disease mortality due to medical treatments, other 50% due to reductions in risk factors1 • NY state ban on smoking at worksites associated with 8% drop in hospital admissions for heart attacks2 • Similar declines seen in cities that have implemented smoking bans (e.g. Bowling Green, OH, Pueblo, CO, Helena, MO) • One study estimates about 40% of the decline in male death rate from lung CA between 1991-2003 due to reductions in tobacco smoking3 1 (Ford et al, 2007 NEJM) 2 (Juster et al, 2007 AJPH) 3 (Thun and Jemal, 2006, Tobacco Control)

26. Percent of Adults who Smoke Cigarettes by Race - LA County, 1997-2005 Large disparities still exist!

27. Level 2 – Addressing Risk Factors:Benefits of Regular Physical Activity • Life span increase: 2 years • Risk of Cardiovascular Disease: 40% less • Rates of High Blood Pressure and Diabetes: Reduced • Risk of breast & colon cancer: Reduced • Mood and mental health status: Improved • Body Mass Index (BMI): Reduced • Health care costs: $300-$400 less per year for adults • Cost: low to moderate; major cost can be individual opportunity cost but cost varies greatly Source: Surgeon General’s Report, 1996

28. One Way to Increase PA

29. What Are the Combined Effects Of Treatment & Risk Factor Reduction? • The best news you never heard • Gradual improvements are not newsworthy • Not high tech • No single intervention to feature • No quick fix

30. Trends in the Leading Causes of Death,Los Angeles County, 1993-2004 * age-adjusted to year 2000 U.S. standard population

31. Behavioral Causes of Death - 2000 Source: Schroeder, NEJM, 9/20/07

32. Life Expectancy at Birth by Sex & Race/Ethnicity - LA County, 2000 Life expectancy in LA County increased by approx 2.6 years from 1991 to 2000 Source: 1991 PEPS and Census 2000 Summary File 1

33. Movements in Wrong Direction • Alzheimers – As population continues to live longer, disease will become more common • Diabetes – Increase allType 2 and directly correlated with increase in overweight and obesity • While not on list, dental disease is very common, often inadequately treated—and mostly preventable

34. Estimated Number Of NewAlzheimer Cases (In Thousands) Source: Hebert et al. (2001). Alzheimer’s Disease and Associated Disorders, 15(4), 169-173.

35. Trends in the Leading Causes of Death,Los Angeles County, 1993-2004 * age-adjusted to year 2000 U.S. standard population

38. Impact of Alzheimer’s Disease • Healthcare costs – medical care; hospitalizations; skilled nursing; home care; long term care costs often lead to depletion of patient’s personal savings and assets • Personal costs – disease progression with memory loss, wandering, behavioral problems, injuries, depression • Caregiving – caregiver stress, caregiver illness, paid and unpaid costs of caregiving • Costs to businesses – absenteeism due to caregiving, etc.

39. Health Disparities Persist • Caveats • Not just about health insurance/access • Latino health paradox • Major difference among Asian American groups • Possible causes • Does culture play a role? • What about environment? • Noxious environment theory • What about income inequities and wealth distribution? • Example of US vs other OECD countries on health indicators

40. Comparison of Economic Equality Within Nations Note: Data presented by PBS based on OECD Reports: Income Distribution in 13 OECD Countries (2000).

41. Source: Schroeder, NEJM, 9/20/07

42. Cost-Related Access Problems, by Income, 2004 (Percent reporting any of 3 access problems because of costs^) * * * * * ^ Access problems include: Had a medical problem but did not visit a doctor; skipped a medical test, treatment, or follow-up recommended by a doctor; or did not fill a prescription because of cost. * Significant difference between below and above average income groups within country at p<.05. Data: 2004 Commonwealth Fund International Health Policy Survey of Adults’ Experiences with Primary Care (Schoen et al. 2004; Huynh et al. 2006).

43. Health Status by Income, 2004 ^ Chronic illnesses include: hypertension, heart disease, diabetes, arthritis, lung problems, and depression. * Significant difference between below and above average income groups within country at p<.05. Data: 2004 Commonwealth Fund International Health Policy Survey of Adults’ Experiences with Primary Care (Schoen et al. 2004; Huynh et al. 2006).

44. How We Can Approach Disease • Level 3 – Focus on the underlying determinants of disease and injury • Pros: • Addressing the underlying determinants of disease can affect positive change for wide variety of diseases • Cons: • Difficult to understand the complex relationships of the underlying determinants and interrelated factors that affect health • Traditional sources of public health funding will not cover cost of these efforts • Requires working on issues that require knowledge and actions in non-health and non-public health sectors

45. Interrelated Factors Affecting Urban Health Source: Dr. Howard Frumkin

46. The Underlying Determinants of Health and Their Contribution to Premature Death Source: Schroeder, NEJM, 9/20/07

47. Level 3 – Addressing the Underlying Determinants:Figuring Out What To Do • LAC DPH decided to create 2 new strategic initiatives to address factors that affect health in the: • Physical Environment • Social Environment

48. Underlying Determinants of Health in the Physical Environment • Air quality • New research showing that small particle pollution contributes to excess mortality • LA area studies showing that proximity to roads increases asthma incidence and symptoms • National and international ramifications as pollution in Midwest affects New England and some of pollution in California originates in China • Water quality • Issues of quantity and conservation • Climate • Global warming impacts public health • Catastrophic events (e.g. hurricanes, heatwaves) have had devastating effects on urban areas

49. Underlying Determinants of Health in the Physical Environment • Urban Planning/Land Use • Walkability • Places for physical activity • Access to mass transit (impacts access to work and health care services) • Zoning requirements • Neighborhood safety • Can impact likelihood of residents being physically active • Housing • Crowded conditions influence communicable diseases • Availability of affordable housing and housing stock

50. The Rising Cost of Housing Percentage of households spending at least 50% of their income on housing in 2006 US average in 2006 = 14% US average in 2000 = 10% Source: US Census data