A recent report in Health Affairs highlights a disturbing trend in mortality in the United States: mortality among women is rising in 43 percent of counties, while mortality among men is rising in only 3 percent of counties. Local readers will be pleased to note that female mortality in western Massachusetts’ counties is declining. This striking finding is more interesting because of the factors associated with increasing or decreasing mortality; it’s NOT health care!
None of the mortality changes (rising or falling) in either gender were related to primary care access, percentage of uninsured, or rates of preventable hospitalizations. The factors most associated with a rise in mortality for women were smoking, lower rates of college education, lower density of Hispanics, lower median household income, lower population density, and living in the South or West. Wow, that’s quite a list!
And what about the density of Hispanics? Epidemiologists refer to this as the Hispanic paradox; no one is quite sure why, but one fascinating theory is that a higher rate of breastfeeding and lower rate of birth trauma are causal. The lower rate of birth trauma may be due to differing birth practices, which is even more paradoxical because Hispanics use western obstetrics less often than other ethnic groups. Another epidemiologic observation is that Hispanic neighborhoods have high rates of intact families and social networking.
The importance of these observations is very significant for health systems and public policy. As the authors point out, communities and health systems must broaden their thinking about improving health and use community health assessments (now required by the Accountable Care Act) to focus investments in early education, smoking reduction , poverty reduction, jobs creation, school quality, or obesity reduction. Each community is different, so the health assessments are critical to guiding those investments to be customized for the very local population. As Cooley Dickinson’s Community Health Assessment has shown, there are differences in mortality by neighborhoods, so where to focus the investments can be highly specific.
As a health care provider, this really squeezes my brain. For a community health system to improve health means sitting with our public health partners and community agencies, figuring out our local population’s needs, and targeting our interventions. There are communities where hospitals buy grocery stores and housing to improve health. And maybe we should turn to our Hispanic neighbors to find out what they are doing right.
The urgency for this work is not just the unaffordable cost of health care; now we add the finding that women’s death rates are getting worse in nearly half the country and health care won’t make a difference. It’s time to change our approach and provide an environment for women in America that improves their health.
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