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, 我们的播客邀请了来自纽约中部唯一的学术医疗中心的专家. I'm your host, Amber Smith.

在奥农达加县卫生局最近制定的社区健康评估和改进计划中，肥胖率、吸毒率和孕产妇健康被确定为当地最重要的健康问题.

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: 首先，我鼓励所有正在听的人回顾一下社区健康评估报告. 可以在奥内达加县卫生局的网站上找到(http://www).ongov.net/health/documents/OnondagaCountyCHA-CHIP.pdf), and it's really an incredible resource, 它总结了我们的社区在一系列健康指标方面的表现, so there's lots of data.

然后它也进入社区，评估我们的社区对我们的所作所为的主观看法，以及他们关心的问题, and then, finally, reviews some of our assets in terms of environment and resources.

So for me, 这是我作为卫生专员第一次有机会审查社区卫生评估. 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, 我们看到我们社区有色人种居民的健康状况, 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. 你能给我们简要介绍一下我们的社区在这五个方面是如何做的吗? 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.

如果我们纵观全县，我们的高中毕业率与州相当. But for economically disadvantaged students, 他们的毕业率比非经济困难学生低20个百分点，分别为77%和95%. So there is lots of room for improvement.

Host Amber Smith: What about economic stability?

Katie Anderson, MD, PhD: 这是来自社区健康评估的另一个令人担忧的数据, for me, so looking at census data through 2020, 我们看到大约三分之一的锡拉丘兹居民生活在联邦贫困线以下, and that's compared to about 14% of county residents as a whole. 所以，我特别强调了住在锡拉丘兹的人的这些差异.

And then, 在贫困线的统计数据中隐藏着的是，该县有27%的家庭生活在联邦贫困线之上, 但他们没有足够的基本资源来维持生活，并继续挣扎.

And then finally, 我们看到锡拉丘兹儿童的贫困率特别高, 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, 这是一个人的生活经历影响他们健康的更间接的方式之一. But we know that strong relationships with others, family members, a strong community, can help protect individuals against mental, emotional, physical health impacts.

报告中提到的一个指标是创伤和不良的童年经历. And that sounds like somewhat of an abstract concept, 但这些不良的童年经历是发生在童年时期的创伤性事件，可能包括暴力, abuse, growing up in a family with mental health or substance abuse problems, 童年经历的压力会改变大脑发育，影响身体对未来压力的反应.

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, 该报告指出，奥农达加县约40%的成年人报告称，他们经历过两次或两次以上的不良童年经历.

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: 这就是你很难理清“我们如何解决这些问题”的地方?" Because it's all so interwoven and complex.

但与此同时，我觉得当我们看到这些数据时，指令是明确的. So from preconception to even gestation, 我国的一些居民处于不利地位，健康状况不利, 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: 所以这是我们国家在自然环境方面有很多优势的另一个领域, parks, green spaces, we're increasing bike lanes and sidewalks and things like that. 我们也有一些计划希望能改善奥农达加县的建筑环境, 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, 哪一种会降低个人拥有所有权并妥善维护这些财产的可能性.

Host Amber Smith: 现在，健康的最后一个社会决定因素是医疗保健的获取和质量.

Katie Anderson, MD, PhD: 这是我们国家在某些方面做得很好的另一个领域，还有很多改进的空间.

Fortunately, 我们国家98%的孩子都有医疗保险，成年人也有同样高的比例.

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. 因此，在接受调查的成年人中，有二分之一的人表示要等很长时间才能预约. And then, in our county, similar to the rest of the country, 我们面临着医疗人员水平、初级保健和其他预约的挑战.

Host Amber Smith: 评估指出，23%的全县居民在65岁之前死亡, 但黑人居民的过早死亡率要高得多，为48%，西班牙裔居民为41%. What are the reasons for the disparities?

Katie Anderson, MD, PhD: So this is a really troubling statistic, 我认为它反映了许多因素和差异的累积影响，这些因素和差异是我们国家的一些居民从怀孕开始一生中所经历的, or in the womb, to the time that they die.

所以我们知道我们县的有色人种更容易早产, 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, 他们更有可能经历暴力和其他导致童年创伤和影响心理健康的因素.

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.

因此，我们社区有色人种的早期死亡率高出两倍，这绝对是可怕的. 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. 这些差异凸显了改善本区域卫生公平的迫切需要.

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. 造成这种情况的原因与造成生命末期死亡率的原因相同吗?

Katie Anderson, MD, PhD: 它们很可能是相似的，并且在某种程度上与死亡率的差异有关.

奥内达加县有色人种居民与白人居民早产率的差异可能是由于青少年怀孕率较高等原因, as well as access to quality prenatal care.

And, terribly, 同样的差异也可能反映在奥农达加县有色人种居民中观察到的较高的婴儿死亡率上.

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, 我想说，这些数字在种族之间应该是相似的，或者同样优化, across residents of different colors. There's likely, and it's important to say, there's likely room for improvement across the board, 但造成这些种族差异的根本原因并不是生物学上的. They derive from a combination of social, 我们系统的经济和特点，累积起来影响我们的一些居民实现最大健康的潜力.

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, 用同样的方法对待不同的群体和社区的不同成员. 不需要太多的思考就能意识到，虽然这在某种程度上更容易、更直接, things don't work the same for everybody.

Health equity is a more complex but more optimal state, 每个人都有公平和公正的机会达到他们的最高健康水平. But it's harder. It means that we need to consider social determinants of health. 我们需要谈论和认识到不平等，这并不总是令人舒服的. 我们需要承认并解决种族主义等对公众健康构成威胁的问题.

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, 报告称，该县可预防的住院率为144 / 10,000, and that's higher than the state, excluding New York City, which is 120 per 10,000.

什么是可预防的住院治疗?为什么我们有这么多可预防的住院治疗?

Katie Anderson, MD, PhD: “可预防的住院”一词可以涵盖各种各样的临床情况, 但也许与本次讨论和我们国家最相关的是与医疗保健获取有关的问题, 这些情况代表了慢性疾病的恶化，通常应该在医院外妥善处理. So this could include asthma, heart failure, high blood pressure, 这些情况最好由个人和他们的初级保健医生来处理.

So my guess is, and we need to look into this further, 我们较高的数字反映了获得预防保健和初级保健以及预约等待时间的问题.

But this is something we need to delve into further.

Host Amber Smith: Now, obesity is also addressed, 奥内达加县34%的公立学校儿童和60%的成年人超重或肥胖. 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.

我们的高肥胖率可能与健康的经济和环境决定因素有关, so things like: Can individuals access healthy food, fresh fruits and vegetables, 无论是在成本方面，还是在交通方面，考虑到食物沙漠(难以购买负担得起的新鲜食物的地区)，以及健康的体育活动空间.

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, 但你是否怀疑肥胖在我们邻近的县也可能是一个问题?

Katie Anderson, MD, PhD: I think that it likely is. 我认为肥胖和无法获得适当营养是经济上处于不利地位的问题, 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: 很难确切地解释为什么我们的自杀率比其他地区高，或者在某些群体中更高.

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: 我们的卫生部门一直高度关注，试图更好地了解我们地区自杀率的驱动因素，并解决这个问题. So some of our programs, again, 与社区的人们合作，促进学校的适应力训练, 试图通过我们各种各样的项目解决健康的社会决定因素, 然后，我们还完成了一项自杀死亡案例的审查，审查我们国家所有死于自杀的人，这样我们就可以开始确定趋势和主题，并试图找到采取行动的方法.

Host Amber Smith: Now, in looking at substance abuse, 报告指出，阿片类药物过量的急诊室就诊率为59 / 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. 但阿片类药物过量，急诊就诊数据，可能是由两个因素驱动的. 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. 有可能纳洛酮(一种商业品牌的纳洛酮)——在我们的社区里有成千上万的剂量——实际上有有益的效果, more people may survive to get to the emergency department.

Host Amber Smith: 我想问一下你对疫情对我们社区影响的评估. 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, 我的看法和经验是，我们的县和我们的社区确实令人钦佩地应对了大流行的挑战.

它把各个小组聚集在一起，创造性地思考，合作，并迅速作出跨部门的反应, community-based organizations, academia and education, clinical groups, in the county, and I hope, and I intend, 我们继续加强这些伙伴关系，我们继续合作，现在解决其中一些更大的问题, I don't want to say day-to-day because it shouldn't be day-to-day, 但健康评估确实强调了我们需要继续共同努力的事实, 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 hhtactical.net/informed.

This is your host, Amber Smith, thanking you for listening.