Well, good morning. In the interest of time, we're going to go ahead and get started. It's my distinct pleasure to read about the Murray Goldstein Commemorative Lecture in Public Health and General Preventive Medicine. Dr. Goldstein is near and dear to a lot of our hearts, still serves as a special advisor to our board. So except for Dr. Berkowitz, he's the only other one that I know of that was in the class of 1950. This lecture is given each year in honor of Rear Admiral Murray Goldstein, DOMPH fellow, distinguished of our college. He's a founding member of the College and Division of Public Health and General Preventive Medicine. Dr. Goldstein was designated as a fellow in 1985 and served as president of the college in 1990. He was later bestowed the honor of being a distinguished fellow in the inaugural class. Rear Admiral Goldstein is an osteopathic physician with postdoctoral clinical training in internal medicine and neurology and research training in epidemiology and clinical research. Rear Admiral Goldstein was the first DO to reach flag rank, serving as the Assistant Surgeon General of the U.S. Public Health Service at the National Institutes of Health for 40 years. He served for 11 years as director of the National Institute of Neurological Diseases and Stroke and was the federal government's focal point for brain research. Dr. Goldstein also serves on the National Center for Complementary and Alternative Medicine Education and Training Review Committee from 07 to 11, and he's an advisory board to the National Headache Foundation. This is a named lecture given at the midyear convention of the American Osteopathic College of Occupational and Preventive Medicine by someone who exemplifies service in the field of public health and preventive medicine. This year our lecture is on social determinants of health and is given by Dr. Rex Archer. Rex D. Archer, MD, MPH, is the director of population public health and professor for their curriculum and integrated learning at the College of Osteopathic Medicine, Kansas City University. Retired from KCMO after 23 years as director of the health for the city of Kansas City, Missouri, he was responsible for safeguarding the public health of nearly half a million residents and the daytime population of almost 1 million. He has served as a physician in charge of employee health programs for the Ford Motor Company and has held local and state public health positions in Maryland. Thank you so much for presenting to us, sir. Thank you. Wow. Great. So I am not the reincarnation of Johnny Ash, and I can't play the guitar and you would not want to hear me sing, but I'm wearing black on purpose today, and it's because we're collectively going to a funeral for a million plus lives that were lost in this country that could have been prevented if we had done as well as a couple of other nations did. So in that spirit, I'm going to challenge us this morning about what we need to do differently in the future. You'll notice I played around with the title because I'm not really comfortable anymore with the title of Social Determinants of Health. They don't totally determine the influence. Some books now are talking about social and structural determinants of health. For a number of years, I've really talked this way about social, political, and economic because I think all of those are involved. So the objectives today are to talk about why our modern healthcare system needs to think beyond the care for individual patients on an ad hoc basis and understand these components if we're really going to promote health of our patients and community, and explore some of the newly emerging social determinants of health, and I'm going to leave you with homework of potentially five areas or strategies that I hope you'll get engaged with if you're not already. Go back to the future, I love this quote from Andrew Steele, find health should be the object of the doctor. Anyone can find disease. I actually think that that's really the title of this college and of preventive medicine and occupational health. Oh, I'll back up for a second. This is actually in our strategic plan for the next five years as part of our moving forward as a university. Why is this professional education changing? Obviously, there's evolving science on disease and injury. There's more emphasis on national boards. Our students are actually demanding this. And we can't assure the best outcomes unless we start getting further upstream. I don't know if you've seen this before, but to me, traditional injury and illness care looks down on that cone and sees a circle. From a population public health, we look at the side and we see a triangle. So it really does take both perspectives to totally understand what we're dealing with. So my challenge this morning is to cover a review of over 16,000 articles, but obviously that can't be done. But I'm going to try to hit the highlights and pull it together in a way that you can then fit these things into place. You can see the exponential growth of articles on social determinants of health. That last bar looks like it's a drop off, but that's actually just half year. So if you actually then calendarize it, you could see it would be above that. So we've got to move beyond thinking about diseases as the main thing to be focusing on. We've all probably seen variations of this. It's preventive medicine and occupational health 101 that we're talking about secondary and primary prevention and the ethical questions of where in this process do we actually intervene? And unfortunately or fortunately, social determinants and structural determinants of health actually influence all these stages. And in fact, actually the ordinary prevention, as you know, which is eliminating medical errors. I think both of omission and commission. One of my favorite science fiction authors talks about, I've never learned from a man who agreed with me. So my hope and design is that I actually challenge some of you where I'll say something that you're not going to agree with, and you're going to have to go back and do some homework. And then you can argue with me either now or after the lecture or in the future. The so-called father of cellular pathology, Dr. Verkhoff, says that for medicine is really to accomplish its great task, it must intervene in political and social life, must point out the hindrances that impede normal social functioning, vital processes and the effect of the removal. And I mentioned this with the humble and caveat that Verkhoff didn't believe in the germ theory. So nobody is perfect. I'm sure there will be things that I will say today that a decade from now will be proven to be, well, maybe not fully true, but I'm going to do my best. Let's start with problem number one. What do you mean by politics? If you define politics as dirty, partisan, divisive, dishonest, power-grabbing attempts to make us winners and them losers, then no, that doesn't have a place in this. However, if we really think about politics as the way groups of people organize their lives together, as an organization, you have politics. You elect officers and you have processes by which you make collective decisions. Second problem, sometimes it's said that physicians aren't or shouldn't be political. But how do we really influence things if we're not? I love this quote, there are no Republican or Democratic thermometers, although there may be in the future the way things have been going. I'm a big proponent of individual responsibility, but I draw the line at telling our patients and communities that it's their responsibility to boil their own water, that we can't provide it for them more cost-effectively, and even if they want to buy it, that we will regulate those that are selling it. I'm going to give you a list of a couple of countries, I want you to be thinking about what are these lists and which is more important. This list has the U.S. number one, followed by China, Russia, Great Britain, Japan, etc. And I actually give a lecture now in the ACOM has an academic recognition program for third-year students on population and health equity types of issues. I do the intro lecture and I ask them, okay, which of these do you think is part of that list? And I show them the next list, with the U.S. down at 46, then I show them, okay, which of those? And it turns out that, as you may have guessed, this was the Olympic medal count. Unfortunately, think about March Madness, we are more a sports, a competitive sports culture than we are a health culture in this country. Notice that the second list, though, top five in the first list, only one, Japan, is still in the top five. And in fact, the U.S. not only is down to 46, but the recent projections in Lancet, and these projections have been pretty good over the last couple of decades, is now projecting that we're going to drop to 64th. In 63 other countries, you're better off being born and lived in because you'll live longer than in the U.S. I'm not going to show this video, but if you've not done it, I would recommend that you think about clicking to the YouTube video here. It's a great little four-and-a-half-minute video that can help you in explaining some of these issues I'm talking about to other audiences. Spoiler alert, the narrator is George Takai, Captain Zulu from Star Trek. I tell you that because sometimes people are trying to figure out, well, who's this voice? I recognize it. And then they don't hear the video as well, so I just kind of give you an alert on that. So, how's the U.S. been doing? Well, as you can see, we're bottom, that black line down there, and it's even been going down the last few years, so we're losing track and status, as mentioned. How many of you have heard of the River Parable in public health? I had a few head nods. I was lucky enough when I was in medical school to have been introduced to this. The Minister of Health of Canada was getting an international award that was published in the Journal of Preventive Medicine, and he gave this parable as part of that. And I was able to track it back, actually, to a medical sociologist in 1971 in New Zealand. But it basically goes like this. You've seen Brush Creek down at the plaza. 1977, we had 25 people drown there in a flash flood. So, let's say that we were out after it rained and walking along, and we heard a cry for help. And sure enough, there's somebody in trouble. And we go over, and we figure out who's the best swimmer, and we take our belts and purse straps, and we make a rope, person dives in, and we save a life. We're about to have a group celebration. We hear more cries for help, and we look, and there's dozens of people grounding before they even get to our point. We're working like crazy, splitting up into two or three teams, and still, folks are dying afterwards past our point. So, if we think about this, we understand in the medical model that unhealthy behaviors, risk factors lead to disease and injury and lead to death. If you think about quality improvement in the five whys, why death, disease, and injury? Why that? Unhealthy behavior, why that? I agree with you that it is more than physicians, but I would say it cannot be without them. The challenge, which I said I would like for challenges, is that it is not the physician that is the main player in regards to power and leadership, but it is attorneys or lawyers. I do think they have a role, but I will get to that in a little while here. In 1990, we had a warning, over 30 years ago, that the worse we may get in regards to life expectancy. In this article, it talks about the challenges that we have had with this pandemic and can we learn from it and make system changes that we need to. This gets at your question, have we allowed the dominant community to narrow the role of the physician in such a way that they are not responsible for preventing disease and protecting patients, or just on an individual basis? I worked with Jonathan Fielding when I was at Ford Motor Company, he was Vice President of Johnson & Johnson, has now been a major contributor to the U.S. School of Public Health, it's named after him. But I want to put this out here because this is our economic challenge. If we think about it, where we are in spending compared to other countries, to get by 2040 to where at least a few other countries, so that we're only ahead of 90% of the high-income countries, as opposed to all of them on expenditures of illness care and injury care, we'd have to reduce by 1.3% a year. We'd have to go down by 3.3% a year to get to countries, all of which do better than we do on health outcomes. So we can't just eliminate waste, we actually have to reduce the demand on health care. How do we do that? Through the things that you guys are all trained in regards to preventive medicine and public health. So if we think about this, following up years later, Zimmerman is doing the same thing. We clearly have reached the point where the more we spend, the more we reduce our life expectancy in this country. We're actually losing our international competitiveness, because the companies that end up providing health care and health insurance in this country, where they're covered in other ways in other countries, or those countries are healthier, we now have a competitive disadvantage. When I was at Ford back in the 80s, the only thing that was covered in health care was the steel we put into vehicles at the time. That obviously is larger than any of those other factors in an automobile. If you think about this, we started our health department here back after Galea published in 2011, these factors for premature death. So this is the same thing as rates, cholesterol, high blood pressure rates, diabetes in our community. And we could predict life expectancy in that community pretty accurately over the next few years if we knew that. Well, it turns out that these six factors, from not graduating to high school, from our racial segregation, sins of the current and past, social support factors, individual poverty, community poverty, and income inequality, that somewhere between two or three of our deaths every year in Kansas City, these are actually the root causes. Obeying isn't an option unless we get and deal with these fundamental issues. So if we look at our death certificates in Kansas City, Missouri, what you'll see is that our lowest life expectancy zip codes are those brown bars, so the rates are about twice as high across the country as our lowest life expectancy zip codes, with one exception. And why is that? Well, you know, we all understand allostatic load, toxic stress, when we talk with lay folks, but that allostatic load is messing up people's cortisol and norepinephrine and keeping them at elevated levels and not letting them return to baseline, then throws the secondary mediators out of whack, which then create these, and I don't really call these disease and causes of death, I call these diseases symptoms of death, because they're, you know, if we had on our death certificates, the cause of heart stop, or they stop breathing, you know, that's not the cause, that's that point, we've got to intervene and prevent, we've got to move further upstream. You'll notice, I have felt for years and felt that the stress of living in high violence areas was contributing to all these other endpoints. And sure enough, we've got now last year an article, so the 320 square miles in Kansas City, Missouri, what you'll see here is that just across the plaza down with the hotel is not too far south of that is our longest life expectancy zip code, and just a few miles to the east is our second lowest life expectancy zip code in the city. We actually have a 19 year difference in life expectancy between our longest and shortest living zip. So Dr. Block, former president of the American Academy of Pediatrics, talking about the adverse childhood experiences, and if you think about this, you think about all these conditions, if we basically in this country eliminated the adverse childhood experiences, or brought them down to the baselines of many of these other countries where they live, we'd have plenty of resources for a lot less money to treat those that still became ill. And in fact, just as one example, let's look at divorce. Well, it turns out that UCLA RAND study showed that states that increased the minimum hourly rate for divorce rates dropped by 7% to 15%. The question I have is, how many of you have been increasing the living wage, or more living wage? Now, I've been out, we've had a lot of the meetings here, couldn't get things because the state legislature actually preempted us from raising it locally. We had to organize statewide to put it on the voter's degree. If we think about these adverse childhood experiences, in general, basically none. They have those advantages, about one, about half are the three categories in this country that have four to 10, and a significant number that actually have seven or more. What you'll see here from a relative risk standpoint is your 2.7 times as likely to become addicted to nicotine if you had seven cases than if you had none. You can go down that list, you can see heart attacks, 2.3 times as likely. Attempting suicide, 19 times as likely to attempt suicide if you had seven or more cases than if you had none. Parts of our city and our lowest life expectancy zip codes, these are reversed almost. Maybe only one out of six of those kids have none, maybe a third have half, and over half have four or more. When we think about this river parable, we can think about downstream providing clinical care and medical interventions. We can move further upstream, individual needs, screening patients for these conditions, trying to get them to resources in the community. But ultimately, we have to move up, deal with the lawyers on the tactics, the law, the politics, the regulations that import this disease challenge and burden on us. Robert Wood Johnson Foundation, really the largest and paying for healthy types of policies and procedures in the country, has this great model they developed back in 2014 with the University of Wisconsin. What you'll see is that the top 50% is based on life expectancy and 50% on quality of life. Those come from health factors, whether it's health behaviors, clinical care, social economic factors, and the physical environment. You'll see the percentages there of health behaviors with this model to about 30% social economic, 40, physical environment, 10. This was back in 2014 before about 15,000 of those social determinants of health articles were published. I actually believe if we revisited this, that health behaviors would drop a little bit, clinical care would drop, social economic factors as well as the physical environment. Going back to VRCA, all diseases have to be taken into consideration, not saying all diseases, but the vast majority do. We have to be social political influencers of health, and we have to be experts in these areas. Now, we have to individually be expert, we have to partner with others in these areas. We do have to come together and affect all of these. They then create psychosocial stress, they create these injustices. Why? Because of health analysis. We can't just look at those bottom lines, we have to be politically involved in all of these. We're actually going to improve health in this country. All of these come from our social structures, our institutional racism, class oppression, gender discrimination, exploitation, et cetera. All the isms. This is a very busy slide, and we could have spent the whole lecture on this one, but I want to say this to you because this chief health strategist role that I believe that all of us in this room can be a part of, it doesn't mean you have to be the only one or the lead. You may be partnering with your local health department director, you may be partnering with your chief medical officer for a hospital, et cetera, elected officials, but it's not just enough to understand the strategy, you actually have to catalyze the change. And you can work with there on the left, you can work with businesses, any of our accomplishments here in Kansas City were because our chamber bought into and got involved. We passed tobacco 21, raising that, they knew that they were going to be paying for that tobacco epidemic in their workforce, if they didn't prevent a problem. Sometimes the chamber didn't fully agree or were mixed, but they would still fight. Oh, on the living wage as an example, they didn't come out fully supporting it, but they decided to stay silent. So you can partner with groups that maybe you just neutralize them or get them to realize not to get into the battle or fight. Social movements have been the biggest improvement of health in the country over the years. I think it's extremely important. We're just over 100 years now from one of the biggest social movements in improved health, and that's women getting the right to vote. Would we have had child labor laws? Would we had a lot of the things that got passed over the years if women weren't voting? Working with social movements, how many of you have actually been out and been on a picket line group protesting about an issue? It's an experience. Okay, in the 60s. Well, I'll take that. And, yes. You know, I've had a meeting and we went out and protested and got the media out about Home Depot being with different suppliers to clean their facilities after hours, but then those suppliers weren't paying their workers or making them buy their own cleaning material. And we actually protest against that. So public health crisis. If you've not read Joshua Sharfstein's book, he's a professor at Johns Hopkins, was more state health department director in Maryland, as well as Baltimore city health department director and a deputy for the FDA. And I love this because each one of you that are interested in this, just not figuring out when you've got a crisis going on, but also managing the crisis so that you pivot to prevent the next crisis. And we're really almost at the point of losing that ability now with this pandemic. So if you think about this, our epidemic with COVID was not the virus itself as much as all these other inequities in our community that caused our deaths. I published an article in Johns Hopkins journal, health security back a few years ago on the fact that we don't have paid sick leave. And you'll see 159 countries that do, and we don't. How do we manage outbreaks? If the local public health authority doesn't have the ability to make sure that people can stay paid and not end up getting evicted because there's an outbreak of measles. Now they're being evicted because they can't pay rent, because they can't go to work and their work won't pay for them being off. And this shows us as one of the major outliers of this. Again, if we don't fix this as a country, we're gonna have even more deaths potentially. Osteopathic physicians have been ahead of the game back 10 plus years ago. They came with this framework. I will tell you though that complex is still a little behind at putting these things into the questions. And I don't know how many of you may be involved with writing or actions, but I really encourage you to get engaged with that and to help push this forward because the U.S. MLA is further ahead in now adopting this so that they're moving forward a little faster. Thank you. I'm not gonna go into detail. Dr. Frieden developed this when he was New York City Health Commissioner and then used it at CDC. I've added to the bottom of the pyramid the contributive and social justice issues. I think the bottom line is that yes, those things at the top of the pyramid are important, but they actually have smaller impact than the things at the bottom. Part of the reason why is those things at the top take more effort than the things at the top. So if you think about it, as you move down this pyramid, coming into this building, particularly if you were upstairs, you're gonna find the stairs easier than finding the elevator. So it's structured to promote healthier behaviors, whereas in some buildings, it's just the opposite. You can't really find the stairs or they're even locked on some levels so you can't get to them unless you're trying to exit it from a fire stem. Another way of visualizing this is to think about, you can throw all the money, which we are doing, the $4 trillion at the tree on the left, as opposed to countries that have healthier roots and trunk. And that's part of this challenge. So unless we're focusing on these issues and getting engaged, I can tell you when advocates are pushing on these things, when you're in front of an elected body and officials, you can make a big difference. We first got our non-smoking laws here in city Missouri. It was actually the medical society that partnered with me as my elected officials kind of see me at that time as the quote hired to do those things. When the medical society showed up, they listened and often would even listen along as I was speaking on an issue. Many of you have heard of the bathtub test. I was at my doctor and I asked her, how do you determine whether an older person should be put in an old age home? And she said, well, open a bathtub, give them a teaspoon, teacup, a bucket. Oh, I understand a normal person would use a bucket because it's bigger than the spoon or teacup. No, a normal person would pull the plug of the faucet. You want to bed by the window? But as a nation, we fail this test. One of the challenges is today, if we look at a primary care doc that's got a panel of 2,500 patients, just to do the primary care, product disease management, the acute care document, it's only 26 hours a day. Even if you have a good team, probably still going to be nine to 10. Oh, again. So if you think about it, we're spending at least 95% of our time, physician education and our dollars down here. Whereas at least half of the cause of our disease is up here. So what are some of the strategies? So five strategies. First of all, how many of you have actually gone to, every year and coming up here, the most recent County Health Rankings is going to be published by the University of Wisconsin and Robert Wood Johnson Foundation. And so you can look up those County Health Rankings for every county in this country. You can find out whether or not your health department in that area that has responsibility is using that data. Are they moving forward to become that? I'm the immediate vice past chair of the International Now Public Health Accreditation Board. We actually have accredited the foreign nation now and we've accredited federal military bases. And so going through the accreditation process, just like a hospital would do, local health departments are supposed to be doing that with their communities. And if they're not, then physician leadership and medical staff would be pushing the elected officials to do that. And the different kinds of exploitation, well, they've mentioned Missouri State Legislature actually preempts us from passing required. So what are our code of ethics say? Physicians should respect the law. That doesn't mean that we have to obey the law. And respect it, then we will stand on issues. And some physicians are at a time. When necessary, a physician shall attempt to help formulate the law by all proper means in order to improve patient care and public health. In the state of Missouri, well, directors of health departments, of which some are fewer physicians, but most are not, were actually gagged from speaking out for or against certain legislation once it's been introduced. I violated that all the time. I figured if they end up taking me to jail, a jury panel would probably let me off because I just had to face the consequences. You may not be aware, one of these newly emerging social determinants is voter registration. And if you map out all the states, base them on four different parameters in regards to access to voting, you can see a strong relationship correlation between life expectancy longer in states that have better voter registration and longer in states that have better voter access and states that don't before. And I actually think this is pretty close to being actually a strong probably in both directions. It also ties with infant mortality. So if you've not seen this, you can actually get a voter on to this group and you can have that and it'll have the code there so that patients that they've got their phone and actually hook on it and be able to go through the process to get registered to vote. AMA has a policy on social determinants of health and that they actually contribute to other social determinants of health. American Public Health Association has a longer policy document. It's about, I encourage you to look at that because it's got 61 references that helped build this case of why access to voting actually influences health of communities. So those last two strategies are working on voter access and then resolutions in the bodies that you support to move this issue forward. With this policy statement that American Osteopathic Association has. At the end there, they say that social determinants of health physicians role in eliminating healthcare disparities, but one, they're making it narrow to just healthcare disparities, not overall health disparities. What probably the most frequently misquoted quote is about Martin Luther King and Dr. King's quote about inadequacies in health or injustices. He didn't say healthcare, but it's often misquoted as healthcare. That I don't even use the term disparities on health anymore is because I think it's too value neutral. We really need to be talking about health inequities and injustices. And I like Dr. Whitehead's definition there that health inequity is the differences in population, health status, mortality rates that are systemic pattern, unfair, unjust and actionable, as opposed to random or caused by the person that became ill. So I'm gonna stop there from Thomas Merton. When I criticize a system, I think I criticize them. That is of course, because fully accept the system and identify themselves with that. Other comments, questions, disagreements, arguments? Yes. Oh, good. Okay. I wouldn't, because I don't think that's going to get us where we need to go. The root causes influence the diseases. And for years, we downplayed smoking as an example. And I launched my career in many ways on tobacco advocacy. I chose my preventive medical health residency at Michigan. I went there because of recommendations about how to reduce addiction and deaths from tobacco. And I had actually narrowed down my... The other one was at University of North Carolina, UNC. And I actually liked the program a little better, but they wanted tobacco at that time. I will run my head up against a brick wall. I just don't like it falling on me every minute. So I went to Michigan to get involved with tobacco advocacy. And one of the challenges at that time was that the percentage of harm with any one disease from tobacco was significant. But it wasn't enough to move it to the top priority until you looked at all diseases that were influenced by tobacco. And then all of a sudden, it moves up there. Other conditions, poverty certainly has a huge impact on how long people live. And in fact, if you look at COVID and deaths from COVID, those folks that are... Great California study is much more likely to have lost many more years of life expectancy from COVID than those that were in the top income bracket. But a lot of this has to do with, do voters have access? And are they engaged? And are they understanding these factors or not? And so I think actually voting access would probably be the thing that I prioritize would be the most... At least in this country.

Murray Goldstein Commemorative Lecture

public health

preventive medicine

social determinants of health

Dr. Rex D. Archer

health equity

preventive measures

upstream interventions