An Accurate Census – Our Health Depends on It!

When I was a skinny, naïve teenager, I worked the summer of 1980 for the US Census Bureau going door to door, pencil in hand, filling out census forms. Or rather, I went trailer park to trailer park in the outskirts of Odessa, Texas, where I was assigned to work. Do you know how many pit bulls and Doberman pinschers live under the steps of trailer houses in West Texas? I do. Fortunately, that was not one of the census questions.

The US Census counts each resident of the country, where they live on April 1, every ten years ending in zero. The count is mandated by the Constitution to determine how to apportion the House of Representatives among the states.  The US has counted its population every ten years since 1790. Households will be able to respond to the 2020 Census online, over the phone, or through a paper questionnaire. Results are anonymous and confidential; answers cannot be used against you by any government agency or court.

My appreciation for the US Census has grown tremendously since my days walking trailer parks. Far beyond being a simple head count, an incredible $1.5 trillion in federal dollars are distributed according to census counts. Myriad local and state governments, businesses, and community groups rely on US Census data to determine needs, guide investments, provide services, and lobby for state and federal funding.  If the count isn’t accurate, the distribution of funds isn’t fair. We have one shot every ten years to get it right.
Healthcare in particular has much at stake if the US Census does not get accurate information. As I love to mention, the healthcare sector drives our local economy. The State of Texas cannot ignore the healthcare sector either. Elena Marks, president and CEO of the Episcopal Health Foundation, states, “No sector is as dependent within the state budget in drawing down federal funds than the health sector, and those funds are based on population that's determined by the Census. Health clearly stands the most to gain, and the most to lose if there's an undercount.”  In fact, experts estimate that a 1% undercount in the Census could cost Texans about $280 million per year for health programs alone. Current forecasts predict anywhere from a 4%-8% undercount in Texas.

From political representation to federal funding for clinics, Medicaid, the children's health insurance program and much more, a complete and accurate Census count is crucial for community health – especially for low-income and vulnerable populations like many in deep East Texas.  The $1.5 trillion in federal money guided by census data helps fund the Children’s Health Insurance Program (CHIP), Medicaid, Medicare, the Supplemental Nutrition Assistance Program (SNAP), the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and community health centers funded through the Health Resources and Services Administration Health Center Program. Indivar Dutta-Gupta, co-executive director of the Center on Poverty and Inequality at Georgetown Law, notes that the groups that tend to be undercounted at the highest rate, unsurprisingly, are also the ones that would probably most benefit from greater access to and provision of health care and coverage.

The Census is also fundamental for population health data, including calculation of death rates, birth rates, and fertility rates.  A recent journal article titled Census 2020—A Preventable Public Health Catastrophe  points out that population counts provide denominators used to derive disease prevalence and rates. Inaccurate counts limit our ability to understand and track disease over time. If we cannot accurately stratify our populations by social factors such as education and race/ethnicity, we cannot assess their relationships to health.  Rural populations with spotty Internet connectivity are also likely to be undercounted.  Simply put, if we can’t measure social disparities in health, we are hindered in working to reduce them. Given our history of hurricanes, we need to understand that a flawed Census will compromise efforts to track and effectively manage natural disasters and emergent public health threats (coronavirus?), which require geographically focused provision of food, water, and shelter.

Lately, it seems as if politics gets in the way of everything. We must understand that federal dollars follow people. More people counted equals more funding coming our way. Whether or not we like with the ways those dollars are raised or spent, we should all agree that we deserve our fair share of whatever dollars are distributed. An accurate US Census is something we should all be able to count on and get behind!

The Graduation Speech I Would Give

Facebook and YouTube are full of graduation speeches that go viral and become memes representing personal life views, political stances, or just feel good, philosophical pablum. Usually, speakers invite you to follow your passion, love what you do, and learn to overcome failure. In other words, graduation speeches motivate you to change the world (like the speaker has) but provide little, if any, real life advice.

That’s not to say the speeches aren’t inspirational.

One address by Naval Adm. William H. McRaven at the University of Texas in 2014 has garnered more than 10 million views on YouTube. McRaven’s speech famously opined, “If you want to change the world, start off by making your bed.” He explained, “If you can’t do the little things right, you’ll never be able to do the big things right.” Coming from a Navy admiral, the importance of discipline is sound.

Denzel Washington’s speech at Dillard University, a private, historically black, liberal arts university in New Orleans, Louisiana, has 21 million YouTube views. Denzel’s advice? “Put God first in everything you do.” Having a spiritual foundation in life is wise counsel.

For even more YouTube views, check out Steve Jobs’ 2005 Commencement Address at Stanford University, which has racked up 33 million views. Steve Jobs, co-founder of Apple, urged graduates to “Follow your heart,” saying, “The only way to do great work is to love what you do.” Passion can certainly keep you going when life throws you curves.

Most graduation speeches I’ve heard or read suggest believing in yourself and having the right attitude will result in success – success meaning significant global impact or financial gain. Is that what graduates want or need to hear? Having finished high school 40 years ago, I got to thinking about what practical advice I wish I had gotten back in 1979.

One of the most important lessons I learned is that making money rarely equates with true success. There is a joke that goes, “How much money does it take to live in New York City?” ”All you have!” Of course, this can apply to living anywhere, if we are always chasing the bigger apartment and the more expensive car. True success is not about accumulation of wealth. Learn early to separate financial gain from successful living.

That being said, you still must save and plan for the future. My parents set the expectation early on that my brothers and I were to get an education and make a living on our own to be able to save and support a family. That was their minimum definition of success. I’d love to hear a graduation speech that focused on saving. Saving should start early. With the first paycheck you bring home (and every one thereafter), set aside some to save.

But don’t just save; give! Yes, you work for you. But it’s not all about you. Give of your time, talent, and treasure to support causes that you believe in (religious, civic, non-profit, etc.). Then live within your means with whatever you have left. Occasional splurges can be planned, but don’t borrow to keep up with the Joneses. That is playing with fire. A major illness (like cancer) at any age can trigger unbelievable expense and a significant risk of bankruptcy. The focus on inequality or “keeping up” breeds jealousy. Equal work does not guarantee equal results, much less equal pay. You can’t live your life comparing yourself to others. Yes, fight for justice. But do your own work without resentment when others happen to have more financial success, fame, or glory. Don’t envy.

Happiness, especially if based on accumulation of things, is fleeting and deceptive. Joy, on the other hand, is a mindset. One of the most joyful people I’ve ever known never had a dime to her name. Reverend Bettie Kennedy was too busy giving whatever she had away, feeding and clothing others. Learn to give.

The Protestant Reformation brought with it the idea of our vocation as our calling, indicating the spiritual nature or our work. Whether Martin Luther actually said it or not, the idea that even a milkmaid can milk cows to the glory of God is encouragement to find meaning in even our most trivial tasks. When we do, we don’t cut corners. We always put forth our best effort. And we treat each person we interact with as the most important person there is at that moment. View your own work as a calling and your interaction with others as your ministry. Love God; love others. Simple to say; hard to do.

Don’t forget to make time for yourself. Burnout is real in any profession. Maintaining your mental and spiritual health is just as important as your physical health, maybe even more so. Learn to retreat.

Finally, expect to regret certain decisions, actions, roads taken. I don’t believe anyone who says they never regretted anything they’ve ever done. In fact, I feel sorry for them. That attitude exposes a selfish view of a life lived with callous disregard for any hurt inflicted on others, much less yourself. A life without regret is a life without grace. Embrace grace.

To summarize, the best graduation advice I can give is to save often, give freely, live within your means, treat your work as a calling (but take a break every once in a while), treat others with dignity, and accept and extend grace. Success is not found at the journey’s end; it is embodied in the life well-lived. Sounds like good New Year’s advice as well.

Modifying Your Alzheimer’s Risk

One of the most feared illnesses today is Alzheimer’s disease. Aloysius Alzheimer, a German psychiatrist and neuropathologist, first described the characteristic brain changes and associated dementia more than one hundred years ago.  Despite the rapid advance of medicine and technology over the intervening century, we still know far too little about this devastating and incurable disease.

Diagnosing Alzheimer’s dementia requires expensive testing looking for particular damage due to accumulation of beta-amyloid and tau protein, which cause the signature plaques and tangles in the brain. As a result, many patients with dementia never get tested and may not get labeled with actual Alzheimer’s disease. Regardless, most dementia – 80% – is the result of Alzheimer’s.

Alzheimer’s disease can last more than a decade, starting with mild cognitive impairment (MCI) and relentlessly progressing to more difficulty solving problems, personality changes, getting lost, forgetting people or significant life events, and ultimately losing the ability to care for oneself, to toilet, to speak, to walk. Some people progress more rapidly than others. The Alzheimer’s Association website https://www.alz.org/ can be a great resource for caregivers or those wanting more information.

Unfortunately, currently available prescription medications, which may help somewhat with mental function, mood, behavior, and ability to perform activities of daily living (like bathing, dressing, eating, etc.), do little to change the course of the illness or the rate of decline. We don’t yet have a magic bullet.

Genetic factors can increase risk of dementia, but most dementia cases occur sporadically in older adults in whom multiple genes influence risk.  We cannot – yet – modify our genes. Changing our lifestyle, however, is one way to improve the odds of developing dementia, even for those with high genetic risk.  Many of the dietary and lifestyle habits and activities recommended to improve overall health (think heart disease, cancer, diabetes) may also be of some benefit with dementia.

One Mediterranean-type diet, which researchers named the MIND (Mediterranean-DASH Intervention for Neurodegenerative Delay) diet, focuses on foods that impact brain health: leafy green vegetables, berries, nuts, olive oil, fish, wine in moderation, and avoiding red meat.    The point is these broad dietary recommendations are not new and not exclusive to affecting Alzheimer’s risk. Let’s just call it healthy eating.

In addition, physical and mentally stimulating activities – such as reading or crossword puzzles – are important as we age. Both diet and exercise may help with Alzheimer’s risk by virtue of preventing conditions like diabetes, hypertension, and coronary artery disease that can exacerbate cognitive decline. Most older adults cannot keep up the same rigorous workout routine they might have when they were younger. But exercising at least 150 minutes a week, whether by biking, walking, swimming, gardening or doing yard work, can increase the flow of blood to the brain, improve the health of blood vessels and raises the level of HDL cholesterol, which together help protect against both cardiovascular disease and dementia.  One study found that people who engaged in more than six activities a month—including hobbies, reading, visiting friends, walking, volunteering, and attending religious services—had a 38% lower rate of developing dementia than people who did fewer activities.  Along with physical and mental activity and a healthy diet, individuals who avoid smoking tobacco have a lower dementia risk. 

There is mixed evidence about the use of fish oil supplements to improve thinking and memory in Alzheimer’s.  Given the benefit for cardiovascular health, it is reasonable for most people to take a fish oil supplement.   Vitamin D deficiency has been identified as an independent risk factor for the development of dementia of any cause, and supplementation is recommended for patients in whom deficiency is diagnosed.  Finally, no dietary supplement has been proven to be effective in boosting memory or preventing dementia. It is wise to talk to your doctor about the risks and benefits of any over-the-counter medications or supplements you are taking.

As with any recommendations, we must acknowledge that playing by the rules will not guarantee we will prevent Alzheimer’s (or any other disease, for that matter). Probably two-thirds of the risk of developing Alzheimer’s simply can’t be modified.  But adopting a healthy lifestyle with heart- and brain-healthy diet and exercise habits will lessen your chances of developing any number of chronic and life-threatening illnesses. When we all work toward that goal, our entire community is healthier. That’s worth striving for!

How and Where People Die – Is it Good?

All of us, at some point, have pondered what it means to have a “good” death. A common theme is to fall asleep in one’s own bed and simply not wake up. Woody Allen famously said, “I’m not afraid of death; I just don’t want to be there when it happens.” The underlying desire is comfort, serenity, peace.

According to the Centers for Disease Control (CDC), the top ten causes of death in the United States in recent years were heart disease, cancer, accidents, lung diseases, stroke, Alzheimer’s disease, diabetes, influenza and pneumonia, kidney disease, and suicide.   These top ten account for three out of four deaths, and most are chronic diseases marked by decline over years with increasing need for medical care and hospitalization along the way. Yet all along there is this denial of illness and death.

We used to be familiar with death. Before the 1940s – prior to antibiotics, chemotherapy, heart surgery – people usually died in their homes over the course of a few days or weeks.  Sir William Osler, frequently described at the Father of Modern Medicine (d. 1919), called pneumonia – a leading cause of death in his time – the “friend of the aged” because it was an “an acute, short, not often painful illness.”  With the advent of the intensive care unit (ICU) and an ever-expanding medical-industrial complex, we now have approximately 4 million ICU admissions per year and about 500,000 ICU deaths annually.  The contrast between death at home versus in a technology-overrun ICU could not be more stark. In 2010, 28.6% of Americans died in the hospital.  Yet nine out of ten Americans say they would prefer to die at home if they were terminally ill and had 6 months or less to live. 

Unfortunately, death in the hospital is rarely pretty. Believe me; hospitals do not want patients dying in their facilities. It messes with statistics and quality ratings. It is also far more expensive.  So, if hospitals don’t want us dying there, it costs more money, and we say we would prefer to die at home, where is the disconnect?

There are several problems. Doctors don’t like talking with their patients about death and dying. Doctors don’t want to appear to be giving up hope by talking about end-of-life care, nor do they want to appear helpless, as if nothing more can be done. Patients, having watched one too many TV medical dramas, believe that technology and medicines are so good now that they can overcome any illness, even at the very end of life.

Perhaps the most egregious of these technological and communication disconnects at the end of life is with a procedure called cardiopulmonary resuscitation – the “Code Blue” you hear overhead periodically in hospitals. A code blue is an actual life-threatening emergency situation in which a patient is dying – typically their heart has stopped beating and/or breathing has ceased – and an entire medical team works to revive him/her with medications, chest compressions, intubation, electrical shocks, and more.

Cardiopulmonary resuscitation (CPR) can be life-saving in the community setting when a person suffers a heart attack or drowning, for example. According to 2014 data, nearly 45 percent of out-of-hospital cardiac arrest victims survived when bystander CPR was administered.

For hospitalized patients who suffer cardiac arrest (essentially, who die), the overall rate of survival from a “full code” procedure leading to hospital discharge is barely 10 percent. But most people, when asked in a scientific study, believe the survival rate to be more than 75 percent.  Unfortunately, the quality of life of patients who do survive resuscitation in the hospital is often not good. Rarely do the few survivors return to their previous functional status, which in hospitalized patients was probably poor to begin with. There can be brain damage from prolonged lack of oxygen, bruising and pain from broken ribs, and need for prolonged rehabilitation or nursing home placement.

But unless you – or a family member speaking for you – explicitly states otherwise, this likely will happen to you if you are coded in the hospital. And despite the resuscitation attempt, you will very probably die anyway. Is this really what you want your minutes to look like?

The good news is that we have far more control over where and how we die than one may think. First, talk with your spouse and your kids – and your doctor! – about how you wish to die and where you wish to die if you were to find out you had a terminal illness. Second, make every effort to write your wishes down. In Texas, there is a document called a Living Will available online at https://hhs.texas.gov/laws-regulations/forms/miscellaneous/form-livingwill-directive-physicians-family-or-surrogates. Both English and Spanish versions are available. This Directive to Physicians and Family or Surrogates lets you, the patient, tell your doctors and others what types of treatments you do or do not want if you are terminally ill and no longer able to make medical decisions.

In addition to this advance directive, Texas law provides for two other types of directives that can be important during a serious illness. These are the Medical Power of Attorney and the Out-of-Hospital Do-Not-Resuscitate Order. Don’t wait until a crisis to make your wishes known. It may be too late.

Finally, hospice care is available through Medicare, Medicaid, and most private insurers to help patients achieve the “good” death they say they want, not by hastening death, but by helping terminal patients to fully live the life they have left as comfortably as possible and most often at home.

Vaping Dangers are Frightening

Over the last few months, a rapid rise of vaping related acute lung disease has come to light. Both the CDC and the Food and Drug Administration (FDA), which regulates electronic nicotine delivery systems (ENDS, which includes products known as “e-cigarettes”), are actively engaged in investigating this outbreak, which some are calling an epidemic.  Certainly, vaping is epidemic among our youth.

As of the end of September, the number of confirmed or probable cases of life-threatening vaping-related lung disease has risen to 805 across 46 states and the US Virgin Islands. About three-quarters of the reported cases are male; nearly 4 in 10 are age 21 or younger.   Most importantly, all reported cases have a history of e-cigarette product use or vaping. Patients often require ICU and ventilator support. Thirteen people have died so far.

Authorities don’t know which chemical(s) are responsible for these vaping-related illnesses. An early idea was that only illicit THC products (black market marijuana oils) were to blame, but this evidently is not the case. Yes, these illnesses are more prevalent among THC vapers than users who self-report using only nicotine products, but vapers who don’t use THC are also getting sick. Vitamin E acetate is also being considered as a potential cause, but no single chemical has been consistently identified in all of the samples tested. At the present time, no particular device, brand, flavor or substance has been definitively linked.

According to the Centers for Disease Control and Prevention (CDC), symptoms of lung injury reported by some patients in this outbreak include  cough, shortness of breath, and chest pain, nausea, vomiting, or diarrhea, fatigue, fever, or abdominal pain. These symptoms usually have a rapid onset over a few days, but some patients have reported that their symptoms developed over several weeks. A lung infection does not appear to be causing the symptoms. NPR reports that in all confirmed cases, patients reported vaping within 90 days of developing symptoms, and most had vaped within a week of symptom onset. 

What should you do?

If you vape, stop. There are other ways to control nicotine addiction. Playing Russian roulette with your lungs is not smart and not cool. Certainly, anyone who vapes should not buy products off the street or add any substances, like THC or CBD oils.  If you have recently vaped and you have symptoms, see a healthcare provider, and let them know of your concern. They can notify the health department or CDC if necessary.

Vaping is not a harmless fad. Our lungs are elegant, fragile, life-giving organs that don’t react kindly to smoky chemicals, whatever the source. The acting head of the FDA admitted recently in testimony before a House subcommittee that the FDA “should have acted sooner” to contain the youth vaping epidemic.  And the CEO of Juul, maker of vaping products that targeted kids with enticing flavors like mango, grape, and strawberry lemonade, stepped down amid intensifying scrutiny of the brand’s marketing practices.  His replacement, unfortunately, is a seasoned tobacco executive, so don’t expect Juul to give up the fight. Too much money is at stake.

But our kids’ health and future is at stake as well. We must remove flavored e-cigarettes from the marketplace. And any marketing practices that target kids with addicting and dangerous products are unacceptable. E-cigarette products flooded the marketplace and were never appropriately reviewed. Frankly, the FDA dropped the ball on this, and people are dying as a result. Finally, until and unless sales to kids can be prevented, online sales of e-cigarettes should be stopped.

Let’s hope our federal agencies can act quickly and forcefully both to identify what is causing these illnesses and deaths and to regulate access to e-cigarette products. If the federal government won’t act, our state legislators should. The health and safety of our kids is at stake.

How to Lose Weight and Improve Health

Weight loss is always high on most people’s New Year’s resolution list. For something that is desired by so many of us, it is surprising how difficult it is to achieve and how controversial or ineffective the proposed methods are. Half of all Americans ages 20 and over say they've attempted to lose weight in the past year.  Exercising more and eating less are the two top strategies people use to try to lose weight. Yet so often we fail.

Our focus needs to shift to healthy living as opposed to weight loss alone. No single diet can be recommended for everyone, because – and you knew this already – what works for one person may not work for another.  Of all the individual diet programs out there, Weight Watchers (now called WW, to move the emphasis away from weight loss) seems to be more effective than others, at least according to US News & World Reports.  Noom is a more recent (and expensive) addition to the behavioral change and app-integrated weight loss arena. What these programs recognize is that weight loss is more than just counting calories (or, as is the case in the WW system, points). Weight loss requires behavioral change, community, and a lifestyle of eating healthier and moving more.

Though we don’t know enough about the genetics involved in weight loss and weight gain, the observation that some people have to work harder than others to stay thin or lose weight appears to be supported by scientific data. Apart from genetics, some people’s intestines are 50% longer than others. (Shorter guts absorb fewer calories.) Differences in gut microbiomes can alter how people process food.  Cooking increases digestion of food and absorption of calories.

All of this means that just counting calories is not the answer to weight loss. The old adage calories in, calories out is simply false. That’s because a calorie is not a calorie. If that were the case, a diet of donuts alone would be fine. But it turns out the rate your body absorbs calories may be as important as the amount of calories you take in. In other words, that sugary donut hits our bloodstream far faster than calories from more complex carbohydrates or from fat and protein.  And, those quickly absorbed sugars are far more likely to create body fat – and make you paradoxically hungrier in the process.

For years, the culprit of the obesity epidemic was thought to be dietary fat. Low-fat, high-carb diets were all the rage. Only recently has it come to light that sugar companies secretly funded studies designed to blame fat for making us fat. But low-fat, high-carb diets didn’t work; we kept getting fatter. For an entire polemic on the subject, check out The Case Against Sugar by Gary Taubes. It is enough to scare anyone off sugar. That is not to say that we know for certain the extent to which sugar is responsible for the obesity epidemic. Gina Kolata, writing in the New York Times, notes that a number of societal factors may have contributed to the obesity epidemic, from growing portion sizes, the popularity of restaurants and fast food, snacking, the cultural acceptance of obesity, and even the decline in smoking.  The science is not settled.

That’s not to say that you shouldn’t watch what you eat. Keeping a food diary can help you understand what and how much you are eating and the types of calories you are consuming. A study of nearly 1,700 participants showed the best predictors of weight loss were how frequently food diaries were kept and how many support sessions the participants attended. Those who kept daily food records lost twice as much weight as those who kept no records.  I wrote about my so-called Bar Code Diet many years ago and that if I couldn't scan it or enter it into my phone, I didn't put it in my mouth.  That – along with regular exercise with a group of friends, who kept me accountable – did help me lose weight and keep it off.

What can you do realistically on your own and without added expense?

1. Keep a food diary. You may not be aware of just what you consume in a given day. For the technologically savvy, phone apps like MyFitnessPal and Lose It! can be helpful. Remember, some days you may have more success than others. Just keep going.
2. Avoid high fructose corn syrup and sugary drinks, and cut your daily sugar intake significantly.  Having an occasional celebratory dessert is fine. But make it a rare and portion-controlled treat, if for no other reason than sugary foods are seductive and lead to overeating.
3. Focus on overall healthy behaviors, eating fewer processed foods, and increasing physical activity as opposed to weight loss per se. That includes avoiding smoking and excess alcohol intake as well as taking advantage of a host of other preventive, screening, and early detection programs. Weight is just a number; health is a lifestyle.
4. Be a part of a community or small group. Accountability – both for diet and exercise – is a great motivator and reinforcer. Fat shaming doesn’t work; encouragement and support does.

Emphasizing physical activity and healthy behaviors at all ages is key to reducing morbidity and improving health outcomes in communities. Far from ignoring obesity, when we emphasize a lifestyle that includes awareness and adjustment of eating habits and sets exercise goals (such as increasing walking speed, strength gains, etc.), our overall health – and the health of our community – will improve. And you know what? We will lose weight along the way.

A True Community Health Needs Assessment

The IRS requires charitable hospital organizations to conduct a community health needs assessment (CHNA) every three years and to adopt an implementation strategy to meet the community health needs identified through the CHNA. CHI St. Luke’s Health Memorial recently completed their 2019 Community Health Needs Assessment and will now begin the process of developing, adopting, and implementing a strategy to address identified needs. Much of this strategy will depend on working together with community stakeholders, many of which participated in the assessment data collection and interview process. Additional data was obtained from sources such as the Texas Department of State Health Services, the US Census Bureau, the Centers for Disease Control and Prevention, the Episcopal Health Foundation, and the Robert Wood Johnson Foundation’s County Health Rankings.

The 2019 CHNA was created by the Center for Community Health Development at Texas A&M University at the request of CHI in collaboration with multiple non-profit community organizations, churches, school districts, and individuals. The entire CHNA is published on the CHI website at www.chistlukeshealthmemorial.org/about/health-needs-assessment/. Because CHI St. Luke’s Health Memorial is a regional health system, the assessment covered not only Lufkin and Angelina County, but a seven-county region that included Polk and San Augustine counties, where CHI facilities also are located.

I have a number of thoughts after reviewing this recent assessment.

1. The health of a community is dependent on far more than just availability of health care. This is well-demonstrated by both the Robert Wood Johnson Foundation’s County Health Rankings (www.countyhealthrankings.org/) and the Episcopal Health Foundation (www.episcopalhealth.org/en/research/county-health-data/). To improve health, we must identify and address everything from education level and health behaviors to racial, ethnic, and socioeconomic factors that affect a community’s health.

2. The 2019 CHNA is community-driven, and solutions to our health needs must include the community as well. So many partners exist, including Burke, the Angelina County & Cities Health District, the Coalition, our many school districts, DETCOG, the Texas Forest Country Partnership, and, of course, our city and county governments. All will need to be engaged in moving the needle to improve the health of our communities.

3. The role of the hospital in the community has changed. In the past, hospitals were primarily a destination to deal with an acute episode, like having surgery or managing a heart attack. Now, hospitals must be part of the chronic care management team for patients with heart disease, diabetes, cancer, mental health issues, and more. Hospitals are being graded – and paid – on how successfully they keep patients out of the hospital, if you can believe it! That requires coordination with community partners to ensure that people get the care they need both before and after they require care in a hospital facility.

4. Risk factors – behaviors – such as smoking, obesity, and exercise must be addressed, as well as substance abuse and mental health needs. We are doing this already, to some extent, across organizations and municipalities. More can be done.

5. Education is widely recognized as one of the primary social determinants of health. The St. Luke’s region has a lower proportion of residents with a college degree (14.2%) than either Texas (28.7%) or the US (30.9%). Within the region, the rate varies from a low of 11.6% in Jasper County to a high of 16.7% in Angelina County, yet both are significantly lower than Texas or the US. Household income and insurance status, which are closely linked to education level, also impact community health. Affecting change in these areas will require a generation of effort.

6. One of the key findings of the CHNA – and one that will require a lot of thought and planning to address – is the inadequacy of local and regional transportation. Lack of transportation impacts access to preventive services and early detection of illness as well as access to treatment and follow up.

As a result of the needs identified in CHI’s 2019 CHNA, with few exceptions, premature death rates in our region are higher than the State in virtually every category. This CHNA must not be an exercise on paper only. Follow up must happen. We have a good idea now of the need. We also have strong communities with excellent resources that can come together to find and implement solutions. Our health depends on it.