(Plain Press, July 2015) The Health Improvement Partnership (HIP) – Cuyahoga released the first ever, countywide Community Health Improvement Plan (CHIP) on June 11th at the Ariel International Center on E. 40th Street in Cleveland. The plan, many years in the making, was spurred along in response to a 2009 analysis of life expectancy in Cuyahoga County which showed a 24.5 year difference in life expectancy between areas of Cuyahoga County where people lived the longest lives and areas where people on average lived the shortest lives.
Over eighty government and nonprofit organizations and many individuals joined in the effort to complete the CHIP. The mission statement of Cuyahoga’s Health Improvement Partnership states, “HIP-Cuyahoga’s mission is to inspire, influence, and advance policy, environmental, and lifestyle changes that foster health and wellness for everyone who lives, works, learns, and plays in Cuyahoga County.”
A chart in the report shows life expectancy in different neighborhoods and municipalities in Cuyahoga County in the period of 2008-2010. With the exception of Downtown Cleveland, all the neighborhoods in Cleveland had life expectancies of 78.6 years or less. Seven Cleveland neighborhoods – four on the West Side and three on the East Side had life expectancies of 72.7 years or less. The West Side neighborhoods falling in this low life expectancy category are: Brooklyn Centre, Clark Fulton, Stockyard and Edgewater neighborhoods. The East Side neighborhoods in this category are: Fairfax, Kinsman and Euclid Green. In contrast some suburban areas had life expectancies of 82.8 years or more. Areas with the highest life expectancies included: Rocky River, Broadview Heights, Brecksville, Pepper Pike, Gates Mills and Chagrin Falls.
An introductory letter from three government health board or department administrators speaks of opportunity gaps for individuals saying, “Resources that help create health such as stable housing, access to good education, availability of healthy food choices and safe places to exercise are not universally present and, where lacking, are largely responsible for creating these opportunity gaps.”
The goal of the CHIP is to assure that all residents of Cuyahoga County have “the resources, access, and ability to live their healthiest lives.”
To that end the health planners participating in the study identified 14 health priorities: Infant and Early Childhood Mortality, Tobacco Use and Prevention, Chronic Disease Management, Mental Health and Substance Abuse, Improved Nutrition and Physical Activity, In School and Out of School Supports, Quality of Life for Older Adults, Violence Reduction, Health and Land, Natural Environment, Public Health Job Development, Public Education Reinvestment, Eliminating Racism As a Social Determinant of Health, and Improving Coordination between Clinical and Public Health.
Of those 14 health priorities, HIP-Cuyahoga chose to focus on four priorities to address over the next five years: Eliminating Racism as a Social Determinant of Health, Improved Nutrition and Physical Activity, Improving Coordination between Clinical and Public Health, and Chronic Disease Management.
Eliminating Structural Racism
Greg Brown, Executive Director of PolicyBridge spoke on the work of the Subcommittee addressing Eliminating Racism as a Social Determinant of Health. The report noted that certain racial and ethnic groups “face steep obstacles and barriers to living healthy and prosperous lives.” The plan hopes to address “systems and structures that act to disadvantage people of color.” Brown said, “We must change our systems and structures to reach the outcomes we want to see.”
In explaining structural and institutional racism, the report notes racial differences in power, status and access to opportunity. It also describes how racism can impact people’s self image, their interactions with others, their health and quality of life. It talks of structural racism contributing to loss of economic opportunity, increased stress, and social isolation and exclusion. Some factors cited are “who gets jobs, how schools treat students, and even the availability of transportation in a neighborhood.”
Brown talked about historical patterns such as redlining of neighborhoods, which impacted the ability of residents of certain neighborhoods to obtain house loans or insurance. He said conditions in some neighborhoods today are a result of red lines drawn on maps back in the 1940s.
Neighborhood Family Practice’s Chief Executive Officer Jean Polster said the issue in the neighborhoods her agency serves is more structural poverty than structural racism. She said people of all races and ethnicities, including Caucasians, facing the same issues talked about in the report that lead to poor health outcomes. Brown said he was familiar with the West Side neighborhoods and said, “the data in those neighborhoods aligned with the data in the African American community.” He said lack of educational opportunities and employment opportunities in those neighborhoods were structural problems that increased poverty.
Healthy Eating and Active Living
Erika Trapl, PhD, of the Prevention Research Center for Healthy Neighborhoods at Case Western Reserve University, spoke of efforts of the Subcommittee on Health Eating and Active Living to help assure all areas of Cuyahoga County have access to healthy foods and safe places to engage in physical activity. The Cuyahoga County Health Improvement Plan outlines three strategies it says “will help create the environments that make the health choice the easy choice for everyone in Cuyahoga County.
First, in communities without a full service grocery store, the group hopes to identify corner stores that can serve as a reliable source of healthy produce and food. A Healthy Corner Store Certification initiative will help the corner stores secure healthy food and produce so it can be sold at an affordable price. The goal is to have a healthy corner store or full service grocery within a half mile of every resident within the next five years. Trapl talked about Tremont West Development Corporation’s Corner Store Initiative as an example of how to pursue the goal.
The second strategy is to provide streets with safe places to walk, run, ride bicycles, and access public transportation. The goal is to institute complete street initiatives in communities throughout Cuyahoga County, establish safe routes to school, and develop networks of protected bike boulevards.
The third strategy is to develop shared use agreements that would allow members of the public access to facilities that would increase their opportunity for physical activity. The agreements would allow use of facilities such as schools and businesses in off hours for recreational activities. Trapl hoped that neighborhood organizations would get involved in creating these agreements with institutions in their neighborhood.
In light of this third strategy, Ann Hill of MetroHealth Medical Center challenged HIP-Cuyahoga to get involved in a concrete issue. She said that the Cleveland Metropolitan School System is currently deciding what schools to rebuild and what schools to tear down and eliminate. She said, under different scenarios the gymnasium and pool at Lincoln West High School, very much in use, could be torn down. State dollars that offer matching funds to the school construction fund won’t pay for rehabbing the swimming pool. Hill challenged HIP-Cuyahoga to work to change the state policy about what the state will pay for. She also urged the group to rally to save the pool and the gym. She said, “It is criminal to tear down major assets.”
Terry Allan, Health Commissioner of the Cuyahoga County Board of Health, said the group needed to make this issue known to decision makers and use Community Engagement Networks to galvanize efforts around the issue. He promised to bring the issue up at one of the next meetings of HIP-Cuyahoga.
Clinical and Public Health
The plan notes that while Cuyahoga County has highly ranked health care institutions and high quality public health institutions, the county ranks 65th out of 88 counties in Ohio for health outcomes. In order to make progress to changing this low ranking, HIP-Cuyahoga CHIP calls for clinical care “to join the current public health movement to broaden its focus from the treatment of illness and disease to include prevention efforts that address complex social issues like education, racial segregation, poverty and inequality.”
Heidi Gullet, MD, MPH, assistant professor – Case Western Reserve University School of Medicine, spoke of the importance of health care organizations doing some soul searching and understanding what health equity means and how to break down barriers to health equity. She stressed that equity didn’t mean that everyone was given the same thing, rather, equity involved getting everything needed by a specific group. As an example, she said, if she offered everyone in the room a pair of size seven pumps, how many could wear them? In contrast, if everyone was fitted with shoes of their size and width, they could use them.
Gullet talked about the importance of health care providers working with public health agencies to understand how to work together to improve the health outcomes in the community. One early initiative involves an effort to tackle pediatric asthma with home interventions that help to reduce asthma triggers in the home. The effort is targeting a Medicaid qualified population. The group hopes to convince Medicaid to pay for the cost of the home interventions.
Chronic Disease Management
The HIP-Cuyahoga Health Improvement Partnership report notes “It is harder to practice healthy behaviors when you live in vulnerable communities where you can’t get healthy food, where you don’t have safe places to play or exercise, and where companies spend a lot of money marketing fast food and tobacco products.” Many Cleveland neighborhoods are such places. The CHIP report further states, “Individuals of color and poorer individuals live in the City of Cleveland; thus they get chronic diseases more often and are more likely to have problems with controlling their chronic diseases. All of this leads to groups of individuals, in vulnerable communities, living sicker and dying earlier.”
The study notes examples of chronic diseases such as diabetes, high blood pressure, heart disease, asthma, and mental health illnesses. It notes such diseases keep coming back or never go away. The study proposes improved clinical management and self-management of these diseases. The group’s effort involves instituting best practices in area clinics and making area residents aware of self-help resources.
Rita Horwitz, Director of Business Development and Operations for Better health Partnership, spoke on behalf of the Chronic Disease Management Subcommittee. Horwitz noted that an early initiative of the subcommittee involves duplicating a program designed by Kaiser (now Health Span) that dramatically increased the number of patients with high blood pressure that had it under control.
In concluding the roll out of the HIP-Cuyahoga CHIP, Terry Allan, Health Commissioner of the Cuyahoga County Board of Health said, “Everyone deserves the right to be healthy. It is time to put words into action.”
Editor’s Note: To learn more about HIP Cuyahoga Health Improvement Partnership or to volunteer for one of the subcommittees visit: www.hipcuyahoga.org, email: firstname.lastname@example.org or call 216-309-2447.