In medical school, Raleigh internist Dr. Stuart Levin learned to examine patients as if they were in a vacuum, then use that information to assess a litany of symptoms, diagnosis a problem, and prescribe treatment. What he wasn’t taught was how to address the underlying causes of poor health, which research increasingly shows is tied not only to behaviors and access to quality health care but also to socioeconomic circumstances and a person’s physical environment.

“It makes me think outside of what I’m doing in the exam room,” Levin says. “It’s not just a question of giving the patient the right medication or ordering a test—it’s a much more community-based solution, and it’s an attempt to start thinking about what health is. Health is not just health care.”

Levin cochaired Wake County’s Population Health Task Force, which sought to broaden the county’s approach by infusing health outcomes into every stratum of government services, from law enforcement to land-use planning. The Board of Commissioners unanimously approved the task force’s report on November 19. County staffers are now developing strategies to implement the task force’s findings and will present them to commissioners in February. 

A core element of this effort is redefining the way the county thinks about health, not merely as a product of personal choices or DNA destiny but as a symphony of social determinants. According to the Robert Wood Johnson Foundation’s Healthy Communities project, the biggest influence on people’s health outcomes is their socioeconomic circumstance, including education, employment, income, and community support. This, along with environmental factors such as air and water quality, housing, and transportation access, accounts for 50 percent of a person’s health outcomes. An additional 30 percent is determined by behavior—diet, exercise, drug use, and sexual activity—while the remaining 20 percent stems from access to quality health care. 

“What we now know is that your zip code is a bigger determinant of how long you are going to live than your DNA code,” says Commissioner Sig Hutchinson, who also cochaired the task force. “One zip code difference can mean an eighteen-year difference in your life expectancy, as well as well-being within that life.”

The county sees this as a call to action: 70 percent of these factors are within its control. To improve the community’s health, the county must first understand the role its services play and incorporate this understanding into training and policy. 

“Every professional who works for Wake County not only has an impact on the health and well-being of our citizens, but should be seen as a health care professional and should see their job from the perspective of how it impacts the health and well-being of our citizens,” Hutchinson says.

A major aspect of this effort begins with providing children with the skills and support they need to overcome adversity. An ongoing, two-decade-long San Diego study on adverse childhood experiences, or ACEs, shows that childhood trauma has a substantial effect on a person’s long-term health outcomes. The more childhood traumas—including neglect, sexual abuse, substance abuse, incarcerated relatives, divorce, and mental illness—a person is exposed to, the greater risk of heart disease, cancer, stroke, depression, drug addiction, obesity, and diabetes, among other negative outcomes. 

The study showed that 64 percent of the population has at least one ACE, and more than 12 percent have four or more. The antidote to ACEs is a wide-ranging approach to public health focused on teaching county employees from all departments how to deal with trauma and build community resilience. This would entail everything from improved social services to crafting policies for land use, transportation, and economic development that prioritize public health.

From a criminal justice standpoint, it means an emphasis not only on holding people accountable but also healing, says District Attorney Lorrin Freeman. 

“When we look at offenders who we deal with and prosecute that we know also have a history of similar types of abuse or addiction, trying to solve the root cause of their behavior is the best way to reduce recidivism going forward,” Freeman says. “Having endured some sort of trauma in childhood is fairly prevalent. [County staffers] may not realize that the work they are doing is interfacing with folks who may have experienced those sorts of things, and yet the data shows we all do.”

The task force recommends expanding the scope of the Community Health Needs Assessment, a component of the Affordable Care Act that requires tax-exempt hospitals to assess community health needs and gaps in care. The expansion would introduce social determinants as health factors that need to be assessed along with traditional metrics. It would also create an implementation plan based on the data from the CHNA. In addition, the task force wants to align ongoing public health initiatives with statewide efforts and create public-private partnerships with local businesses, philanthropic organizations, and government operations to coordinate and evaluate public health efforts.

To spread awareness of ACEs and trauma-informed care, the local organization Advocates for Health in Action is screening the film Resilience, which reviews the findings of the San Diego ACEs study and looks at ways to build community support systems through trauma-informed care. The next screening will take place at 8:30 a.m. on January 9 at Marble’s Kids Museum.

AHA will also be hosting a training session on December 10 at N.C. State’s McKimmon Center. It includes a free keynote address from Becky Haas, a trauma-informed administrator for Ballad Health, a health care provider servicing parts of northwest North Carolina, Tennessee, Virginia, and Kentucky. Attendees can also attend a training session on trauma-informed practices from 10:00 a.m. to 2:30 p.m. for $40. 

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