As a social determinant of health, geography matters, but it isn’t a life sentence

CLEVELAND – Stop me if you’ve heard this one: ZIP code is more important to your health than your genetic code.

It’s a pithy phrase that carries some serious truth. Where people are born, and where they grow up, significantly affects how long they’ll live and what diseases they’re likely to develop. Birthplace and geography are known as social determinants of health, and along with race, economic status, education and a few other factors, play a big role in how long a person will live and how healthy they will be.

In Cleveland, a county study found a 24-year life expectancy difference between two neighborhoods that are less than eight miles apart. The life expectancy in a wealthier area of Cleveland, Lyndhurst is slightly more than 88 years. Babies born in Hough, closer in the city, will live to be only 64 years old, on average.

United States from space. Image courtesy NASA Goddard Space Flight Center

United States from space. Image courtesy NASA Goddard Space Flight Center

This geography was the social determinant being discussed at the Association of Health Care Journalists conference, where Dr. Edward Barksdale spoke about his experience as a pediatric surgeon and surgeon-in-chief at University Hospitals Rainbow Babies and Children’s Hospital. He was joined by Kate Fox Nagel, Delores Gray and Dr. Sarah Redding on the panel “The tyranny of geography: Place, race and the social determinants of health.”

Barksdale moved to Cleveland more than 15 years ago, and he said he was initially shocked to see what his patients experienced everyday.

“I found violence against children that I could not imagine,” he said.

Growing up in Pennsylvania, Barksdale was familiar with the old miners’ expression about the canary in the coal mine, and he felt the children he treated, some of them gunshot victims before they could walk, were a symptom of a much larger problem in Cleveland.

“My office shared the ZIP code of many of these, what I felt were urban violence and atrocities,” he said. He wanted to do something to challenge the shootings and gang activity in the neighborhood where he worked. That neighborhood was regularly identified as one of the most dangerous in America.

Together with the Cleveland police and a number of charitable organizations, Barksdale helped implement Operation Focus. The program identified potential gang members in the area and brought them in for educational sessions. These talks spanned awareness of the effects of gun violence on their neighbors, presentations from former felons about the realities of prison and alternative lifestyles to get out of the gangs.

During this effort, Barksdale learned that 67 percent of urban crime in Cleveland was being committed by less than 1 percent of the population, so targeting that group could measurably decrease the violence. After treating young victims of violence for several years, Barksdale said he had preconceived notions about the perpetrators that didn’t always turn out to be true.

“I thought of them as sociopaths but when I looked at them, I saw they were hurt,” he said. “Because they had been hurt, they needed healing. And as a physician, that was something I could understand.”

Working with the Operation Focus program, Barksdale found that many of the gang members had been victims of crime or poverty when they were young, and the result of these intense stressors was violence. When young people grow up in impoverished neighborhoods, the consistent trauma has a measurable affect on their psychological well-being.

“The greatest healthcare threat is really poverty and the toxic stress it creates,” he said. “It is incendiary.”

Cleveland’s intervention seems to be working to break the cycle of poverty and violence. Operation Focus and related programs started in 2008 and in two years, the neighborhood it targeted had the lowest murder rate in the city, Barksdale said. The organization received a grant from the U.S. Department of Justice to expand and continue its efforts and they’re continuing to see improvement.

As a pediatric surgeon, Barksdale said he cares for only the “blossom on the tree” of a city which is often fragile and subject to problems in its environment. But by improving the environment, he hopes to help the blossoms thrive.


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