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Chris Norwood

Chris Norwood

Posted: December 19, 2008 05:22 PM

First, Repair the Human Infrastructure


The human infrastructure of the United States is so shattered that some 35% of officially poor, middle-aged adults have three or more chronic conditions. Ill health is not just ill health anymore; it's a major cause of poverty, as disability rates soar. Yet, so far, plans for the massive "infrastructure" stimulus funding, which is supposed to put America back on its feet, alas, have only targeted the built infrastructure of roads and bridges, while bypassing any effort to restore the human infrastructure. In David Brooks' succinct phrase, the known plan, especially for an Obama Plan, is disappointingly "not attached to any larger social vision." It will leave little changed when the money runs out.

But, stimulus funding can readily be central to change -- and a social leap forward. In fact, using stimulus money to also rebuild our human infrastructure offers an unique scenario; it targets funding and employment to the poorest neighborhoods even while providing services that start to immediately save the nation massive public dollars. In barely a decade, stimulus funding used strategically now to prevent and control chronic illness will save billions in the galloping costs of medical care and disability. How often can you truly spend money to save money?

The reason for the unique stimulus value of "human rebuilding" is quite simple -- although little recognized. Education occupies a key role in both chronic disease prevention and effective self-care. Massive evidence also underscores that training and empowering people who live in low-income communities to, themselves, become the educators and leaders to reverse the ever increasing toll of chronic disease would be remarkably successful. For just one example, personnel ranging from summer camp counselors to local peer health educators, many without high school degrees, have been trained to teach proper self-care to children with asthma and their parents. Typically, after a short series of family education sessions, even when conducted by such "nonprofessionals", children's asthma hospitalizations, emergency room visits and lost school days plunge by 50% or more. The education, obviously, more than pays for itself in saved medical expenses.

But, before we go into more examples, let's understand where we are really. Chronic disease, much of it avoidable, is not just bankrupting the nation; the ever tightening grip of chronic illness on poor neighborhoods, reflected in soaring disability rates, assures that these neighborhoods become constantly poorer. For instance, in the South Bronx neighborhood where I run a grassroots health education organization, when we assessed some 1,000 adults living in nearby public housing for diabetes risks, 30% already knew they had the disease, and another 30% were at high risk for developing it in a few years. Meanwhile, in New York City, the $650 million overall cost of diabetes alone, including treatment, disability, and lost work is now the equivalent of 10% of the entire city budget! The nation as a whole is looking at direct medical costs for chronic illness approaching one trillion dollars in fifteen years if nothing intervenes.

And what could be a better intervention than stimulus funding that enables the neighborhoods worst hit by chronic disease to train and field local residents as health educators to teach well-proven protocols. For diabetes prevention -- clearly the nation's most urgent health task -- targeted education is absolutely it. In fact, educating people with "prediabetes" to just moderately change their diet and moderately exercise -- even walk for a half hour five times a week -- is twice as likely to prevent them from proceeding to the dismal life of outright diabetes as starting them on medication. This was proven in one of the most remarkable National Institutes of Health studies ever undertaken. It involved 27 research centers across the nation, from the Bronx to California, and enrolled 3,000 people with "prediabetes" -- blood sugar levels so high that, without help, most of them will have diabetes in ten years.

Despite the common notion that changing people's lifestyles is almost impossible, counseling and coaching prediabetics to reach two goals -- lose 7% of their body weight and exercise for a half an hour 5 days a week -- impressively stalled their descent into diabetes. In three years, 29% of the placebo -- or "no treatment" -- prediabetics developed diabtes as did 21.7% of those prescribed standard medication; but only 14.4% of the "lifestyle" group did. The costs savings, even with "lifestylers" receiving at least 16 counseling sessions, were staggering: $1,100 for a year of good health gained for "lifestylers" versus $31,000 for a year of good health for the medicated group.

These results, similar for men, women and all racial and ethnic groups, were announced to great acclaim in the New England Journal of Medicine in 2002. And then -- nothing happened. The nation still doesn't have a national diabetes prevention program based on this breakthrough study.

In a similarly depressing vein, hundreds of other expensively researched chronic disease prevention and patient self-care "mini-courses" -- for hypertension, asthma, diabetes, and heart disease alike -- now sit moldering and largely unused at the National Institutes of Health. The nation's vast medical industrial complex cannot -- and will not -- switch its focus from drugs and technology to, as the chronic disease crisis requires, teaching human beings about their health. The current "health care" approach, among other things, results in 88,000 diabetics a year -- most low-income and black or Hispanic -- losing their lower limbs to disease-related amputation, guaranteeing an endless escalation of disability.

But, the Obama Administration can make that change to education and empowerment -- and do it now. What is especially attractive about a stimulus jolt to rebuild our human infrastructure is that actual jobs can very effectively go to very low-income people who are rarely taken seriously for the leadership and progress they can offer their own neighborhoods. Over almost two decades, my own organization has probably trained more health peer educators -- in our case, people representative of the nation's poorest urban Congressional district -- than any group in the United States; at least half of those we've trained are recovering drug users and/or on parole, nearly all are on welfare or disability and many haven't finished high school. But, after being trained as health educators for some three months, these women, men -- and teens -- alike have provided a very sick neighborhood with empowering education which has reduced HIV infection, asthma hospitalizations and smoking, as well as helped diabetics measurably lose weight and start exercising.

Indeed, when we consider the true capacity of the poorest neighborhoods to themselves organize and fight endemic and epidemic disease , all we need to do is look properly at the AIDS epidemic. Because we rarely think of public policy in terms of what poor neighborhoods can do for themselves -- rather than what has to be done "for" them -- it is little recognized that the AIDS epidemic in the United States saw the spontaneous rise of a public health army never before seen, if even imagined. This national army of the sick, the poor, the variously stigmatized and outcast, fought its battle daily, month-after-month, year after-year; it was an army that trudged down alleys, into crack dens and sex dives and slogged tenement stairs, carrying its message of prevention, condoms, clean needles -- and hope. Underfunded as it was -- and is -- it is the main force which has kept the U.S. epidemic, despite the enormous HIV infection rates which had already taken hold before AIDS was "discovered", from expanding into the full disaster seen in many nations.
It is long past time for the United States, which has 54 million prediabetics alone, to activate a similar army to fight chronic disease. With a few strategic rules, particularly that money has to be assigned to community groups (which includes faith-based groups), actually located in the neighborhoods where education will occur, and stimulus funding of, say, $5 billion -- minuscule compared with the probable $500 billion for the built infrastructure -- the country can widely train the unemployed for a task of health education which must proceed.

In the process, it will slash its future health bill by literal billions -- but also impressively restore its human infrastructure on multiple levels that reap not just health, but considerable happiness.

Chris Norwood is the founder and Executive Director of Health People:Community Preventive Health Institute in the South Bronx. In 2005, she was one of 1,000 women from around the world chosen for a groundbreaking Nobel Peace Prize nomination honoring women's local work.