In August of 2010, I received a phone call no one wants. My cousin’s stepson had just returned from Afghanistan. He’d joined the Army after a tough childhood, surviving the divorce of his parents, his birth mom’s mental instability, and a patch of substance abuse. With tough love and endless family support he got clean. He planned to go to college, but opted first to serve in the military, where he served with distinction before an honorable discharge. During a visit with his dad and stepmom, the PTSD became too much, and he shot himself in his head in their bedroom. In their bedroom.
No parent could ever be prepared for the nightmare, but it’s more common than any of us want to admit. Every day, 20 veterans commit suicide. And it’s not just veterans — suicide is the second-leading cause of death in adolescents. And it’s not just suicide — 64,000 Americans died last year of drug overdose. Mental disorders, including depression, are the costliest health condition in the United States. Jails are filled with people with serious persistent mental illness. Every year, 43 million people in the U.S. have a mental health issue. In 9.3 million people, it is severe enough that it impedes the affected person’s ability to manage their daily activities. Yet among these seriously affected individuals, only 65% are treated each year; and for adults with any mental illness, only 43% receive treatment. Somehow, we have created a mental health system with inadequate treatment capacity, with the overflow managed through crisis-based criminal justice intervention. Houston, we have a problem.
Despite our outsized spending by most public health measures, the U.S. performs below other OECD countries. Less well known is that when we add health spend to health care spend (including education, housing, food security and long-term care), the U.S. investment is much closer to par. The ratio is dramatically different, though. Other countries spend about 2.4 times as much on social care as they do on health care; the U.S. spends about 1.1 times as much. If we believe the data about the social determinants of health, the larger investment in the upstream drivers of outcomes — changing the environment and impacting health behaviors — makes total sense.
As public health leaders have known from the time John Snow removed the handle from the Broad Street pump, breaking the cycle that perpetuates a problem by intervening upstream is far more effective than trying to cure every patient manifesting disease. We’ve done this with dental health. Since the early 1970s, by investing in fluorinated drinking water and toothpaste, the rate of teeth that are diseased, missing, or filled has dropped by 90%. A bit of investment upstream has saved both countless smiles and dollars. The lessons for mental and behavioral health are no different.
A foundational driver of poor health outcomes includes health disparities mirroring income and educational disparities. Today, maps on community commons show the same distribution for the percentage of people living under the federal poverty level, the incidence of diabetes, the incidence of depression, and premature mortality. In my neighborhood in the East Bay area of San Francisco, the average life expectancy at the 12th St. BART station is 73 years old; four stops away in Walnut Creek, it’s 84. As researchers have noted, ZIP code is a better correlate to overall health than genetic code. A frightening fact that should cause alarm bells for the future: 49% of children today are born into families poor enough to qualify for Medicaid. The health effects of poverty are impacting the future of the country.
The cycle that perpetuates poor health outcomes, including mental and behavioral health outcomes, makes sense after reading the literature on adverse childhood experiences (ACEs). When a child grows up in a home with child abuse, neglect, or household dysfunction, the risk of virtually every health morbidity increases. Compared to a child with no ACEs, if a child experiences four ACEs during their formative years, the risk of alcoholism goes from 1 in 69 to 1 in 6; the risk of becoming an intravenous drug user increases from 1 in 480 to 1 in 30; the risk of attempting suicide rises from 1 in 96 to 1 in 5; and overall life expectancy is 20 years less. My cousin’s stepson fell into this bucket: an uphill climb to build the mental resilience to survive the trauma of combat.
Communities of deprivation are disproportionately communities of color. While whites and African Americans use illicit drugs at the same rate, the rate of incarceration is six times higher for blacks. The U.S. system of mass incarceration has dramatically altered family life in African American communities. A black man born in 2001 has a 1 in 3 chance of serving jail time, a Latino man a 1 in 6 chance, and a white man 1 in 17. A parent serving jail time is considered a condition for an ACE, meaning a large number of children of color grow up in homes with not only poverty, but also a missing parent.
The neurobiological and psychosocial changes with exposure to traumas lead to high-risk health behaviors (smoking, drinking, promiscuity), which can lead to low resilience and high rates of depression/anxiety, in turn increasing risk of dropping out of school, perpetuating poverty, and increasing the risk of substance abuse and poor parenting that starts the cycle all over again.
But all is not lost. Despite the fact that poverty is in itself a key driver of poor health and well-being outcomes, we don’t have to solve poverty to improve mental health and wellness. Well-developed initiatives have helped improve health outcomes despite the inequities that exist. We don’t have to solve for both socioeconomic inequities and health outcome disparities concurrently to improve the lives of the next generation.
Of the successful programs that have made demonstrable impacts improving health outcomes and lowering the overall costs of care, leaders are adopting three key principles that are focused on upstream intervention:
- Understanding: They spend time understanding the problem in the local community before rushing in with solutions. Southcentral Foundation (SCF) in Alaska is a wonderful illustration of this approach. When SCF did their community health needs assessment in the 1990s, they heard how child abuse and neglect was endemic and top of mind. Based on the feedback, they completely redesigned their health care system to embed 1:1 behaviorist: clinical caregiver on their health care teams. They normalized talking about not just blood pressure and immunizations, but feelings, school performance, and relationships. The result has been markedly improved health outcomes (and two Baldrige Awards for exceptional quality) in a Native American community with high rates of poverty.
- Engaging: They engage a broad, diverse group of participants to design solutions, not relying solely on health care to solve the issue. A wonderful example in Scotland is the NHS-led Early Years Collaborative, focused on making Scotland the best place to grow up. By putting clinicians, educators, preschool teachers, public health advocates, and parents in the room, they decided a key driver of poor outcomes was poor parenting skills in the underprivileged group perpetuated from generation to generation. They designed the “bedtime bear” — giving every child a bear and book, with instructions to read the book to their bear every evening. These children (naturally) asked parents for help, increasing the rate of parents reading to children before bed. With a suite of other initiatives, they made real strides in improving formative early relationships between parents and children, breaking the cycle.
- Connecting: They connect the dots on implementation, ensuring coordination between health care, education, police, criminal justice, government, and business. In the early 2000s, San Antonio, Texas, had more mentally ill people incarcerated than in treatment, so the police and criminal justice system led a redesign. The police and the National Alliance on Mental Illness partnered to train crisis intervention teams to de-escalate and more effectively manage people in crisis. Health care, criminal justice, substance abuse treatment, and public housing collaborated to build a restoration center. People with a mental or behavioral health crisis (who have not committed felonies nor are significantly physically ill) are brought to the center, which offers inpatient and outpatient treatment, counselling, and even housing assistance. Today, the city’s redesigned system helps more than 18,000 people annually and saves more than $10 million each year.
A clear-eyed view of the current state — with physical and mental health infrastructure fractured into pieces — is a prerequisite for enabling change. Asking each community its top needs and paying attention to local conditions is job one. Building coalitions of all members of civil society to create solutions will diversify actionable possibilities, and ensure the pieces come together to truly impact the upstream social and behavioral determinants of health. This can make deep, broad, and sustainable impacts in the health and well-being of our nation. While income inequality and entrenched geographic and racial divides feel like insurmountable hurdles, individual organizations are doing it. By learning from what works and building on the successes that innovative communities have created around the world, we have the opportunity to change the course of the stream, impacting our health and well-being for decades to come.