What makes us healthy?
A talk with UC Davis’ Dr. Richard Pan about solutions in health care
Richard Pan wants to change the world.
No, he’s not running for president, he’s not running for governor and he doesn’t have a plan to balance California’s budget. The 42-year-old Natomas resident is a pediatrician and an associate professor at the UC Davis Medical Center who believes that improving local community environments is the best way to better public health. Dr. Pan believes this so strongly that he set up and runs an organization named Communities & Physicians Together, designed to encourage medical professionals and community organizers in the Sacramento region to collaborate on public-health initiatives.
In May, as a result of his work with this organization, Brown University awarded Pan its nationally renowned Thomas Ehrlich Faculty Award. Shortly afterward, Pan began circulating a “white paper” tentatively titled “Regionalism in California: the Road So Far, and Further What Makes Us Healthy,” exploring his holistic ideas around promoting good health. Although it has not yet been published, Pan’s much-anticipated paper has generated much buzz in the public-health world over the last few months.
SN&R sat down with Pan to discuss his views on health care and find out what makes him tick.
One hundred years ago, the public-health movement would have had no problem with a community vision of health. Then something happened and we started thinking about it all being about the individual. And now it looks to me like you’re trying to get back to a more communitarian-based model of health. Talk me through the key ideas, how you got there, what the social implications are.
In my view, one of the things that happened is that in some ways medicine evolved and we’ve developed more and better tools for treating individuals. And there’s been more focus on individuals and treating individual disease. A more reductionist approach. Of course, physicians in the beginning, when they had very few tools to start with—I wrote an article and talked about how the founding physicians in our medical society didn’t have a lot of tools to work with. They knew of five or 10 drugs that worked; surgery was a hazardous affair—they had anesthesia but didn’t have aseptic techniques. … So when you’re a physician back then and thought about reducing disease, you thought about how to intervene in the community. Sanitation. The cholera epidemic in Sacramento—you thought of public-health interventions. We’ve developed antibiotics and other tools, so of course there’s been more focus on individuals. The next iteration that’s happening is now the health problems we’re facing are ones that aren’t so amenable to just a very individual approach. Or let’s say it’d be very expensive if we just say, “OK, you have a problem, we’ll fix it.”
Let’s take obesity. It’s the No. 1 public-health issue. When we look at obesity, certainly we can do interventions. There are drugs that have very bad side effects. But it’s a very expensive approach to say the answer to obesity problems is we’re going to eliminate obesity by treating it once it’s happened. It’s such a resource-intensive approach to doing so. If we really want to look at how to address obesity, you need to look at social and physical environments in which people live—not just individual people but entire communities. Because children of obese parents are more likely to be obese; people living in environments where they don’t have appropriate food are more likely to be obese; people living in environments where they don’t have access to exercise—the environment, lack of facilities, things like that all drive obesity. Not to mention the larger things or marketing. Every time you turn on the TV, there’re all those food ads out there. So environment is going to impact obesity. If our primary approach is to try to fix it after the fact through medical intervention, we can’t afford to do that anymore. It’s getting too expensive. It’s too resource-intensive.
Let’s back up for a minute. How did you get started in all this?
I grew up in the East Coast, up and down the East Coast, and went to medical school at the University of Pittsburgh. There were two experiences that changed my direction. I was in college, a biophysics major; was interested in pediatrics, academic med, basic science—the molecular basis of health kind of thing. I did some lab work, then got interested and involved at the School of Public Health at Johns Hopkins and later, at Children’s Hospital in Boston. I ended up working for Center for Hospital Finance and Management with a bunch of lawyers and those types. I got exposed to the more financial and societal issues relating to health care. They were dealing with the economics and policy-making. I worked there as a research assistant. … It broadened my perspective on improving community health. And then I did my residency out in Boston and a fellowship at Massachusetts General, in child advocacy and primary-care research. This was at Children’s Hospital in Boston. So while I was there, I worked with a physician named Judy Palfry, and she’s someone who very much was interested in looking at the influence of community on child health.
Then I came to UC Davis, because they were interested in creating a program to train residents around child advocacy. That’s how I ended up setting up Community & Physicians Together. I recognized that when you look at the epidemiology of things, the amount the health-care system actually influences someone’s health status is 10 to 25 percent. So if I wanted to improve the health of children, I had to get out of the office. I said, there’s 75 to 90 percent out there, so I better figure out what that’s about.
So how do you apply this awareness to your work today?
We talk to our medical residents about determinants of health. What’s the role of the physician in the community? We could say our main role is to deliver health-care services, which we do—we work in a hospital or clinic, we do surgery, provide counseling. So we certainly deliver health-care services. Is our main job to be effective deliverers of health-care services or is our role to actually improve health? If it’s just to deliver health-care services, certainly we need to do it more effectively and a higher quality and so forth, but it’s a fairly narrow role. But if we’re supposed to be seen as healers in the broader sense, then we need to engage people in the community. As health-care professionals, we bring a certain amount of expertise, our knowledge of the human body, the experience of treating people who are negatively impacted, who have the diseases; we bring that knowledge to the table. We then need to partner with people in the community to help develop broader health.
How exactly does the community come into this?
It’s the community itself that creates the social norms. We talked about the importance of developing the capacity of the community to make the changes they need to affect their health, to empower the community, to develop social networks in the community. To increase social capital in the community, building bridges between more isolated parts of the community and, I guess, the more mainstream professional community. There are communities that for many reasons may be very distrustful, particularly poor and immigrant communities, of the mainstream. Because of that they often have poor access to services that are available, are less amenable to receiving messages that can improve health in those communities. At the same time, those of us who are more in the mainstream are less aware and less able to be sensitive to the needs of those communities. Bridging gaps, developing increased trust and reciprocity is essential to making changes to social and physical environment that then lead to behavioral changes we want to see to improve health in the community.
One example is we had a medical resident who spoke Russian—she had emigrated over with her family when she was young. We have a large Russian/Ukrainian community whose expectations of what they expect from health-care professionals are very different from what we deliver.
In what way?
If you have a positive PPD [tuberculosis skin test], you’re expected to take six months of antibiotics in case you’re carrying the TB germ. However, most people who emigrated had another type of test, the BCG. But the recommendation from CDC [the Center for Disease Control and Prevention] is if someone has a positive PPD, even if they had the BCG, you’d go ahead and still treat them because BCG isn’t considered to be effective; so what do you do when you tell them their PPD is positive and they have to take antibiotics? “What are these crazy American doctors up to?” That doesn’t exactly build trust and communication. Immunization is often another area where there may be differing expectations. So those are just examples. [One resident] worked with a local Russian radio station and actually had a call-in show to bring in questions about their children and their children’s health, bring in perspective. That’s just one example of one of the projects. The idea is to help bridge the understanding gap, trying to understand where the differences are and trying to understand both directions.
Is this a very new approach?
It’s somewhat new. On the one hand there are many other health professionals who are doing this kind of thing. There hasn’t been as much formal training in this. So that’s one thing that’s a little more unique. Our program is part of a larger program within pediatrics that recognizes more of this needs to be done. Children’s health is impacted by their social and physical environment. Physicians need to go out in the community and understand the environment in which children are living and partner with the community on how to impact that. We don’t just have our UCDMC residents partner with the usual suspects, institutions like schools and health departments, the other people in professional mainstream community; but also, how do you link with local associations, grassroots organizations in community composed of people who actually live in community? What are the priorities of that community? What are the things they identify as being the issues they think are most important, their own perceptions of what health is? We have our own ideas. But the community may have different priorities.
Have you seen marked changes in Sacramento?
It depends what you mean by marked changes. We’ve interviewed people about the impact of the program on their community. The biggest impact is the people who live in the community feel more comfortable interacting with physicians and health-care professionals. … One medical resident did a health- and safety-care show that brought together people in the community in the Alkali Flat Washington Elementary School. It’s now an ongoing thing that happens every year, and community has taken ownership of it. It started four or five years ago.
We had another medical resident who met with a group of parents up in [the] north Sacramento area, what’s now the Clinton Rivers school district; the event was a PTA—and they talked about what to fundraise for. They talked about nutrition. They ended up taking funds they were originally going to spend on sports equipment and instead invested in buying salad bars for the school. The school committed to purchasing the food if parents would fundraise upfront for the equipment. So now the children have the opportunity to be able to have fresh vegetables at lunch. So increasing their access to fresh vegetables. We took the knowledge of a physician and paired it up with parents who wanted to do something and weren’t sure what to do. And put it together and led to sustainable change at the school.
Have you seen measurable public-health indicator changes?
We’re not operating at a scale [where results can be statistically measured], if someone’s looking at a county scale. We started out with pediatrics. Now family and community medicine started last year. And we’re probably starting with internal medicine residents this year. We started with pediatrics in ’99 and have evolved since then. They spend three years with us as residents here; it’s a longitudinal program, roughly six weeks over a three-year period with us as part of their education. Spending a couple weeks in the first year getting to know community, and the next two years working on a project and developing a partnership with the community.
It does lead to attitudinal changes in the way our medical residents see their role in the community. When they first begin, we interview them during orientation. We ask them about the role of physicians in the community and what physicians would be doing in the community. Again, there’s a little bit of self-selection too, because residents who come to our program know they’re going to be doing it. So they’re already community-minded. They say the role of the physician is to speak for people who can’t speak for themselves, a paternalistic approach. If you’re poor, you’re a child, their job is to speak for people who can’t speak for themselves. After their experience, they talk more about how to support the community, and they know the community can speak for itself. Their job is to facilitate, to support the community with their knowledge and expertise and help community identify what they want to do, and how their role in health is broader than just seeing the patient. Helping coach kids in softball or soccer can help community health as much as just doing doctor things.
How does all this impact the broader health-care debate?
There are several different angles. There are issues of access, cost, quality. So, with access, I think certainly on one level we need to improve access to health care. I’m involved in a children’s health initiative here to try to provide increased coverage to kids: Healthy Kids, Healthy Futures. I chair the regional health initiative. So in terms of the uninsured, we need to improve that through providing them coverage. At the same time, obviously improving the environment in which they live and decreasing the demand for health-care services, while it doesn’t eliminate the need for health-care when you need it, overall benefits us as a society. If we take a more communitarian approach, hopefully there’ll also be more political will and collective efforts to improving health-care access.
People who recognize the broader view of health, that health care isn’t just about the individuals, it’s about the environment you live [in]; if somebody else doesn’t have coverage I’m affected. Let’s take influenza, if we have people uninsured, they’re less likely to get the influenza vaccine. So even people who do have health-care access are more likely to get influenza, because they run into somebody who hasn’t been vaccinated and are more likely to get the disease. It has an impact on the people around them as part of the environment in which people live. The other thing we recognize is even if you have access to health care, if you don’t adjust the environment in which people live there’ll still be health-care disparities. Even on Medicare, blacks have equal access as whites, but they don’t have the same outcome.
When we talk about costs, access to health care is important to health, but it’s not the whole picture. As a society we can’t afford to just try to fix things at the back end. It’s getting to be very, very expensive, and that’s the orientation our health-care system has; it’s designed to take care of acute illness, episodic care that isn’t going to fix you. To reduce costs we have to look at prevention and the environments in which people live.
Sometimes people say we can bring health-care costs down if people were just more aware of the costs, but what we know is most of the health-care expenditures are spent by people who are very sick—so there’s not much of a choice there. There’s only a limited amount of health-care costs we can reduce by saying we’ll make people buy health care the same way they buy food. It’s not quite the same thing. Your level of choice isn’t there. I’m a big believer in market mechanisms; I think they’re very effective. But the markets themselves include certain assumptions. When those assumptions are violated, the market doesn’t work as well. When you’re talking about health and choices about health, one of the market assumptions is that people have a choice about whether to purchase the good or not. You don’t have much of a choice if you have cancer or a heart attack. I guess the choice is spending the resources or ending your existence. So it isn’t the same as choosing what kind of food you buy or clothes or other kinds of items. Often health-care choices made by individuals have impacts on other people’s health as well as their health care. So basically, unless we as a society decide people should be allowed to die on the street, then there’re certain limitations to what degree we can leave health-care decisions solely up to the individual. In addition, individual health-care decisions can certainly have a greater impact on the larger society and everyone else’s health. So decisions about immunizations aren’t just about protecting the individual but any person who has contact with that person.
Philosophically, it sounds like you’re talking about a way of life rather than just a health-care crisis. What is your philosophy of life?
Well, everyone is connected to everyone else. No man is an island. Individual actions have effects on other people. So there are certain levels of responsibility individuals need to take, and collectively there are decisions we need to make as well. As members of society we need to all contribute to the well-being of the society. And we need to recognize that there are going to be limitations to our individual decisions that are necessary to ensure that society as a whole will not be unduly impinged by philosophical decisions made by individual members or components of society. That means we need some ground rules.
The right for you to swing your fist stops at my nose. So when it comes to overall health, we talk about the social and physical environment. And also to recognize that you have to include not just the explicit costs but also the implicit costs in calculating what kind of market signals you need to send. That’s a role for society, making sure these costs are built in. When you’re looking at tobacco, implicit cost is what society has to pay in health-care costs for people who choose to smoke. Or you can talk about pollution and use of energy. What’s the input cost of the pollution? There are health costs associated with that and other environmental costs built in. It’s not just a matter of how much it costs to pump out of the ground and refine it.
So you need to make the implicit costs explicit.
Right. And make more explicit the health costs to other types of decision making. So if you have a land-development policy that doesn’t incorporate sufficient open space, that doesn’t allow for exercise, that makes intersections unsafe for people to cross so they get hits by cars or bicycles or whatever else, well there are health-care costs associated with that. We require developments to have environmental assessments. We ought to have health-care assessments, too. Does it have health implications in terms of accessibility of schools, grocery stores? Are there adequate facilities for people to congregate and develop social networks and meet people and exercise? That reduces crime—which has health-care implications, too. So some of the social and physical environment issues need to be considered.
And they’re not at the moment?
I don’t think these are explicitly talked about. Sometimes they come out. We talk about smart-growth principles, but I’m not sure we’ve made that a particularly explicit discussion in terms of regional or transportation planning, regional development. I’m not sure we explicitly talk about the health impact of development. Those things do show up in discussions, but there’s not as much of an explicit discussion of how to link the different pieces together.
It’s a very ambitious agenda. How do you implement it?
Raising the awareness of how things interconnect. Broaden discussion of health beyond how to change health-care systems. We need to talk about more than health-care systems. When we talk about costs, we need to talk about more than what to do in the health-care system to reduce costs. What are the other decisions we’re making that will increase health-care needs and we’ll ask the health-care system to try to address? Access is not just coverage, but is also transportation and other things. We might want to look at those aspects as well. When we talk about quality of health care, it may involve how to make health-care systems more efficient, but we’ve also got to talk about prevention. What are communities doing to promote prevention? What are we doing overall on prevention? We need to look at the broader picture, better identify and quantify the linkage between the different pieces. Recognize that social connectivity is part of health, poverty is part of health. And that health is both something very individual and personal, but it’s also a societal construct as well. So it recognizes both parts. Something as individual and personal as one’s own health is impacted by these larger environments. When one wants to improve health, it requires both individual and societal intervention. No man can be an island.
You can buy a house and a gym and build a park around you, but in the end you still live in the larger society. So your health is still going to be impacted, no matter how much money you have, by the environment you’re in and the larger society. So saying I can make my own health just about me isn’t going to work.
Pragmatically, over the next few years, what do you want to see happening on all this in the Sacramento region?
I’d like to see a greater awareness amongst our various leaders and not just people in health care about the relationship between health and their decisions. So when we talk about crime, we talk not just about how many police we can get on the street. We talk about community interventions in health. We talk about the impact greater education and preschool has on health. When we talk about health-care access, we also talk about how do you create programs that will change people’s norms about health? You can give people coverage but if they don’t know how to use it …
We talk about development and transportation and look at the overall health impact. Another level is actually to look at developing, pushing toward trying to build the public-health infrastructure to measure this. We need to develop a better data infrastructure to be able to measure impact, so we can demonstrate it to the public. And we also need to look at trying to incorporate health assessment to impact decision making, particularly around some of the issues like parks and economic development, transportation, education. Those types of things. Perhaps the business community needs to be more engaged, as well as the labor community, in terms of looking at health impacts of economics. People are often looking at health care as a cost. Let’s take a look at the larger picture. What does it mean when an employer underinsures their employees? When someone makes a decision to allow a development that will foster increased disease or promote better health? What kind of environment do we want to have in the workplace that will be health-promoting, that will then have impacts on employers’ health-care costs since they’re providing coverage?
Are you optimistic this’ll start happening?
I have some guarded optimism. We do have a crisis in our health care. On the other hand, many people actually are satisfied with their health care. That’s part of the reason it’s been difficult to engage in health-care reform. But there’s a growing consensus we can’t keep affording the way our health-care system is going, and that eventually efforts will be made to create increased efficiencies to reduce the rising costs. But ultimately people are going to recognize that really the choice is between making our society more healthy vs. saying we’re going to let people die in the streets, we’re going to absolve ourselves of any responsibility over the health of our members. I can’t see the second happening, because that’s the optimist in me. We have too much compassion as a society to let that happen.