NASHVILLE: A TALE OF TWO CITIES

THE NAKED HOSPITAL ROUNDTABLESTEPHANIE BAILEY, MD,MS

AUGUST 26, 2010

Author’s GratitudeHealth Data Source

Metro Health Department, Nashville, TN

Former Director of Maternal Child Health, TN Dept of Health

Your presence at this roundtable

NASHVILLE: A Tale of Two CitiesBackground: Healthcare and the Naked Hospital

Plot: There are messages behind the numbers that need to matter – whether within the 10% or within the entire context of 100%

Characters: a host of them (Nashville’s images, children, data, the 10%/the 70%/the other 20%)

The Rest of the Story…to be written

Charles Dickens“It was the best of times, it

was the worst of times…”

..the rest goes like this…..“..it was the age of wisdom, it was the age of foolishness; it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going direct to Heaven, we were all going direct the other way…”

stephanie bailey:“….these are the times we

find in every local community of our

nation….”

Nashville, TN : Athens of the South

(NFL Team, Predators, Parthenon, # of institutions of higher learning)….but in our neighborhoods…

(2004)

KeishaDad in jail

5 siblings

older teenage sister has a baby

Age 61st grade

RenaldoMother killed at age 6

Father lives in East Tennessee

3 cousins in household

Age 116th grade

KennyFather in jail

1 of 6 children

Age 124th grade

ThomasCrack baby

Kicked out of school for attacking teacher

Kindergarten

RaphaelMother in jail

Waited all day to talk to mentor, wanting only to tell her about seeing his sister being shot the night before

Expelled at end of school year because someone said something about his mother

Age 104th grade

Christopher1 of 6 children

Father on disability

Suspended 2 x week, in school,for anger

All brothers expelled from school

2 older/2 younger

Age 125th grade

CourtneyMother incarcerated

Aunt raising 7 children,none are hers

Age 5Kindergarten

JarvisTwo older brothers, ages 16 and 17

Lives with aunt because both parents incarcerated on drug charges

October 2005, placed back in first grade…

Age 61st Grade

JackieFamily has been put out of MDHA

Was in room when uncle was shot

Has been raped

WHEN SHE GROWS UP……………… ……………she wants to be a doctor

Age 124th Grade

CharacteristicsIncarcerationHandicapsViolence, truancy, suspensionsMixed familiesFailure (academic)Needing and/or wanting attentionLack of toolsAdult indifferenceLow self esteem

Nashville, TN : Healthcare Capitol

But………

Infant Mortality Rates per 1,000 Live Births, Davidson County, TN 2000-2008

10.3

7.8

9.3

8.0

6.76.9

4.7

19.9

17.9

14.6

10.611.6

7.96.6

9.010.0

7.36.3

4.86.0

7.36.5

5.6

11.911.411.9

14.8

0.0

5.0

10.0

15.0

20.0

25.0

2000 2001 2002 2003 2004 2005 2006 2007 2008

Year

Rat

e p

er 1

,000

Liv

e B

irth

s

Total White Black

1960 1970 1980 1990 2000 20041 Sweden Sweden Sweden Japan Singapore Singapore

2 Netherlands Netherlands Japan Finland Hong Kong Hong Kong

3 Norway Norway Finland Sweden Japan Japan 4 Czech Rep. Japan Norway Hong Kong Sweden Sweden 5 Australia Finland Denmark Singapore Finland Norway6 Finland Denmark Netherlands Switzerland Norway Finland7 Switzerland Switzerland Switzerland Canada Spain Spain 8 Denmark New Zealand France Norway Czech Rep. Czech Rep. 9 Eng. & Wales Australia Canada Germany Germany France10 New Zealand France Australia Netherlands Italy Portugal

11 United States Engl. & Wales Ireland France France Germany12 Scotland Canada Hong Kong Denmark Austria Greece13 N. Ireland Israel Singapore N. Ireland Belgium Italy14 Canada Hong Kong Engl. & Wales Spain Switzerland Netherlands15 France Ireland Scotland Scotland Netherlands Switzerland16

Slovakia Scotland Belgium Austria N. Ireland Belgium

17 Ireland United States Spain Engl. & Wales Australia Denmark18 Japan Czech Rep. Germany Belgium Canada Austria

19 Israel Belgium United States Australia Denmark Israel20 Belgium Singapore New Zealand Ireland Israel Australia21 Singapore Germany N. Ireland Italy Portugal Ireland22 Germany N. Ireland Austria New Zealand Engl. & Wales Scotland

23 Cuba Slovakia Italy United States Scotland Eng. &Wales24 Austria Austria Israel Greece Greece Canada25 Greece Bulgaria Czech Rep. Israel Ireland N. Ireland26 Hong Kong Puerto Rico Greece Cuba New Zealand New Zealand

27 Puerto Rico Spain Puerto Rico Czech Republic United States Cuba28 Spain Greece Cuba Portugal Cuba Hungary

29 Italy Italy Bulgaria Slovakia Poland United States30 Bulgaria Hungary Costa Rica Puerto Rico Slovakia Poland31 Hungary Poland Slovakia Bulgaria Hungary Slovakia32 Poland Cuba Russian Fed. Hungary Puerto Rico Puerto Rico33 Costa Rica Romania Hungary Costa Rica Costa Rica Chile34 Romania Portugal Portugal Chile Chile Costa Rica35 Portugal Costa Rica Poland Russian Federation Bulgaria Russian Federation36 Chile Chile Romania Poland Russian Federation Bulgaria37 Russian Federation Russian Federation Chile Romania Romania Romania

Infant Mortality Rankings (Ascending) – 1960-2002; Selected Countries (Health United States 2007)

USWhites

USWhites

USWhites

USWhites

USWhites

USWhites

US Blacks

US Blacks

US Blacks

US Blacks US

BlacksUS

Blacks

Diagnoses of HIV Infection By Race and Ethnicity: Davidson Co., TN, 2005 - 2009PROVISIONAL DATA

0

10

20

30

40

50

60

70

80

90

2005 2006 2007 2008 2009Year of diagnosis

Cas

es p

er 1

00,0

00 p

eop

le

Black Hispanic

Other White

Data include persons with a diagnosis of HIV infection regardless of disease progression.

Note: The data contained in this document are provisional, as such, statistics should not be cited for publication. Data represents actual cases and are not adjusted for reporting delays.

Source: Metro Public Health Department analysis of HIV surveillance data diagnosed through December 31, 2009 as of June 18, 2010, Jeselyn Rhodes, MSPH

Numbers of Deaths by Diabetes for 100,000 Population, Davidson County, TN

0

5

10

15

20

25

30

35

40

45

50

Y2004 Y2005 Y2006 Y2007 Y2008

White Black Other All

Numbers of Deaths by HIV/AIDS for 100,000 Population, Davidson County, TN

0

5

10

15

20

25

30

35

40

Y2004 Y2005 Y2006 Y2007 Y2008

White Black Other All

10%–14%No Data

1995

(*BMI 30, or about 30 lbs overweight for 5’4” person)

2005

1990

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 1995, 2005

≥30%25%–29%

20%–24%15%–19%<10%

Nashville, TN : Music City USA

…and a church on every corner………but

Davidson County # 1 in SYPHILIS 1999

P & S Syphilis, Ranking of Nashville and Memphils among 64 Cities with More than 200,000 Population in US, 1989-2001

28

15 16

19 1917

28

15 16

19 1917 17

5

28

15 16

19 1917 17

5

122

5

11

3

5

2

443

2223

455

122

5

11

3

5

2

443

2223

455

122

5

11

3

5

2

443

2223

455

30

25

20

15

10

5

0

1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Nashville

Memphis

Background : Major Impacts on Healthiness

Genetics20%

Lifestyle50%

Environment20%

Access to Care 10%

Background: Health Status and Healthcare

SaferHealthie

rPeople

VulnerablePeople

Affected People without

complications(undiagnosed, asymptomatic)

Affected Peoplewith

Complications

Traditional healthcare

Disease CareExpenditures

Emphasis: end-of-life disease care

Access: unaffordable & unavailable for many

Results: variable & not transparent

Cost: variable & not transparent

Best results: not usually rewarded

Value: consumers lack information when making choices about care

Employers&

Businesses

Governmental Public Health

SystemHealth

Partners

HealthcareDeliverySystem

Traditional HealthcareCapable of miracles, but…

Public Health System Expenditures

Background: Traditional Public Health

SaferHealthie

rPeople

VulnerablePeople

Affected People without

complications(undiagnosed, diagnosed,asy

mptomatic)

Affected Peoplewith

Complications

Governmental Public Health

SystemHealth

Partners

Other Govt Agencies

Community &Faith-based

Organizations

HealthcareDeliverySystem

Traditional Public Health

Capacity: under-valued and under-resourced

Results: variable & not transparent

Cost: variable & not transparent

Best results: not usually rewarded

Value: consumers lack information when making choices about tax investments

Capable of miracles, but…

Clinical and Preventative Practice1971, Walsh McDermott

Cecil’s 13th Edition, Textbook of Medicine

Pubic Health System vs. Constituency Type System

1979, 15th Edition

2010: no watchdog, same dilemma, need for correction

Hippocrates

“the function of protecting and developing health must rank even above that of restoring it when it

is impaired”

The Rest of the Story: A Health System:Health Protection for Life!???

Public Health Network

Health Protection: Health Promotion, Prevention, and Preparedness

Healthcare Delivery System

SaferHealthie

rPeople

VulnerablePeople

Affected People without

complications(undiagnosed, asymptomatic)

Affected Peoplewith

Complications

Disease Care

The Rest of the Story: A Value-based Health System?

Emphasis: health protection(health promotion, prevention, preparedness) as well as disease care

Access: affordable & available for all

Results: measured & transparent

Cost: measured & transparent

Best results: rewarded

Value: equitable; transparent to consumers when making choices

WHO

EducationSystem

Employers &Businesses

Governmental Public Health

SystemHealth

Partners

Other Govt Agencies

Community &Faith-based

Organizations

HealthcareDeliverySystem

Capable of miracles!

“ When health is absentwisdom cannot reveal itself art cannot become manifeststrength cannot fightwealth becomes useless

and intelligence cannot be applied. ”Heruphilus 325 BC,

Physician to Alexander the Great

Improving Health in Our Communities

CONCLUSION……..“It is a far , far better thing that I (we) do, than I

(we) have ever done; it is a far, far better rest that I (we) go to, than I (we) have ever known.”

dickensdickens

THE HEALTH OF NASHVILLE

ARE US!