Healthier Cities for All: Can We Distribute Health and Wellbeing Equitably?

There has long been a paradox at the heart of healthcare in Cleveland, Ohio. While home to some of the best medical care in the world, Cleveland’s own neighborhoods experience some of the poorest of health outcomes. Now, one of Cleveland’s “big three” healthcare titans is pursuing pacesetting innovations for the health and wellbeing of communities of working people at the margins and communities of color beginning in its own backyard. And the EcoDistricts Protocol is playing a vitally important role in the innovation and transformation. 

Dr. Akram Boutros, President and CEO of The MetroHealth System, is an essential voice for transformation in the healthcare sector locally and nationally. In a recent speech to the City Club of Cleveland, Boutros highlighted these heartbreaking statistics from Cuyahoga County, its home county, and its largest center city, the City of Cleveland:

  • In Cuyahoga County, the death rate for cardiovascular disease is 21 percent higher than it is in the rest of the country.
  • In Cuyahoga County, cigarette use is 35 percent higher and in Cleveland, it’s 127 percent higher.
  • In Cuyahoga County, suicide rates are higher and flu vaccinations for those on Medicare are lower than national benchmarks.
  • In Cuyahoga County, of the 13,865 babies born in 2018, 117 died before they turned 1.

The shocking statistics had not been evident to some in the audience. And, to the surprise of many, Boutros continued: “we’ve got to stop promoting what happens inside our hospitals as if it really matters to the health outcomes of our communities. It doesn’t!”

Boutros is, sad to say, right. In the post-WWII United States, the focus has been on individual behavior and genetic inheritance as the essential determinants of health. Now, a greater awareness has emerged within medicine, epidemiology, geography, psychology, and sociology of the health effects of the social and physical environment in all its many varied forms. We now see the relationship between health outcomes and poverty; substandard housing; food deserts; unaffordable and inaccessible nutrition; poor early childhood support; inferior educational programs and opportunities; difficult working conditions; inadequate neighborhood and community networks; remoteness of safe greenspaces; and structural discrimination based on race and other attributes. These factors are what healthcare stakeholders have long recognized as the social determinants of health and these factors play a much larger role in health outcomes than clinical care itself.

Nationally, our healthcare system fails to ensure that all of us can achieve an optimal and equitable level of health. The CDC has reported that the historical gain in longevity has plateaued for three years in a row. In Cleveland and too many cities like it, health disparities vary widely across racial, ethnic and class lines. In an often-cited study, the life expectancy of a baby born in Glenville, a largely Black neighborhood in Cleveland, is 12 years shorter than one born in Lyndhurst, a mostly white suburb only 10 miles away. And most paradoxically of all, the poorest health outcomes by race and class in Cleveland occur in neighborhoods directly in the shadows of world class anchor hospitals. That’s the case with all three hospital giants in the city.

In the context of these menacing realities, Boutros and MetroHealth are nevertheless decisively determined to reverse these trends and offer the possibility of good health for all the people of Cleveland starting with the neighborhood the hospital anchors, Clark-Fulton, a community of color and working-class people. An imperative this bold requires a new approach and a rethinking of the entire system.

Systems level challenges require systems level solutions. Listening to a pitch from ReThink Advisors, Boutros quickly recognized that the EcoDistricts Protocol represents just such a systems level theory of change, one particularly well suited for innovation at the neighborhood scale and one which sees health and wellbeing as interdependent with other priorities and imperatives. An expert in population health and the research on the social determinants of health, Boutros immediately understood the ethos of the EcoDistricts Protocol: the neighborhood a child is born into does more to influence that child’s future than any other factor.

Adopting the EcoDistricts Protocol as a process and implementation framework, Boutros charged hospital executives and ReThink Advisors to convene a diverse group of community leaders from across sectors – a group now designated the Clark-Fulton Core Team – all working on a paradigm shift in how to foster inclusion, equity and greater health and wellbeing in the Clark-Fulton neighborhood. The Clark-Fulton neighborhood with its 12,000 residents, is home to the densest population of Hispanic and Latinx residents in the State of Ohio and, sadly, has, for decades, seen some of the poorest health outcomes in the City of Cleveland. But Clark-Fulton is now positioned to benefit from significant investments through the Mayor’s Transformation Initiative championed by Cleveland’s Mayor Frank G. Jackson, a comprehensive Community Master Plan led by MetroWest, the local CDC, and the MetroHealth Transformation, an emerging $1B investment the hospital is making on its main campus.

So, in the midst of a once in a generation neighborhood development opportunity in Clark-Fulton, the EcoDistricts Protocol is supporting MetroHealth and the Clark-Fulton Core Team in advancing a new approach to community building, one in which the health of people and the health of the planet are integrally linked and deeply considered. And, by adopting the EcoDistricts Protocol, MetroHealth and its partners including the City Ward Council Representative, Mayor Jackson and his administration, the Cleveland Foundation and the CDC are championing a model of health and wellness that rightly puts people at the center and genuinely focuses on societal and human needs.

The approach is already paying dividends. The process of developing an Imperatives Commitment – the first step in the EcoDistricts certification process – as a collaborative effort served to center tough but productive conversations on race and racism and added emphasis to MetroHealth’s efforts to shrink the health gap between whites and People of Color in Cleveland –  one of at least 20 cities nationwide to declare racism a public health crisis –  and Cuyahoga County. The process of developing a Declaration of Collaboration among the members of the Core Team along with a cohort of 12 resident ambassadors from the Clark-Fulton neighborhood fostered consensus on how the community can and will advocate for and decide upon change strategies while making sure the benefits and burdens of change are shared equitably among all residents including the most vulnerable. Completing the Declaration during the social isolation due to the COVID pandemic merely reinforced the principle that social cohesion and a sense of agency through collective impact are key social determinants of health.

Having completed and attained endorsement for the first two work products required for EcoDistricts certification, the Core Team and the resident ambassadors under the guidance of ReThink Advisors are now leveraging the Clark-Fulton Community Master Plan and its wider resident engagement process to develop the EcoDistricts Roadmap, a comprehensive action plan with metrics and performance targets across a wide range of priorities. The project partners will achieve EcoDistricts certification next year upon completion of the Community Master Plan after which they will launch a Performance Phase and begin to implement strategies. MetroHealth and the Clark-Fulton Core Team along with the resident ambassadors will begin tracking some 50 interdependent indicators across all priorities, publicly report progress toward performance targets, use the results to strengthen implementation and share the lessons learned. 

MetroHealth, principally through its Institute for HOPE, already seeks to address patient social needs as part of clinical care. A national leader in population health, the hospital uses patient screening metrics related to the social determinants of health. Still, it knows it can always improve and do more. Other hospitals tend to over focus on the technical characteristics of health metrics without sufficient attention being paid to the ecosystem surrounding an indicator, including who the end users are how they interpret the indicators, and the role that the indicator and its ultimate end user plays in health outcomes. MetroHealth and EcoDistricts are learning from each other. The process of developing the EcoDistricts Roadmap in collaboration with the local citizens’ assembly is serving to ensure the health metrics being measured are highly relevant and meaningful to the local population thereby improving treatment. Ultimately the data will better inform population health research and eventually healthcare policies (indeed all policy making) making them more targeted and effective by looking broadly at the on the ground conditions of the environment – the places including homes schools, workplaces, neighborhoods — where people learn, live and work.  

The project partners know that systems level change takes time, a decade or more perhaps to see appreciable improvements in health outcomes in Clark-Fulton. But they understand that transformation doesn’t always happen in a linear fashion either; it happens in cycles convergences and bursts. As an anchor institution, MetroHealth persistently focuses on the long game. The hospital is already a leading catalyst in the long-term transition toward value-based care. The planning, development and lessons learned in Clark-Fulton will continue to inform the transition in the healthcare industry from volume to value, and from a system focused on episodic, non-integrated medical care toward one of ongoing partnership with allied community players. Like EcoDistricts, MetroHealth focuses on sustainable “deep code” level change that addresses the root causes of disease rather than merely treating the symptoms.

For MetroHealth, the long view is both necessary and beneficial. By leading on knowledge and research of the social determinants of health and the reduction of health disparities by race and class locally in Clark-Fulton and Northeast Ohio, the hospital is capitalizing on a national and international opportunity to transform all of healthcare by highlighting the economic risks of inaction as well as building knowledge that is specific to the sector. Ultimately, systemic innovation to reduce health disparities by race and class in Clark-Fulton will benefit all communities at the margin and will be of incalculable value nationally and globally. MetroHealth is adopting and implementing new care models, propagating them, and exporting them as health care innovations. As a key thought partner, EcoDistricts is playing a fundamental role in this urgently needed innovation and transformation.

This work, that is the better understanding of health inequities and identifying the root causes, is vital. By defining health as integrated well-being, with environmental and social factors having equal emphasis alongside individual lifestyle choices, MetroHealth and EcoDistricts are helping Clark-Fulton, Cleveland and all of society see upstream, shifting the focus from treatment to prevention, and thereby creating more and better health and healthfulness for all.

About the MetroHealth System

The MetroHealth System, Cuyahoga County’s public health system, is honoring its commitment to create a healthier community by building a new hospital on its main campus in Cleveland. The building and the 25 acres of green space around it are catalyzing the revitalization of MetroHealth’s West Side neighborhood.

Today, its staff of 8,000 provides care at MetroHealth’s four hospitals, four emergency departments and more than 20 health centers and 40 additional sites throughout Cuyahoga County. In the past year, MetroHealth has served 300,000 patients at more than 1.4 million visits in its hospitals and health centers, 75% of whom are uninsured or covered by Medicare or Medicaid.

As an academic medical center, MetroHealth is committed to teaching and research. Each active staff physician holds a faculty appointment at Case Western Reserve University School of Medicine. Its main campus hospital houses a Cleveland Metropolitan School District high school of science and health.

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About ReThink Advisors

ReThink Advisors works at the intersection of urban design and planning, architecture, sustainability and community collective impact to realize large scale urban revitalization projects. Launched in 2008 by Irwin Lowenstein, ReThink Advisors taps a multi-disciplinary network of consultants to work with anchor institutions, municipal governments and community development organizations that are planning, building and leveraging strategic investments or seeking systems-level change. Utilizing a holistic systems-thinking approach – coupled with hands-on project management expertise – the firm guides development projects toward their maximal civic impact. 

ReThink Advisors’ clients recognize the importance of investing in capacity-building, which requires assembling a multi-disciplinary team and managing a complex process. This may involve any combination of interrelated services: smart master planning, empathetic community engagement, prudent financial oversight, active stakeholder facilitation, high-performance sustainability, resilient infrastructure planning, innovative urban design, equitable economic development, as well as inspired civic architecture. A successful process results in a deeply engaged community that continues to enliven, evolve and own the spaces, places and programs that result from the collaborations the firm assembles and guides.

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