Healthy and Healthier
The Doctor by Luke Fildes
Vermont is healthy, at least compared with the rest of America.
(It is mere coincidence that this appears the morning after the whole of America may – or then again may not – have taken a consequential step toward getting healthier; a topic for another day)
To take just one example, last year’s “America’s Health Ranking” by the United Health Foundation concluded that Vermont was the healthiest state in the Union, with “a low percentage of children in poverty…, a low prevalence of obesity…, a high rate of high school graduation,…
and ready availability of primary care physicians.”
But nothing is perfect. Even that United Health Care study showed that Vermont had too many binge drinkers and only moderate immunization coverage. Now three new studies reveal a few more possible flaws in Vermont’s health care situation.
And possibly some flaws in health care studies.
Take Cost of Delay, a new report by the Pew Dental Foundation finding that state policies across the country “fail one in five children” when it comes to their dental health. The report gives Vermont a middling grade – a C – leaving the impression that kids across Vermont must have mouthfuls (mouthsfull?) of cavities.
But no. Vermont children have one of the lowest rates of childhood tooth decay in the country, and nowhere else in America does as large a percentage of children receive dental services (though it’s only 57 percent; no state does all that well). Nor does the state suffer from a dentist shortage. Only 2.5 percent of Vermonters live in a “Dental Health Professional Shortage Area,” and the approximate number of dentists needed to remove the “shortage designation” is…one.
So why the mediocre grade? There seem to be two reasons. First, Vermont does not have a “sealant” program in 25 percent of its high-risk schools. In fact, Vermont has no sealant program in any school. Second, the state does not provide fluoridated water to 75 percent of the people served by public water systems.
But Dr. Patrick Rowe, the Oral Health Director at the Vermont Department of Health, said that even without the high school programs, Vermont has a higher rate of sealant use than most other states.
“In Vermont we do a great job with sealants,” said Dr. Rowe, speaking of the “thin plastic coatings… applied to the grooves on the chewing surfaces of the back teeth to protect them from tooth decay,” in the words of the Center for Disease Control and Prevention. It’s just that Vermont uses a different technique, Dr. Rowe said, employing a “tooth tutor dental access program” to reach children who haven’t been to the dentist.
Dr. Rowe agreed that Vermont should be doing better on the fluoridation front. “We do fall short of the national measure,” he said. Adding that his agency “tries to work with communities” where there is public opposition to fluoridating the water supply.
Vermont also seems to score relatively well in a scathing report about the treatment of poor pregnant women in America. According to the 101-page Deadly Delivery: The Maternal Health Care Crisis in the USA, a report by Amnesty International, “lifetime risk of maternal deaths (in the U.S.) is greater than in 40 other countries, including virtually all of the industrialized countries.
Here again, Vermont might be considered among the best in a not very impressive bunch. The state’s maternal mortality rate per 100,000 live births is 2.6, even lower than the recommended 3.4 percent, and the second lowest in the country. The study also praises Vermont for requiring employer-based health insurance to cover maternal care and prescription contraceptives, and for not allowing pharmacies to refuse to provide contraceptives.
On the other hand, Vermont does not have a maternal mortality review board, mandatory reporting of maternal deaths, or cultural competency requirements (sensitivity to different cultures, (ethnicities, non-English speakers) for doctors. More than 12 percent of the women in Vermont are uninsured, more than 10 percent of pregnant women (and 17 percent of nonwhites) received delayed or no pre-natal care, and almost 62 percent of those women were “unable to get care as soon ass desired.”
Amnesty International is an advocacy group, not a disinterested research organization, and some of its statistics are based on the findings of other advocacy groups, such as the National Womens Law Center. But the report also referred to official U.S. Government studies and to findings by the respected Kaiser Family Foundation.
Dr. Donald Swartz, the Health Department’s Chief Medical Director, said he wasn’t sure how Amnesty International came up with Vermont’s good 2.6 maternal deaths per 100,000 figure (it was from the National Womens Law Center) but he didn’t argue with it, either.
“We’ve always been among the very top for infant mortality (which is closely related to maternal mortality), an honor we routinely share with New Hampshire, Maine, Washington, and Minnesota,” he said.
At the state’s low rate, Dr. Swartz said, there wasn’t much left the state could do medically to get any lower. The challenge now, said, is “ is to improve living conditions, the social environment, and economic status to reduce stress to low-income women,” especially non-white low-income women.
Finally, from the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation comes an exhaustive report about the health situation in every single county in the United States.
Once again, Vermont looks pretty good by comparison. In this case, though, it is the differences within the state that are more interesting. Not surprisingly, Chittenden County is the state’s healthiest, and Essex in the Northeast Kingdom the least healthy.
Not surprising because Chittenden is Vermont’s wealthiest county, Essex is least wealthy. And where 45 percent of Chittenden County residents have college degrees, only 15 percent do in Essex County. That could help explain why people in Essex County are more likely to smoke or to be obese.
But as Dr. Swartz pointed out, they are also more likely to have graduated from high school. Ninety-four percent of Essex County residents have high school degrees, compared with 82 percent in Chittenden County, and 78 percent in both Caledonia and Bennington. And perhaps surprisingly, binge drinking was slightly more common in Chittenden County than in Essex or Caledonia..
“The exciting thing about this study is the recognition that tracking disease is not the way to track health,” Dr. Swartz said. “The University of Wisconsin and the Robert Wood Johnson Foundation figured out that prevention of disease is really based not on counting diseases and stamping out the causes of diseases. It’s building the social structure that allows people to be healthy.”
The information in the study, he said, could help health policymakers figure out how to build that social structure. “For instance,” he said, “you can take advantage of that 94 percent (of Essex County teenagers) in high school.” It makes them, he said, reachable, and therefore perhaps teachable, about good health habits as well as academics.
Maybe Vermont can become even healthier, at least compared with the rest of America.
