Healthy questions: For measuring region's health outcomes, questions are complicated

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GRAND FORKS—In the era of WebMD and Dr. Google, the average person is more empowered than ever to make a slightly educated guess at determining his or her health.

At the same time and the other end of an educational spectrum, health care professionals across the country are expanding that query beyond individuals to make it apply to states like North Dakota and Minnesota. The answers usually draw from any number of metrics commonly applied to population health and, by most of those metrics, both Upper Midwest states are in fairly good shape. But depending on who you ask, the diagnostic question could take on a much larger scope.

Grand Forks Public Health director Deborah Swanson has seen her role expand with a growing consciousness of health. She remembers when the job was mostly focused on communicable diseases, or illnesses that spread from one person to another. Now, as she parses through a recent community health study done by her office in cooperation with Altru Health System, Swanson says the mindset of public health reaches far beyond.

"We think of ourselves as the chief health strategists," Swanson said. "We're involved with bringing people together around a number of issues."

Whereas the department might have once centered on initiatives fighting infectious diseases like influenza, hepatitis and HIV, it now includes a heightened discussion of concepts like affordable housing, income inequality and educational attainment levels—as well as a raft of mental health items that fall under the category of behavioral health. Substance abuse and addiction have been an area of especially great focus in Grand Forks, where previously existing problems with drugs and alcohol has been compounded by the national opioid crisis.

Two staff members have also been brought on board to oversee the county's response to substance abuse. Michael Dulitz, a specified opiate response project coordinator, and Curtis Scanson, social detox coordinator, now fill roles that likely would not have existed at the public health center of a generation ago.

Dr. Ed Ehlinger is the commissioner of the Minnesota Department of Health. He takes a wide view of what it means to be healthy, especially when talking about the general public.

"Most people want to talk health and then they go into health care," Ehlinger said. "Health care is just a small piece—a very important piece—but a very small piece of what makes individuals and communities healthy. Public health takes into account medical care but also takes into account all the other factors that influence health."

Ehlinger is a proponent of a more holistic vision of health that can sound more like an approach to civics than a trip to the doctor's office. Among the concepts he lists as falling under the umbrella of health are things like voters' rights, public transportation and disparities of wealth and income. For Ehlinger, the idea of community—and, specifically, of individuals feeling connected to each other—is at the root at much of what we think of as societal health.

"There are other ways to address what we call the 'diseases of disconnection and despair,' " he said when discussing addiction. "You need to start building, on a community level, resilience, a sense of connection and belonging."

Back on the west side of the Red River, public health is the domain of Mylynn Tufte, state health officer for the North Dakota Department of Health. Tufte was appointed by Gov. Doug Burgum in February and has overseen the state's population health efforts since then.

Her summary of that work is a little less expansive than that of Ehlinger, but she's still quick to point to the number of moving parts involved.

"There are a million ways to measure health outcomes," she said.

The field is broad, but Tufte tries to distill things. When prioritizing her department's initiatives, Tufte says she's been "moving (our department) and the state to talk about health in a very simple way."

"We're asking what are we doing to improve both the length of life for North Dakotans and the quality of life for North Dakotans," she said. "If what we're doing is not meeting those two parameters—we shouldn't be doing it."

Physical signs

Philosophical approaches aside, it's some of those more tangible pieces that local officials look to when answering the big questions about societal health.

Some of those indicators include the ways and numbers in which people die. For both North Dakota and Minnesota, as for most of the country, lifestyle factors play a key role in the fatal diseases that affect the population.

North Dakota's top causes of death closely mirror those of the nation as a whole, with heart disease and cancer ranking first and second respectively through 2012-16. In descending order, state residents also died from Alzheimer's disease, chronic lung disease, strokes and diabetes.

Minnesotans faced a similar roster when summarizing causes of death in 2014, though cancer was more prevalent than heart disease. Both states counted accidents as their third-highest cause of death.

The timing of death is another indicator of note. Ehlinger highlights total life expectancy, infant mortality and maternal mortality as factors he looks to as some of the "ultimate measures" for gauging societal health. He said Minnesota does well in keeping overall infant mortality rates low relative to the national average. But the state has marked disparities among its ethnic populations, with more infants dying within the American Indian and African American communities. It's also recently seen an uptick in maternal death rates, which had previously been decreasing through the 1900s.

That statistic is concerning, but when Ehlinger generally compares the state to its neighbors, he says Minnesota is doing well for itself, a status he attributes in part to a strong economy.

One particular metric he highlights is the state's fight against obesity. Ehlinger said Minnesota's obesity rate has "not gotten worse, but flattened," a status he said has yet to be attained by neighboring states, including North Dakota.

"Few states have been able to bend the curve like we have with obesity," he said.

Ranking the states

Tim Wiedrich is the section chief of the North Dakota Health Department's emergency preparedness efforts. He echoed Tufte's description of the many ways health can be measured before pointing to a composite strategy used in a national state-by-state ranking conducted annually by the nonprofit United Health Foundation.

"The way they approach it, there are multiple things that define a score," Wiedrich said, listing variables such as rates of obesity, tobacco usage, and health system accessibility. According to the foundation's most recent ranking, North Dakota was the 11th healthiest state in the country for 2016, up one place from the year before. Minnesota was ranked fourth healthiest for the second year in a row and has been among the top six states since 1990.

The ranking named Hawaii the healthiest state in the country for the fourth year in a row. Mississippi came in last place. That state has never risen above the 48th spot in the foundation's annual listing.

North Dakota has seen more fluctuation—which may be due in part to its small population—but Wiedrich says the state has hovered around eighth or ninth place since 1992. He flagged three items, namely a high level of babies born at healthy weights, the lowest number of drug deaths in the country and one of the highest rates of immunization for children, as helping to lift the state's overall ranking. North Dakota also performs well in other categories, such as its low levels of air pollution and violent crime.

Other metrics are less rosy. The state comes in just one place away from last for occupational fatalities. It ranks 34th in the country when measuring rates of obesity. And Wiedrich said North Dakota came in "dead last for the country" for excessive drinking.

"We're the least healthy, in terms of alcohol consumption, of all 50 states," Wiedrich said.

Many, if not most, of the metrics included in the ranking fall under a more preventive approach to health that's increasingly embraced by practitioners and state officials alike. Several touch on the handful of behavioral items described by UND medical school Dean Joshua Wynne, who said they only "sound easy—they're tougher do,"

For Tufte and Ehlinger, who both stress the role of social connectivity in maintaining health, the best answer might be to not go it alone. That's a strategy that Swanson said has long been in play for public health officials—she says it's only more recently that it's been adopted by the wider net of local partners. Ehlinger underlines that point and takes that even farther.

"I believe that health is a community issue," he said. "Individually, you cannot be healthy unless you have a healthy community around you."