Dr. Akram Boutros addresses The City Club of Cleveland
"What Hospitals are Getting Wrong and How We Can Fix It"
Almost a year ago, June 8, 2018, Jon Pinney delivered a speech titled Dead Last: Northeast Ohio’s Economy is Lagging and It’s Time to Do Something About It.
My speech today was going to be titled, Cuyahoga County Health Outcomes: Dead First.
But City Club CEO Dan Moulthrop decided to tone it down.
I think he was afraid it might scare some of us.
With great affection for Dan – he knows I love him – we should be scared.
Not scared out of our wits.
Scared into them.
Scared enough to – finally – do something.
When it comes to health care: we’ve reached our day of reckoning.
We’re killing ourselves.
That’s why I’m going to speak in simple terms today.
I want to be perfectly clear.
It’s time to skip the big words and focus on big ideas. Ideas that require candor and courage.
And it’s time to put away our Midwestern politeness for the sake of honest conversation.
In the Game of Thrones, Ned Stark’s son asks him: “Can a man still be brave if he's afraid?”
Ned answers “That is the only time a man can be brave.”
I can tell you I’m afraid. I am afraid that the chance for us to be a great city for health care, not medicine– there’s a clear and distinct difference is slipping away.
The time for us to be brave has come.
We must hold each other accountable – every person in this room, every person listening on the radio, every person watching online – we must hold each other accountable for improving the health of all of us.
Poor health doesn’t just affect the sick. It impacts entire communities.
Its devastation spreads to those who are healthy, sometimes in quiet – and deadly – ways.
There are no such things as neighborhood issues, these are our issues.
And it’s time to stop ignoring them or speaking about them in polite, sterile, intellectual tones that make us feel, simultaneously good, and superior to those impacted.
For the past six years I’ve been hearing about the infant mortality problem in Cuyahoga County.
That’s one of those topics that we discuss in polite, sterile, intellectual tones.
I think it’s time to call it what it is.
What we have in Cuyahoga County is a black infant mortality crisis.
African American babies in Cuyahoga County die at 4 times the rate of white babies.
When we speak of this as an infant mortality problem and ignore race, we cloud the issue. And if there’s one thing we know about African American infant mortality is that it is due in part to structural racism. And so, to be clear about the definition of this. It doesn’t imply that the people who work in health care are racists.
Structural racism refers to the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, health care and criminal justice.
How can we solve a problem we’re not being perfectly clear about while ignoring one of its root causes?
The deaths of these black children must stop. They are an atrocity. And we must acknowledge that. To not do so is a moral outrage
And it’s not the only outrage we face.
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.
And our opioid deaths? They belong in a category all their own.
The rate of opioid deaths in Cuyahoga County is almost three times the national average. In Cleveland, it’s nearly five times higher.
I could go on.
Think about this! Here, home to some of the best medical care in the world, we can’t get it right.
What’s wrong with us?
What’s wrong is that we continue to believe that good health care can be measured by the size of our hospitals and the prestige of those who work inside them.
We think excellent health care is best defined by complex surgeries for rare disorders. And we – hospital leaders – keep confusing the public by focusing on ever-increasing high technology medical care and equating it to better health care.
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!
Research shows that good health depends far less on your doctors than on what happened to you as a kid.
Suggesting that expert medical care leads to good health outcomes conflates the two. And it ignores what has been staring us in the face since the beginning of time.
The stress of a tough life doesn’t just make you anxious. It changes the biology of your brain and beats the hell out of your body.
What I’m talking about here are Adverse Childhood Experiences or ACE scores.
It doesn’t matter if you’re black or white, rich or poor, born in the United States or immigrated from thousands of miles away, Adverse Childhood Experiences can kill you.
Almost half the children in the United States have experienced at least 1 ACE. One in 10 children nationally has experienced 3 or more ACEs, placing them in a category of especially high risk. In Montana and Oklahoma, 1 in 6 children has experienced 3 or more ACEs. In Ohio, 1 in 7 children has experienced 3 or more ACEs.
And before you ask me, let me tell you children of different races and ethnicities do not experience ACEs equally. Nationally, 61 percent of African American children and 51 percent of Hispanic children have experienced at least one ACE, compared with 40 percent of white children and only 23 percent of Asian children.
What are ACEs?
They are the struggles we survive as kids – things like abuse, neglect, and household dysfunction such as a parent with a mental illness, who’s violent, battling addiction or serving time in jail. Even divorce has been identified as having a significant and life-long negative impact on children.
There’s a second tier of ACEs, too, things just outside our homes – witnessing violence; living in unsafe neighborhoods, experiencing racism or bullying and living in foster care.
This exposure leads to both unhealthy and risky behaviors such as smoking, involvement with gangs, and drug and alcohol use.
The more ACEs in your life, the more likely you are to end up with diabetes, obesity, depression, a sexually transmitted disease or to attempt suicide.
Those connections are real and have been known for 20 years. Twenty years!
Once you think about this, it makes sense. It’s easy to see, for example, how childhood abuse might lead to depression later in life.
It’s not quite as easy to understand how ACE scores increase the risk for heart disease, strokes, lung disease and cancer.
But the link is there.
Whether you end up with cancer or not could be tied to your dad’s schizophrenia or your mom’s use of alcohol. Both of which have little to do with the kind of medical care you’re receiving.
So, I say it’s time!
It’s time to heed the words the Reverend Martin Luther King Jr. spoke 53 years ago when he said, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”
It’s time for us to stop speaking about critical life-and-death issues in polite and sterile terms.
It time for health system executives’ deeds to match both their rhetoric and the needs of our community.
It’s time for us to address the social determinants of health, which as you heard two weeks ago at the City Club from Drs.Toby Cosgrove and Amy Acton, Director of Ohio Department of Health, impacts 70-80 percent of health outcomes. That’s three and a half to four times the impact that your doctor, hospital, medications, and surgeries have on your health.
It’s time to focus on promoting health rather than fighting illness.
Of the billions of dollars raised over the past 10 years by hospital systems in Cleveland, it is estimated that less than 5 percent of that money – 1 in every 20 dollars – is earmarked for programs that deal with the social determinants that impact 70 to 80 percent of health outcomes.
This lopsided support goes to promote the status quo instead of changing it. If the reverse was true, every health system would have to quickly pivot its attention to the programs that improve the health outcomes of the entire community.
It’s time for us – you, me, business, philanthropic, and civic leaders of Cleveland and Cuyahoga County – to come together and invest in fixing the health-outcome crisis before us.
I don’t want you to leave today focused only on all this tough talk. I want you to know that there is hope.
Because health systems are slowly changing.
We’re beginning to intervene long before someone shows up in our emergency department with unbearable chest pain, unable to walk because of a stroke, blind from diabetes.
If we want people to live healthy lives, waiting until those sorts of things happen isn’t waiting too late. It’s immoral.
Which is why there are health systems and community organizations that are stepping in early, working – in dozens of ways – to prevent disease.
Here’s the other piece of good news about what can be done to fix some of these issues – it does not require heroic acts or advanced degrees.
Research shows that having just one trusted adult in your life can reverse the effects of ACEs.
That’s the reason MetroHealth has adopted the Open Table model.
Open Table brings together 6 to 10 volunteers who commit to spending time every week for a year to help a family or person in need by sharing their professional and personal experiences and support.
The team acts as cheerleaders, advisers, advocates, friends. They create an honest, supportive and hopeful system for individuals and families.
Instead of giving people who were homeless or grew up in foster care or recently immigrated one trusted adult, we’re giving them 6 or 7 or 10.
And they are making a difference. One table helped an 18-year-old explore job possibilities, fill out applications and practice interviewing. She landed a job – the best one she’s ever had – within weeks. Another will receive her master’s degree in a few weeks.
I can’t tell you how proud MetroHealth is to be the first health system in the country to adopt Open Table.
Today, we have five tables up and running. A sixth starts very soon. And our goal is to have 15 in place by the end of the year.
If you want to volunteer, please stop at the table in the lobby and pick up a brochure.
MetroHealth can’t be the only large employer sponsoring Open Tables. The need in Cleveland in enormous. Every company in Cuyahoga County with 100 or more employees should be sponsoring at least one Open Table. Every house of worship should be sponsoring at least one Open Table. Every civic and community group should be sponsoring at least one Open Table.
If that happens, we can have over 1,000 Open Tables every year. And, in the process, we can be connecting people and communities who don’t interact or trust one another. We can become an inclusive city that improves understanding and harmony. We can become a city where we are our brothers’ keepers.
And yet we can do more!
Promoting health and success in urban youth is why we opened the Lincoln-West School of Science and Health inside our hospital a few years ago.
Doctors and nurses, electricians and plumbers, employees in all careers, make themselves available as role models and mentors to these students. They become that one adult who can make a difference.
Students also spend part of their senior year in “internships,” working in fields – inside the hospital – they may be interested in.
Is it making a difference?
We think so.
Our first class of seniors graduates in two weeks. Their daily attendance rate was 97.27 percent. And every single one of them has been accepted to college. Compare that to our closest CMSD school, where the attendance rate is below 90 percent, the graduation rate is 70 percent, and the college acceptance rate is about 60 percent.
And yet we can do more!
Preventing childhood trauma is why we partnered with the Mount Sinai Foundation to launch the Nurse-Family Partnership, which sends nurses into the homes of low-income, first-time moms to teach them how to care for their babies – everything from breastfeeding to child development to connecting them to other services they need. The visits begin early in pregnancy and continue until the babies turns 2.
The goal is to prevent health problems, especially preterm births – the number one cause of infant death.
So far, we have seen more than 80 percent of moms in this program begin one of the healthiest starts you can give a baby: breastfeeding. And of the infants enrolled in the program, 100 percent had no hospitalizations at 6 months old and 100 percent were current with immunizations at 18 months old.
And yet we can do more!
Reducing financial stress in a family helps reduce chronic stress on our children and better connects the family unit. The chronic stress of poverty has been demonstrated to hinder the development of executive function and to create dysregulation of emotion and attention. These lifelong effects are some of the underlying reasons why children living in poverty may not excel in school, choose risky behavior and have more suicide attempts.
In Cleveland, 35 percent of households and nearly 50 percent of children under age 18 live in poverty. Whether you’re a business person, a civic leader or a social crusader, you must find this unacceptable. Cleveland will never become a great city unless we significantly reduce these numbers.
Businesses and agencies can join MetroHealth in increasing their minimum wage to 15 dollars an hour so parents don’t have the stress of working 2 or 3 jobs in order to pay the rent, keep the lights on and fill their refrigerators. So fewer of our city’s children live in poverty.
At MetroHealth, we don’t see this as a hand-out or a social services program. Rather it helps us attract, retain and promote more effective team members.
I think every organization should have an honest conversation with its lowest-paid employees and find out what life is really like for them. When we did, we found out about the 2 or 3 jobs, the worry about their children’s future, the longing to be more present in their family’s lives.
And yet we can do more!
Businesses can partner with minority business agencies to create synergies that impact a neighborhood.
We partnered with The Spanish American Committee, Turner Construction Company, the Cleveland Foundation, Cleveland Building Trades Council, the Construction Employers Association, the KeyBank Foundation and the Westfield Foundation to create the Latino Construction Program.
That 6-week program pairs a course in English-language construction terms with lessons in safety, understanding unions, work opportunities in the trades and more.
It’s one step of the “I Can” Plan, which leads to home ownership.
The Latino Construction Program began in 2017. And the third class of 25 students has just begun. So far, graduates of this program have earned more than $400,000 and are on their way to self-sufficiency.
I could tell you 100 more stories about what we – and others are doing – to reverse the effects of the social determinants of health which have resulted in our city and county having some of the worst health outcomes in the country while having some of the most advanced and celebrated medical facilities in the world. But those stories are best told by the people who’ve been helped.
If you attend our Annual Stakeholders Meeting on June 28th, you will meet some of them. And what you will find out is that every one of them is worth saving. And our world is better each time we do.
Today, these neighbors, friends, and patients are better employees, better moms and dads, happier people who are working on becoming an inspiration to others. They are being the example for those who do this work and for those who benefit from it.
I’d like to end with one more thought:If we truly want this to be a great city, if we really want to help people become the very best they can be, if we honestly care about our future, we must stop demonizing people who use drugs, who behave differently, are in jail, don’t have a place to call home.
The situation they find themselves in is often not the result of a moral failing.
It is the result of an illness. And these illnesses are born of a society that has invested billions in medical care and little in health care.
And it’s time we all did something to reverse that.
Look, if I have offended you, I am not sorry. I hope I have offended you into action.
I hope every person who listens to this goes out there and proves me wrong. If you or your organization are doing your part to end this health outcome crisis, I beg you to yell it from the rooftops. Let all those who want to join you know.
If you don’t think you’re doing enough. I beg you to join a group that is.
It’s time to stop applauding medical care that’s administered after the fact – no matter how good it is – and start providing health care before people get sick.
Let me say this again. It’s time to stop applauding medical care that’s administered after the fact and start providing health care before people get sick.
It’s time to stand up to people who aren’t doing enough to reverse Adverse Childhood Experiences and prevent childhood trauma.
It’s time to insist that they do.
Time to hold them accountable.
It’s time to be unabashedly honest.
It’s time to be brave.
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.
MetroHealth will break ground on the new hospital in late 2018, using nearly $1 billion it borrowed on its own credit after dramatically improving its finances. In the past five years, MetroHealth’s operating revenue has increased by 44.5 percent and its number of employees by 21 percent. Today, its staff of 7,700 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 percent of whom are uninsured or covered by Medicare or Medicaid.
The health system is home to Cuyahoga County’s most experienced Level I Adult Trauma Center, verified since 1992, and the only adult and pediatric burn center in the state of Ohio.
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 and its main campus hospital houses a Cleveland Metropolitan School District high school of science and health.
For more information, visit metrohealth.org.