Recently the University of Wisconsin and the Robert Wood Johnson Foundation (RWJF) released its second annual County Health Rankings, a within-state comparison of county health covering each county in every state the United States. (Full disclosure, RWJF funds my position at the University of Pennsyvlania, but I was not involved in the county-health project.)
Newspapers and TV news programs jumped all over the results — particularly local outlets serving counties that were ranked comparatively lower than their neighbors. "If you are looking for a healthy county, head north," read a March 30 article in the Inland Valley Daily Bulletin of San Bernandino, Calif.
Some critics took the County Health Rankings to task for not telling us anything new. Which is a fair point — the researchers didn't collect any new data. Nor did they re-analyze data to test hypotheses, a common way that health-services researchers explore questions about health and health care. Instead, they simply aggregated previously collected information and compiled it into lists: some showed actual measures of health (like death and sickness rates), while others covered known determinants of health (including smoking and obesity rates, access to medical care, and socioeconomic status).
These results were not surprising: poorer urban and rural counties landed at the bottom of each state's health rankings and the richer suburban counties reigned.
So why does this study matter? The answer can be found in the big headlines peppering local newspapers throughout the country: people are paying attention. It doesn't matter that the findings fit with conventional wisdom. The goal of the RWJF study is clear — to make health and the things that contribute to poor health a priority for communities and their leaders. How it achieves that goal is all in the framing.
First, the report uses rankings — always a crowd-pleasing gambit — to compare aspects of health, invoking the competitive spirit of citizens and lawmakers alike. Second, it takes social and economic problems like income and education, factors that are often viewed as particularly intractable, and re-identifies them as primarily health issues.
Let's explore the comparative aspect of the rankings. Top 10 lists and college rankings fascinate people even if they don't have a personal stake in the list. But the county-health rankings take it up a notch by being comprehensive — rather than plucking out the top few healthiest or least healthy counties, it ranks them all. The result is that everyone has some skin in the game: any citizen, lawmaker or journalist can go look up his or her own county's ranking and compare it to its neighbor.
Learning that population health differs simply by geography can be galling. And that's the point. The County Health Rankings counteract the fatalism and randomness that many people ascribe to getting sick. Say you find that your county sits at the bottom of your state's list. You might want to know, "Why should my family, my coworkers and my neighbors be sicker or more vulnerable to getting sick than people who live elsewhere?" It feels unfair to you, and it is embarrassing to your local lawmaker, and so it becomes a call to action to improve health in your community.
The second smart thing about the County Health Rankings comes from its health-driven reframing of social and economic factors — these elements account for 40% of a county's health-factor score. Of course, we have known for years that education, employment, income and neighborhood safety are profound determinants of health. Yet, from a public policy standpoint, these factors are often thought of as separate issues, not specifically related to health. They're also some of the hardest problems to change and, yes, efforts to improve them are often the most politically charged. But by putting them into the stew, the County Health Rankings are making it clear that any efforts to improve health must consider social and economic factors. It's a bold and important step.
Here is the key question that the County Health Rankings does not answer: does where people live impact their health, or do people who already have certain health characteristics tend to live in particular places? Social scientists and health researchers have been exploring this chicken-and-egg question for a long time and the answer is, of course, both. (Someone who is very sick may not be able to move out of a bad neighborhood, but also, that neighborhood might not have an available primary care doctor to care for the sick resident).
The County Health Rankings don't try to tease out the directionality of causes and effects. The rankings take into account external environmental factors like air quality, access to recreation and presence of primary care doctors, but they also measure factors related to individual behaviors like smoking, excessive alcohol use and obesity. In theory, a county could improve in the rankings by getting smokers, drinkers and the obese to move away. But, obviously, this wouldn't be helpful from a public health perspective.
Another potential concern with the rankings is that some counties' populations are just too varied in their makeup to say anything meaningful about the individual communities they comprise. For example, Philadelphia, where I live and work, has world-class health care, lots of highly educated citizens and many recreation facilities. It also has areas of concentrated poverty, and high obesity and smoking rates. Where Philadelphia falls in the state's county rankings — dead last — doesn't tell us much about where to focus to improve overall health in the city. Perhaps, then, the rankings may be best used to compare less populous counties with similar demographic characteristics.
But at the end of the day, the concoction that is the County Health Rankings is an excellent starting point for communities to prioritize their efforts around health. An online search for County Health Rankings tells a story in itself: first, a local news outlet reports the rankings as a matter of fact story; then, an editorial uses the rankings as grounds for a health-related recommendation or two; and finally, law makers get in the game, building a new policy or program based on the rankings. "We are all in this together," they say. And it's hard to challenge that call to action when your family's community is languishing at the bottom of the health heap.
Dr. Meisel is a Robert Wood Johnson Foundation clinical scholar and an emergency physician at the University of Pennsylvania.