Welcome to the June 2023 episode of the Healthy Intersections podcast!
This month, we sit down again with Carol Schmitt, Chief Scientist at RTI International, along with Juliet Sheridan, to talk about another of the RTI Rarity interactive state maps. This time, we are looking at North Carolina. We talk about historical redlining, climate change, and mental health — and how these all intersect.
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Transcript below. Click here to listen to/download the audio file.
Lisa Lines
Hello listeners and viewers. I’m Lisa Lines of The Medical Care Blog, producer of the Healthy Intersections Podcast. I’m also a senior health services researcher at RTI International. And I’ve got two other RTI International folks here on the podcast this month.
The Healthy Intersections podcast is sponsored by the American Public Health Association’s medical care section, and the medical care journal. And we’re hosted on the medical care blog. You can find the transcript for this podcast and our video on the on The Medical Care Blog. And I hope that you’ll while you’re there at the blog, I hope you’ll subscribe. And then you’ll get an email in your inbox whenever we have a new episode and a new post.
June 2023. Very excited to share this podcast today about North Carolina. North Carolina happens to be where our headquarters are for RTI. And so it’s a state that we all know pretty well. Some of us know it better than others. And so with that, I’d like to introduce our special guests for this month’s podcast. First, Juliet Sheridan. Over to you, Julie.
Juliet Sheridan
Great, thank you, Lisa. My name is Juliet Sheridan. I have worked in public health in North Carolina since 2015. Specifically in data related to health equity. North Carolina data is near and dear to my home.
Lisa Lines
Near and dear to your home, your literal home?
Juliet Sheridan
My literal home, I live in Durham County. I worked at the local level at a local health department as well as several nonprofits and a couple of regional collaboratives that were working to make sure that we got data in the hands of public health professionals so that we can really make a difference in North Carolina’s health. There’s a lot of really exciting conversations going on on the ground. And I’m excited to be able to share some of those with you all today.
Lisa Lines
Thanks, Juliet. And Carol Schmitt, chief scientist at RTI. Hi, again, Carol.
Carol Schmitt
Hi, Lisa. Yes. I’ve been working in community studies for about 25 years mixed methods, in the last few years has been looking a lot more at how climate change affects public health at the local level, and behavioral health, and who’s most at risk for the most dire consequences of it.
Lisa Lines
So the first thing we’re going to talk about is a static map that we have produced that is actually focused on Durham County. And Juliet, I’d like if you would, if you could talk about this map a little bit and what we see here.
Juliet Sheridan
Absolutely. So as I was looking at this map, I was really interested to see that mapped pretty perfectly onto the maps of redlining in Durham.
Redlining was a practice in the early 1930s and 40s, where mortgages could be insured by the federal government, which increased access to homeownership for a lot of white veterans that were returning from World War II. And areas like Hayti, which is the neighborhood around North Carolina Central University, were redlined, which is where there was a high proportion of black residents, and they were considered a poor investment. So mortgages were not approved, and only about 2% of black families were able to gain home homeownership during this time when 60 to 70% of white families were able to.
So that continued the trend of really targeted racial segregation and economic demolishment, I guess you could say.
Hayti originally was really a thriving community with lots of black businesses and areas where residents could go their whole lives with all of their needs met by other black residents. And in the 1950s, the Durham city council came in with “urban renewal” and tore down about 4000 homes and 500 businesses in the Hayti area, and then didn’t build anything else. So even today, it’s just fenced land, just grassy fields where it used to be homes and businesses and a community.
They also built the Durham Freeway 147, which is the line that you can see just above both of the central Census tracts we’re looking at.
And that was to segregate the Black economic area from the primarily White downtown. And to keep those residents separate. So even today, it’s not a very walkable area. It’s a seven-minute drive. But if you take a bus, it’s 45 minutes and you have to take two different buses.
It’s a food desert. The USDA Department of Agriculture has food desert maps. This is an area where a lot of residents don’t have access to a vehicle, as you can see about 20%, and also more than half a mile away from the nearest grocery store. So if you have no sidewalks and you have very few street lamps, and there’s no public transportation, how are you going to get to a grocery store to get food for your family, or go to the doctor, if the hospital is a 40 minute bus ride — two bus rides, excuse me — away from you.
Lisa Lines
Yeah, all those are really, really important points. And I wanted to just mention a couple of things about the Local Social Inequity score that we’re showing here. For those of you haven’t heard about this before, we’ve been featuring it on the last couple of podcasts. So if you’ve been following along, you may have heard about this before.
But this is a project of RTI. We call it RTI Rarity. And it’s an AI solution of RTI International. It’s an internally funded innovation project that I’ve been lucky enough to direct for the past three years. We’ve created these nationwide scores that are AI-derived predictive risk scores, basically predicting the risk of a shorter life expectancy. So it’s a percentile rank score for every tract in the United States.
Here, actually, we’re looking at just the North Carolina specific scores. So just relative to all of the other tracts in North Carolina, that’s the coloring that you’re seeing here. So the dark purple is sort of the best, or the lowest risk of a shorter life expectancy. If you’re born in that tract, you have a low risk of having a short life. \]
But in the bright yellow tracts, that’s where you have a high risk of a shorter lifespan. And if there’s one thing that the healthcare system really ought to be prioritizing, it’s the that everyone has an equal opportunity to make healthy choices and live a long and healthy life.
So here we have an interactive map of North Carolina and I will put the URL, the location in the notes, you can follow along at home if you if you’d like, you can visit this map yourself. And I want to note that at the bottom of the map, you’ll see that we have linked resources. So you can click there, you’ll go to findhelp.org, and you can put in your ZIP code, and you’ll get a list of all of the resources that are available in your community.
There are often, you know, hidden resources in these communities, and these communities may have resources that folks don’t even know about. So that’s really important. And it’s a big piece of connecting people to care.
So again, we have the bright yellow that indicates the highest risk of a shorter life expectancy, and that’s based on a number of social and behavioral determinants of health. And some of those we have actually highlighted on this map, where you can actually zoom in and click on a Census tract. And you’ll get some information about that tract, including the Local Social Inequity score, the actual life expectancy, and some characteristics of the population. And I want to mention that, outlined on our North Carolina map right now, we actually have the 1st district, the 1st congressional district of North Carolina.
Juliet Sheridan
That district has all of the counties in North Carolina that have a majority-black population. So where more than half of the county is black, all of them got grouped together in the 1st congressional district, which I think is part of a pattern of voter suppression amongst the Black population in North Carolina, along with many other measures.
Lisa Lines
Absolutely. And Carol, we’ve talked about that a lot. When it comes to, you know, interventions, one of the things that we try to tell people is, you know, vote! But if your vote is kind of diluted in that way, it makes it really hard. And when it comes to voting, one of the things that we have to do is vote about climate change, because that’s one of the existential threats that we’re facing now. So, Carol, can you talk a little bit about what the situation is in North Carolina with regards to climate change?
Carol Schmitt
Sure, if you magnify in a little bit down there, yeah, right there. That bottom river there is the Neuse River. It’s the biggest river in North Carolina, and right above it is the Pamlico River. They both go into Pamlico Sound. This is part of what’s called the coastal region of North Carolina, the middle region where RTI is in our view, sits right in the eastern part of the Piedmont region. And then of course, there’s the mountain region to the west.
This part of North Carolina, that whole coastal region, is most prone to the negative effects of climate change. It’s a part with a lot of agriculture, manufacturing, timber, aquaculture, and things like that. It is far more likely to have impacts of climate change in part because it, as you can see, it’s on the ocean. And there’s going to be sea level rise, which has already occurred, and increased hurricanes, a high level of precipitation, that whole area, a lot of it has a lot of rivers going through it. And a good example of what happened, happened in 2018, this was hurricane Irma I think it was, and when you flew over the state, all these rivers were flooded into this lowland, this is all lowlands.
And the other thing is that I’ve been looking at these Washington Post articles with these North Carolina second homes falling into the ocean… places that had hundreds of feet of sand in front of them very few years ago. But those homeowners are either insured by some kind of federal program, or they’re moving out, or something like that. But what else you see in this region is you see real inequity.
Here at the top of the local social inequity index, you have a high percentage of black people living there. Over half the people are poverty, smoking at 29%, which those of you are familiar with these data on, the national smoking rate is something like 12% right now, and this is, this is crazy, this is over twice as much. A quarter of these people are uninsured who lived here. And they’re physically inactive, which is an indicator of poor health. These are the people who are going to be most impacted.
And then this is another [tract] really close to the [first] one, where these people, you know, they have a higher life expectancy, they’re mostly white, very few live in poverty, they tend to be insured, they’re mostly employed, and their smoking prevalence is down around a little bit less than the national average. And so when it comes time when your house is inundated, who can afford flood insurance? And where’s the investment going to be made in in these areas, as the weather gets more and more severe? People who are better off can move, they have the resources to move in with relatives, rebuild their houses, if that’s what they’re going to do.
But people who are poor kind of disappear, like they did after Hurricane Katrina, into different parts of the country, and people don’t necessarily follow what happens to them. So there are going to be a lot of decisions to make in the future about where we’re going to invest our funds to help people adapt to climate change.
Another thing is, Lisa and I have been talking a lot about creating a local climate [impact] score, where we could identify what are the factors that are most associated with people at at risk? I mean, we know these are people who are, these are areas where people are vulnerable. But if we can identify, you know, what are the factors that most predict those who are going to have the most challenging outcomes, for instance, in a flood, then again, there are opportunities to identify ways to help them adapt, to intervene.
Lisa Lines
Yeah, thanks for mentioning that, Carol. Yeah, we have a local climate impact model that we’re working on that marries up vulnerability, resilience, and actual climate impacts. So a three-way kind of lens looking through, to try and understand where we need to pay attention in this kind of area. And I think we already know, you know, through the LSI, the vulnerability and the resilience, but we don’t have the climate piece of it. So that’s what’s going to be coming in.
Juliet Sheridan
So what we will also see in the rest of the state, even if they’re not on the coast and have this really high risk of feeling the impacts from climate change, there will still be areas where populations are adversely affected. So in Durham, a lot of the black families were forced to live in areas called the Bottomlands, which is near creeks that flood on a regular basis without climate change. And so we’ll see all of the same impact from from from flooding in some of the more inland areas, again, with in some of the black neighborhoods where we have seen systemic racism consistently target families that are forced to live in places where they don’t have access to any of the resources that are needed, though families have absolutely yeah, different populations will feel the effects of climate change differently based on the resources in the ways that society has prioritized or targeted them.
Carol Schmitt
And there are going to be decisions made about where money is spent because we are talking about a massive bill coming do it and who is going to get access to that money? Who is going to benefit? And who is not?
Lisa Lines
Yeah, I wanted to ask actually, I sent around earlier before our conversation, the top 10 predictors of life expectancy in North Carolina, in the state. And I wanted to ask both of you, the number one predictor was emergency department visits, I happen to actually write my dissertation about emergency department visits. So I have some opinions about why that might be coming up as important. But I wanted to hear from the two of you about your thoughts. What do you think is going on there where we
Juliet Sheridan
High ED visit rates are usually areas where folks don’t have access to primary care, or regular areas to get care for when they’re sick. So if you have a cold and there’s no doctors anywhere else, then you have to go to the emergency room. A lot of the hospitals in North Carolina recently have had to centralize meaning that especially sort of in the mountains, and in the areas in the coastal plain like Robeson County, the more decentralized clinics that people would otherwise go to have now consolidated into one hospital, in the region. And so we’ll see higher rates of IDI visit there. But a lot of it has to do with folks not having access to regular, regular primary care to prevent things before they happen.
Lisa Lines
One of the things that I think is really interesting about the IDI visit the the IDI situation in North Carolina right now is that there are an awful lot of people waiting for a mental health bed. And so that’s taking away beds for emergency medical situations. So there’s a real shortage of mental health related care and beds. And that is certainly causing a lot of backup in the emergency rooms right now. So I know Carol, you have a lot to say about mental health. Being a psychologist.
Carol Schmitt
No, I was thinking this, you know, those visits are indicators of a bigger issue. If you see a lot of IDI visits, you, you do assume there’s there’s uninsurance, there’s a lot of high uninsurance going on, there’s no advantage to being uninsured comes with a lack of a primary care physician, it means you’re getting treated later for care, maybe you’re getting diagnosed with cancer later, you know, because you, you go to the emergency room, when you’re really, really sick. And by then, you know, you’re really having pretty floored symptoms. So I always think about that more of as an indicator, rather than an individual thing, an individual factor.
Lisa Lines
You know, one of the things that’s really interesting about Edie use, and we abbreviate it that way in the medical circles, but I know it can be confusing, but emergency department rather than emergency room, which was a TV show, so Edie visits, you know, a lot of them are potentially avoidable. And those are the ones that I feel we really could actually make some impact in reducing potentially avoidable IDI visits if we gave primary care physicians more of a stake in preventing IDI visits. Because right now, if you ask people why they go to the IDI, half of them will tell you it’s because their PCP sent them. They don’t want to deal with their low acuity things that actually they don’t have time for. So they send them to the IDI. The other thing I’ve got to say dental care, if you have Medicaid, you may not actually have dental insurance, unless you’re a kid kids often will have mental will have Medicaid, dental coverage, but adults generally will not. And if you have an emergency, a dental emergency, you go to the to the emergency department and you get that tooth pulled and that is it. And so and that is one of the contributors to complete tooth loss that we see in some communities where it’s a really high predictor of short life expectancy, and I know that was on the list as well, and mentally unhealthy days. So that was the other thing that was second on the list was mentally unhealthy days. And that’s a perfect measure. So that’s the percent of people who said that they had mental health, not good 14 or more days in the prior month. So can we talk a little bit about deaths of despair in North Carolina?
Juliet Sheridan
Yeah, absolutely. And also wanted to mention so Durham Community Safety has started a program called HEART, which is an alternative to policing. They do crisis, diversion care, navigation. It’s just started in the last year, but it’s been really successful so far, and RTI’s TRUE, the Transformative Research Unit for Equity, has been working with them in order to show the impact of that. So I think there’s a lot of a lot of ways that we’re hoping to divert some of those mental health crises as well as other primary care needs into other options instead of just the police.
Lisa Lines
Thank you for that Juliet. Carol, anything to add there?
Carol Schmitt
You know, we, you know, those of us who live in In the bluer states than then North Carolina, Tennessee, tend to think that we’re doing so much better on these days, but we’re really not. I live in Colorado, we have a similar program started. But they had to meet some poor young man to death, who was acting out a couple of years ago down in, in Denver in the Denver area. They beat up on some poor lady with Alzheimer on the side of the road, and they did arrest her. And you know, they were very rough with her on the side of the road, because she shoplifted, and she was confused. You know, it’s everywhere
Lisa Lines
Right, we’re trying here to draw attention to the inequity across places, the fact that we can have, you know, two tracks side by side, that have such different health outcomes and such different resources available to make healthy choices. That’s where I feel, you know, if we don’t have you know, for forewarned is forearmed, we don’t have to wait till the next disaster this, this coming. You know, hurricane season is forecasted to be incredibly bad. So can we get out in front of that somehow? Juliet?
Juliet Sheridan
Yeah, I think we had a couple of areas in the area that I worked that that we knew were going to flood. Just even if it was a hard rain, it flooded. And so we were working with those residents. But as you mentioned, a lot of residents didn’t have the money or the time to be able to move from that area. And so it’s sort of an ongoing balance of making sure that the community where we live, is able to be safe and have safe places to go when there’s a hurricane. And also helping them find jobs or cars or other ways that they can change their circumstances so that they also have the resources to move out.
Lisa Lines
Wow, that’s public health? That’s the department of public health? Yeah?
Juliet Sheridan
No, it truly was. We worked with Health, Housing, Social Services, and the Department of Transportation and EMS.
Lisa Lines
A whole-of-government approach. Yes. Right. Right. Very nice. Very nice.
Well, I think we’re pretty much out of time here for today. Thank you for coming on today and talking with us about your home and your work. I really appreciate you joining us and Carol, a pleasure as always to get your thoughts and perspective. Listeners and viewers, thanks for listening and watching, and we’ll see you next month.
Lisa M. Lines