the measure of success.

How do we measure success?

The Pastor and I were discussing the events of the last few months and upcoming events. Elections, the national title game, the end of the church year, the end of the calendar year, the NFL playoffs, the Super Bowl, the upcoming year.  Each of these events has many ways in which those involved can measure success.  For some, success is equal to winning.  For others, success is equal to just being present in something greater than yourself. Success can be measured on a personal level, a team level, a national level.  And not all those measurements will come up with the same answer in the same situation.  Let’s take employment, for example.  If the unemployment rate goes down then, on the national level, it will be counted as a success.  But, if you lost your job in that same timeframe and are yet to find new employment I am guessing you would not agree that there was major success in reducing unemployment.

 

In medicine we measure success in many ways. One of the most common ways is morbidity and mortality.  Morbidity refers to disease or worsening health and mortality refers to death.  We view morbidity as complications or poor outcomes related to disease or surgical or medical interventions. Mortality is easy to measure.  Did the patient live or die?

How does our own nation do?  When we look at comparable countries (those with total and per capital GDP rates above average in the last 10 years) we find that we have worse mortality rates for almost all diseases than in those other countries.  The US spends more on healthcare than any of these nations.  Why the difference? Some of it falls on the healthcare system itself.  We have issues that lead to difficulty in accessing healthcare; we have a complex system that contributes to cost, and for many Americans a significant portion of that cost will be spent in their last year of life.  But there are also social determinants that impact our health.  We have more obesity, a more sedentary lifestyle, and more disease caused by environmental factors.  When we evaluate morbidity, or disease burden, we see that despite having a lower rate of smoking and alcohol consumption, we have higher rates of lung cancer, alcoholic abuse and alcohol related liver disease than comparable countries.

Now those are all national statistics.  Measuring outcomes in a large scale view.  It is not the only way to measure success.  A patient might measure the success of their surgery based on when they are able to get back to their yoga class or weekly run and their surgeon might be measuring success based on the time it took to complete the surgery, or by minimizing blood loss or the patient’s hospital stay. Your primary care doctor may img_5778measure success by looking at vaccination rates, patient satisfaction, personal job satisfaction or seeing that long time patient achieve their weight loss goals or quit smoking.  Your OB might measure success by lowering their c-section rate, improving quality of life in the women they care for or when that patient who has long-suffered with infertility or pregnancy loss finally gives birth.

How will you measure success in 2017? Maybe you will set a personal goal for your health, your business, your family.  Maybe you will look at national data like the unemployment rate or what the Dow Jones does.  Maybe you will measure success by what your own state does for its own citizens.  Hopefully many of us will measure success in ways that are much less “measurable” but in ways that have much more meaning.  May we measure success by how we treat our neighbors, how much our children know that they are loved, by how the widow and orphan are cared for and by how we have given away from ourselves in 2017.

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women on lockdown.

In 2013 the Center for American Progress rated Oklahoma as one of the worst places to live for women. Why?  Well, in addition to our above average gender pay gap, ranking near the bottom for women in poverty, and the huge number of uninsured women, Oklahoma has more women in prison than any other state in America.

As a background, the United States imprisons more of its population than any other nation in the world.  In the last 20 years, the percent growth of female inmates was twice as much as male inmates.  So, as a country we have a trend.  When you look at my own state, Oklahoma, we have experienced exponential growth in female incarceration not screen-shot-2016-12-26-at-9-09-16-pmseen in any other state.  As of 2015, Oklahoma puts 127 of every 100,000 women behind bars.  Compare that to 63 of 100,000 as the national average.  From 2015 to 2016, the number of incarcerated women in Oklahoma increased by 9.5% while the number of incarcerated men decreased by 1%. This begs two questions from me: Why do we have so many women in prison? And then, are we any safer or better off with all these women behind bars?

First, at least 2/3 of the women in Oklahoma who are in prison have committed non-violent crimes. Many are incarcerated due to drug offenses, which up until recently carried serious jail or prison time due to Oklahoma laws.  There is no compelling evidence that we are any safer with a high female incarceration rate.  According to the our state Bureau of Investigation, violent crime in Oklahoma was up about 3.5% from 2013 to 2015, and non-violent crime was down by about 4.5% in that same time frame.  The overall violent crime rate in Oklahoma has decreased 7.3% in the last 10 years, while the rate of female incarceration doubled in the same time frame.

For the last couple of years I have given a lecture to our second year medical students on the state of women’s health in Oklahoma.  The good, the bad, the ugly.  I always touch on our incarceration rate.   Why?  Because our other state health indicators are major reasons why we incarcerate so many women.  1 in 25 women enters prison pregnant.  Over 2/3 of incarcerated women have a minor child. The consequences for these children are devastating.  Also, more than half of incarcerated women in our state have experienced domestic violence in adulthood and/or abuse in the home as a child. About 70% have been diagnosed with a mental health disorder.  Why does this matter? Because in 2013, our state ranked 46th (where 1st is best) in mental health expenditures per capita that were state funded.  picture1Most women in our state who enter prison live in poverty and have a lack of education. Again, we rate 40th out of 50 for number of women in poverty.  When women in Oklahoma are marginalized in health and economics, they are disproportionately more likely to end up in prison.  But is the news all bad? Fortunately, no.  In 2015, our state passed 2 bills that allowed reduced sentences for drug offenses and judges to deviate from mandatory minimum sentences.  Then, in 2016, the people of Oklahoma passed a state question that made certain drug and theft related offenses misdemeanors instead of felonies.  The money saved from the reclassification of these crimes will be used for rehabilitation programs, thanks to another state question supported by the voters in my state.  Tulsa County, along with the George Kaiser Family Foundation, have established a Women in Recovery program.  Since 2009, they have helped 475 women and over 1,000 children.  But we still have a long way to go.

Why should you care?  What can you do?  I think, no matter what state you live in, the rate and growth of female incarceration in our country should alarm you.  As a gynecologist I’m probably biased but I think we can measure the success of our nation by the success of its women.  If we can keep women out of prison their children are more likely to succeed in school and avoid drug abuse and addiction.  We should be advocating for increased mental health services in our states and in our nation; for reduction in the gender pay gap and other measures to reduce the number of women and families in poverty.  We should find ways to reduce domestic violence in our nation.  We should support efforts like the Women in Recovery program, and drug and mental health courts that focus on rehabilitation services.  No one knows this better than my sister-in-law, who also happens to be editor-in-chief of this blog.  She works in the drug court system.  She sees women as offenders every day in her home state of Missouri.  She knows it takes, sometimes, half a dozen times or more for offenders to find recovery.  She will be the first to tell you there are no easy fixes and no simple answers.  But I believe if we begin to change the idea that prison is the solution, then we can begin to create a culture where we focus on restoration and rehabilitation for our women.  I think we will all benefit. We have a shared brokenness.  We should share in the efforts of recovery.

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the least of these.

If you don’t know, the healthcare system in our state and in our country isn’t perfect.  I know, shocker. We have problems in the system like limited access to healthcare, concentrated health care resources, lack of appropriate funding and lack of educational resources.

You also may realize that Oklahoma does not rank well when it comes to being a healthy state.  A review of our state health department’s state health report will reveal that as of 2014 we received an F in overall mortality with the highest rate for death in heart disease, stroke and are near the top in death from diabetes and near the top in obesity rates.  Almost 20% of our state’s residents don’t have insurance coverage and about 1 in 6 Oklahomans live in poverty.  Most of those living in poverty and many of those without insurance are our state’s women and young adults.

We know that individuals without medical insurance have poorer access to healthcare and overall worse health in general.  They visit the ER more often as uninsured individuals don’t have the ability to access preventative health or have a primary care physician they can see when they have a minor illness or need an urgent visit.  The uninsured with disease are more likely to have it diagnosed at a later stage and develop complications that result in long term harm or death due to their lack of healthcare.

The debate about what to do with our large uninsured population has been going on for over 2 decades.  Not many are willing to claim it isn’t alarming.  But most of us can’t agree  on what to do about it.  Our state has failed to pass a tobacco tax and a plan to expand medicaid; we have not found a reliable way to allow small businesses to provide insurance to their employees and we have left undone the poor, the widow and the orphan in our state.  The Affordable Care Act has helped some in Oklahoma but certainly is not the perfect solution to this broken system.  The reality is that healthcare is expensive.  Layers of administration and bureaucracy contribute to this.  A culture that says we must have the best drug or test and we must get it right away contributes to this.  We don’t have good programs to promote health and wellness, physically or mentally.  As our state gets more sick, the cost to care for our state goes up.  But just because we don’t have the perfect solution doesn’t mean we can check out and ignore this huge problem.

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Last week I had the privilege of staffing the Variety OB clinic, our Federally Qualified Health Center (FQHC) here in OKC.  I always leave these days with the distinct feeling that although my life is radically different in economics and culture than almost every patient I encounter there, I have shared experiences with them having been pregnant and being a mom.  In the end, we are all bound by the common denominator of the shared experiences of our health.  It is almost overwhelming to think about the disparities I encounter when I walk into each room.  My friend and former partner in practice Lydia is the director of women’s health at Variety Care.  They are a safety net clinic.  The clinic provides healthcare to those who cannot afford to go elsewhere.  She is working hard to make affordable and accessible healthcare a dream come true for our state.  Every week she sees this problem lived out.  She sees patients choosing between picking up their antibiotics for their infection or buying groceries for their families.  She sees women with advanced stage breast and gynecologic cancers that are no longer curable due to a lack of access to care.  These women, with proper access to care would have had a great chance for cure.  When her patients don’t show up for appointments she knows that it’s probably not because they don’t care but because they have limited access to transportation or childcare, or they work in a job with no paid time off.

So what are we to do about this enormous problem?  I think the first step is to understand that if you have access to good healthcare resources that there are literally thousands of men, women and children who are desperate for that access. If we only care about spiritual health and ignore the physical health of the community around us we are missing the point.  When you visit your healthcare provider know that you and I are among the privileged and recognize that this problem is a problem that belongs to all of us.  Not just if you are an Oklahoman like me; but no matter where you live.  The next step is to begin to advocate for the community around you.   Ignore the voice in your head that says something is good or bad based on the political party that endorses it.  Be a voice for those without a voice in the system.  Donate to your local community health clinic, speak to your legislator, vote with a heart that believes you should decrease so that those around you may increase.  Have eyes that see the hurting, the hungry and the sick around you.

And let the image that your eyes see move your heart to speak up and show up for the least of these.