187: The CDC’s Dr. Karen Hacker explains the link between social determinants of health and chronic disease
It takes a village to find and implement strategies that promote positive health outcomes in communities across the U.S. — and the nation’s public health agency is working to promote these innovations.
“The best innovations that we've had for humankind have come from these types of collective strategies,” says Dr. Karen Hacker, director of the CDC National Center for Chronic Disease Prevention and Health Promotion.
This week on the Health Disparities Podcast, we're joined by Dr. Hacker, who shares her insights on healthcare collaboration and bridging community-clinical services to help address social determinants of health, which are linked to chronic diseases that affect 6 in 10 Americans.
“The number one focus of our efforts is: How do we support the public health system to really think about strategies that are evidence-based to help their constituents across the nation make the healthiest choices that they can make?” she says.
Dr. Hacker joined Movement Is Life’s summit and spoke with steering committee member Sarah Hohman for this podcast episode.
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The transcript from today’s episode has been lightly edited for clarity.
Dr. Karen Hacker: The number of Americans with chronic diseases is pretty astounding. It's literally six in 10 Americans who have at least one but also there are huge volumes of people who have more than one chronic disease, especially as you begin to think about the definition of a chronic disease, and chronic diseases are among the leading causes of death and disability, and that includes number one being heart disease, number two being cancer. I think it's now, number four is diabetes. So basically they're all in there, and there are four risk factors that really contribute to the major preventable diseases.
Sarah Hohman: You're listening to the Health Disparities podcast from Movement Is Life being recorded live and in person at the Movement Is Life's annual health equity Summit. Our theme this year is "Health equity: Solutions from healthcare leaders." I'm Sarah Holman, a member of the steering committee for Movement Is Life and a director at Capital Associates incorporated, a bipartisan government relations firm in Alexandria, Virginia, that specializes in federal health policy. Our guest today is Dr. Karen Hacker, Director of the CDC National Center for Chronic Disease Prevention and Health Promotion. Dr. Hacker's presentation at this year's summit was all about social determinants of health and chronic diseases, and we're thrilled to have her now for this episode of the Health Disparities podcast, Dr. Hacker, thanks so much for being here.
Dr. Hacker: Thanks so much for having me.
Hohman: Most people are familiar with the Centers for Disease Control, but the full name is actually the Centers for Disease Control and Prevention. Many people don't know about that, P that prevention part. So tell us about that and why it's so important.
Dr. Hacker: So really glad that you asked, because I agree with you. I think a lot of people don't really know about that, the broad spectrum that we think about when we think about protecting health and saving lives, and somewhere in the 1900s there was a real radical shift in terms of what was killing Americans. Used to be infectious diseases, and then guess what? Turned into chronic diseases. And it's been that way ever since. And so during that period of time, I believe it was in the '80s or '90s, the name of the agency changed, and our center was birthed in part, I believe the first area that really expanded was in Heart Disease and Stroke Prevention, which is and continues to be the leading killer of Americans. The number of Americans with chronic diseases is pretty astounding. It's literally six in 10 Americans who have at least one but also there are huge volumes of people who have more than one chronic disease, especially as you begin to think about the definition of a chronic disease. And chronic diseases are among the leading causes of death and disability, and that includes number one being heart disease, number two being cancer, I think it's now, number four is diabetes. So basically, they're all in there. And there are four risk factors that really contribute to the major preventable diseases, and those are things like physical inactivity, poor food supply and poor food utilization, you know, nutrition in general, and then also tobacco use and excessive alcohol use and those four things. If we were really able to prevent those, we would probably see a major difference in what is killing Americans right now and the incidence and prevalence of chronic diseases. So we really take prevention seriously, and certainly within our center, which, as you said, is the National Center for Chronic Disease Prevention health promotion, it is the number one focus of our efforts, which is, how do we support the public health system to really think about strategies that are evidence-based to help their constituents across the nation make the healthiest choices that they can make.
Hohman: Wonderful thank you so much. You started to touch on this, but talk a little bit more about your specific role at the CDC, so leading the National Center for Chronic Disease Prevention and Health Promotion. What does that entail? And what are some of your top priorities right now?
Dr. Hacker: So at the CDC, there are currently 10 different centers, and I run one of them. It is one of the larger centers. We have nine different divisions covering the gambit, including cancer and heart disease and diabetes. But we also have a division that focuses on physical activity and obesity and nutrition. We have oral health, we have reproductive health, we have our Division of Adolescent School Health. I'm probably missing a couple. Bottom line is we have a large portfolio, and as the center director, I oversee the activities in all of those places. With that said it's important to also understand how we're funded and the resources. Come to us in a variety of line items from Congress. We have 42 line items in our budget, and they are very specific about what they fund. So there are lines dedicated to diabetes, to cancer, to all of these different divisions. I do not have any authority to move that those dollars around. It is really through the appropriations process that we get those resources. So with that, there is obviously a lot of activity going on in each one of those areas, but a particular import right now is things like maternal mortality, maternal morbidity, which has been a big focus over the last few years and an expanding area for us, but also youth. Mental health has been a big issue in terms of our work within schools and the food and nutrition and lifestyle issues, certainly with the advent of these medications that are focused on obesity, for example, we really are feeling strongly that people should not forget about the lifestyle changes. Many people cannot tolerate the medications or when they go off of them, they gain weight back, and that's going to continue to happen if we are not able to provide individuals with the information that they need to really make those healthy choices and at the same time really support communities to make sure that those healthy options are available to folks. So that's a lot of where we're focusing our attention right now.
Hohman: Wonderful, and how different that looks in different communities across the country, even within those individual centers, I think, is really interesting and certainly makes you have quite, quite a busy job, I am sure. According to the CDC website, your center uses Surveillance and Epidemiology to move data into action. Can you share some examples of what that that looks like in practice?
Dr. Hacker: I'm very proud of our data surveillance systems. I was previously a health department director in a local jurisdiction in Pennsylvania, and probably the thing I used most from the Centers for Disease Control and Prevention was something called the behavior risk factor surveillance system, which is a still random digit dial survey. They call people's cell phones and they ask a series of questions about people's behaviors, about whether they have chronic diseases or not, honestly, what their height and weight is. It's all anonymous. We have no idea who the people are, but this has given us information for years on what we call the incidence and prevalence of these conditions across the country. We do not get data directly from health care systems. I think that's important thing for people to know. Absolutely those, that's protected health information, and it is not required to be reported. Some infectious diseases are we call them reportable conditions, but diabetes is not a reportable condition.
So one of the things that's so critical about this particular data set is that gives us the information to be able to understand trends, to be able to understand in addition to the vital statistics, which tells us what people died of, this is our ability to understand how people are functioning. Do they have access to health care? Do they consider themselves to be have healthy days? You know, do they consider themselves to have the resources that they need? And then on top of that, what we're able to do with that information is to actually do a special type of analysis, which allows us to look at this data from a very, very local level. We call this our places data, P, L, A, C, E, S, go online. It's like fantastic data source. You can actually go over a map, and you can look at your particular community and get, I think it's 27 different variables that come out of the behavioral risk factor surveillance system, and another seven on social determinants that have just recently been added. And that information is so critical, like as a health department director, it would be very expensive for me to have to go out and do a surveillance system of my communities. We would try to do it, but you're talking hundreds of 1000s of dollars to conduct that, and to do that on a regular basis is not something that we could really fathom. So to have this data available from the government, from the federal government, was such a rich resource for us. And I would go out and talk to communities all the time, and they want to know, like, what's going on in my community and my neighborhood, right? They want to know, how do I compare to the other neighborhoods that may literally be across the tracks, literally, or, you know, over the river, or, you know, maybe a mile away. And they want to then people can use that information to make decisions about where to target resources?
Hohman: Yeah, absolutely. And data is such a critical part of that loop as you implement interventions or your states and local areas implement interventions, certainly from the advocacy and policy side of things, without data, it's very, very difficult to advance any of our priorities, and so that's really helpful. That's available to also the states and localities that that you support. Can you share some examples of some of the projects and programs that people may be familiar with but may not realize that they're coming out of your shop at the CDC?
Dr. Hacker: So we are a very large funder at CDC, and 80% of our budget, our budgets rather large, 1.4 billion, but over 80% of that actually goes out in grants. Most of those dollars are going to state health departments or or tribal or territorial health departments. That's part of what we're expected to do. We use the public health governmental system. Some of those do go directly to communities as well. So we're talking almost, you know, can do the math in my head, about a billion dollars. It's literally going out to the field. And we are probably the biggest funder of chronic disease prevention work at the state level. Now a state may turn around, and in some cases, we actually require them to do so and then give money to the locals or identify areas of their state that need particular support. For example, when I was in Pennsylvania, many rural health departments, they don't have a public health department, and so the state is the one that is dealing with public health in the rural communities, and it's often through our resources that they have any ability to really be able to talk about diabetes or heart disease or any of those other kinds of things at the local level.
So those resources, I think, are one of the biggest ways that we are really trying to address health issues and health disparities. And I'm not sure people really realize that with that there are some very specific programs that we have. We have something called the REACH program, which is specifically focusing on racial and ethnic populations. But we also have a high obesity program. Then we have a number we have National Diabetes programs and things like that that are going on to all the states that want those resources, and then, as I mentioned, some of these big surveillance systems, which I think people may not understand where they come from, but probably have heard about them or know about them. We are not a regulatory agency, but our objective is to think about what works and then help our recipients implement those in the field. And I think that is sort of a unique scenario. And again, as someone who worked in the field and wrote grants, a lot of grants, and got them from the CDC, it is a fascinating experience to now be on the other side, shaping what goes out in those Notice of Funding Opportunities.
Hohman: Absolutely. Thank you for sharing that I'm from one of those small, rural Pennsylvania communities that certainly benefits from from the work of the CDC here at the movement of life annual summit, your talk was focused on factors that influence health outside of the clinical delivery system and how they impact chronic diseases. So how do you define those non medical factors? First of all, and then what do you feel are the most important things that folks need to know when it comes to the vital conditions that shape health outcomes and chronic diseases?
Dr. Hacker: So there's a lot of factors, right? So when we talk about the nonmedical factors, call them the social determinants of health, we know that they contribute to more than 50% of our health outcomes. Where you live matters, likely matters because of the opportunities that you may or may not have to live a healthy life, whether that means access to health care or grocery store, whether that means places where you can be physically active, whether that means, you know, I could go on and on. There's a whole variety of things that we know affect our health. In the Chronic Disease space, we identified five specific areas that we thought we wanted to vote work work on. We were already doing some work in this area when I arrived, but we also knew we couldn't do everything, you know. We had to sort of focus our attention.
So the areas that we're really interested in particular. Number one has really been the food security area, right? Making sure that people have opportunity to get healthy food available to them, fruits and vegetables, you know, not highly processed food, for example. And that's sometimes hard, particularly in rural environments, as you know, you know, the irony is, they may be growing the food, but the food isn't staying there, it's going somewhere else. So that kind of opportunity has been something that we've been really looking at. The built environment is another one helping communities think about what their policy decisions are. Can they do a rail trail kind of thing? Can they think about a complete streets policy that makes sure that they have traffic calming, for example, so when kids are walking to school, they're not having to cross a dangerous intersection, a lot of those types of things, as well as when things are being built, that there is a consideration of how that's going to affect the community. You know, is there a park? Is there a green space? All. Whole variety of things like that, then moving into the connections to clinical care, because we know that in the public health space, we may be identifying individuals who have problems, high blood pressure, whatever, but they're not necessarily engaged in the health care system. And how do we help them make those connections? Or how do we support communities to help them?
Again, remember, we're not doing the work. We're giving the money to others, who then, in turn, are doing that work. Social connection turns out to be another big area emerging now. I think people are starting to realize how important those social connections are. There's there's a study that was done a while ago on a heat wave in Chicago, for example, and they had communities with elderly folks, and they actually had a lot of deaths, and the community that did better was a community where neighbors were checking on one another, where there was some social connection to see what was going on in those spaces. So, you know, we saw this during the pandemic as well. People needed to have connection. They needed to know that there were people looking out for them. And those, those are really critical, and we think particularly as in the older populations with healthy aging. And the last one is something we've been doing for a long time, which is really around tobacco policies. We've had enormous success in this area. Over time, our campaigns have been very successful, really driving people to consider cessation, which is fantastic, right? And then on top of it, I think having places where you can't smoke and all of that, and we are at the lowest level ever right now for tobacco utilization. So those are the five areas that we've really been concentrating on in that non medical arena. And again, I think that is a perfect space for public health, because the clinical system is going to do what the clinical system does. We hope they do it well, right now they're starting to do more screening for these social needs and social determinants, but they don't necessarily contribute to the greater good of and I shouldn't say that, because, of course, they contribute to the greater good, but they don't contribute to the population health necessarily. So I have members, they have users, and that's the group that they tend to be more invested in, understand that, right? So public health is sort of the entity that really thinks about the entire population.
Hohman: Absolutely and so important that those opportunities are in place for when the health system, maybe does those screenings, which we are seeing an increase in, which is great that they know where those connections are in the community, those social supports, abilities to connect their patients with some of those opportunities that a lot of your work and things like that has helped to fund and to put in place in those communities. So certainly, a lot of a lot of interplay there to make all of that work. What are some of the additional initiatives and changes that your agency supports aimed at promoting health and encouraging those health, healthy behaviors that we know are so important?
Dr. Hacker: So I mentioned all of these areas, and I think a lot of our work is also in the screening arena, right? So, cancer screening, diabetes screening, catching things, not just preventing it, which we think is important, but recognizing that sometimes you can't prevent things, and recognizing that picking things up early generally means that you're going to have a better outcome, right? So pap smears and breast mammograms and things like that, and making sure that those are available for people who may not have, for example, access to those services, or may not have insurance, or maybe have a high deductible plan or something like that. So, you know, we do help states, for example, provide some of that programming, colorectal screening, really try to push that agenda, especially with the health care system, and really make sure people are getting those screenings that are we know are so connected to making sure that if you do catch something early, that you have those options.
So for me, I think a lot of our work really is around trying to reduce those four risk factors that I talked about, the smoking, the high use of alcohol, the physical inactivity and the food security issues, the whole obviously, the obesity epidemic. We know there are things that work. A challenge for us, of course, is scaling that. I know the money sounds like a lot of money, but we're talking about very large problems in our country, and all these are all connected to one another, right? So we know that obesity is dramatically connected to diabetes, no question there, but also to Heart Disease and Stroke Prevention. And now we know it's connected. It's connected to cancer too. So if we could really address those four areas, we would see we've already seen, again, with the tobacco decreases, we've just seen big changes in lung cancer, for example, over time. So those the strategies, the evidence based practices. How do we get them in the field? How do we work with our jurisdictions to really implement that with our communities? How are they accepting them? Do they want to do them? Them. Where do they put them? I think all those questions are really paramount.
Hohman: Yeah, absolutely. And to just go on that thread a little bit further. So, you know, solutions look a lot different in different communities and for different populations. So how do you help to sort of resource share? You know, you're you're putting the money out to these states and communities, but how do you help to push out those evidence based practices as well that vary by community.
Dr. Hacker: So part of it is making sure communities have choice, and that they individuals and communities have choices to do what they think is the right thing for them. And so we really work with multi sector coalitions, okay, and encourage that. So many of our grants require that there be some coalition when I talk about multi sector, what I'm talking about is that you have health care at the table, and you might have transportation at the table, and you might have development, community development, at the table, as well as public health, because all of them are contributing to the solutions. And anyone by that, you know, we happen to be quite siloed, right? Certainly at the government level, it's true, but having worked at the local level, it's true there too, right? We all have our ways of doing business. We all have our nomenclature for how we do work, and it's hard for one group to get traction in another group, right? I always feel that the intersection is where the magic really happens. That's where we come up with the brilliant ideas. That's where we think together on solutions, and I've seen it work in action. I think what we're trying to do is catalyze that type of activity so that people are thinking in a different way, thinking about strategies. There's never going to be one group, one sector, that's going to have all the answers. I wish they did. You know, I would say, if we knew the answer, we would have come up with it. You know what I mean?
So it does take, you know, if you want to say, it takes a village, it takes a community. It takes people working together. And I think, in many ways, the best innovations that we've had for humankind, and certainly, you know, have come from these types of collective strategies that go on together. So that's a lot of the way that I think we are trying to influence change. But maybe influence isn't even the best word, because bottom line is we want communities to make the best decisions for them and for populations that live there. And I think that's not always something that's understood. You know, I think sometimes people feel government is coming and telling you what to do, and, you know, not allowing for that level of variety, but like what you're saying, you know, if you're in a rural community, what works there is not going to be the same thing that might work in an urban environment, right? If you're people have different cultural perspectives, and so what you provide, even in terms of food choices, might be very different. You think you're doing a great job, and then half the population doesn't use it because you didn't ask them first, you know? So I feel like that is really that underlying mantra. But again, remember, at a federal level, and this is so different than the work that I did in my other jobs. We're not doing the work right. We're really dependent on these other actors to take this information that we've gleaned and provide it to the populations that they're working with.
Hohman: Yeah, and try as much as you can be to be that connector and that facilitator of of the good work that that they're all doing. So you've talked about your background in public health a bit. From 2013 to 2019 you served as director of the Allegheny County Health Department in Pennsylvania. Can you talk about some of the health promoting work you did there, how it might vary, focused on reducing cigarette smoking, obesity and physical inactivity?
Dr. Hacker: Sure. So Allegheny County is a fascinating county. I don't know if anybody in your viewership, basically has been to Pittsburgh. They have really had their ups and downs. As you may know, they have a lot of legacy pollution. They still have steel, you know, in the community and the community itself, for example, is so fascinating to me, because I grew up in the Chicago area. And Chicago, you know, you sort of have the center of the city, and then you have the suburbs, right? It's sort of like people call it sometimes a hub and spoke kind of model. But in Pennsylvania, in Allegheny County, it's not like that. Because around the steel industry. They were all of these communities that basically were their own little areas, right? And they didn't really, they didn't travel to Pittsburgh necessarily, to work, right? They worked right there those communities, and these were thriving communities, you know, setting aside the pollution and the other things that might have been doing, and the hard work and all the other kinds of things that were happening, but they would have their own resources there.
And then later, what happened was, as the steel industry shifted and changed so dramatically, those communities were really depopulated in a lot of ways. So I was faced with a situation with 130 municipalities. House in my county, who were all independent minded, had no intention of merging. And my question was, how do I get a movement going? And we created something called Live Well Allegheny. And what we saw was that, over time, all of the communities started to adopt it, and I would often spend my Saturdays in my exercise clothes, going out to a local community where they were opening a park, or where they were doing an open streets activity, and be there as a health department director, and those kinds of things brought people together, and it was very locally based, right? Because one community did a park, one community created, they did a rail trail that actually, anybody goes to Pennsylvania. They've got this Allegheny Trail, which goes all the way from Pittsburgh to Washington, DC. And that was put together piece by piece by piece by piece across a lot of communities. So provide, you know, really, as a health department director, I had a bully pulpit, so to speak. I didn't have a lot of money. They do have a wonderful foundation community in that area, and so they were very generous, but usually for short term kinds of things, was building the momentum to really see health as a priority, and to really get people thinking about that.
So, you know, I think overall it, it was really helpful. The community was also changing. You know, that it had, Pittsburgh had been a very old community, and then over time, there was a younger population coming in, and they were demanding more opportunities as well. So, you know, that helps, I think, in a lot of ways. But you know, there were, there were certainly policies and regulations that went on. We ended up passing policy to make sure all the children were blood tested, for example. And that happened after there was an elevation of lead in the water in Pittsburgh, which was very disturbing, obviously, for a lot of people. So you know, you really think about, what is it that the health department can actually do in this space, and what is the population interested in us really focusing on?
Hohman: Thank you. We talked about this briefly, but given that our the theme for our summit, I want to spend a little bit more time on it. Talk about the importance of healthcare system collaboration and why it's so important when we consider addressing health disparities, to strengthen the focus on prevention services in particular. So
Dr. Hacker: I think first of all, we, you know, back to that old statement, we cannot do this alone, right? And I feel like we have done a really good job in this country separating Public Health from health care delivery, and we've been talking about trying to figure out how to get them back together, certainly during my entire career. And I think there have been efforts that have been successful, but the health care system is particularly in large urban areas. There's often a lot of health care systems, and none of them own more than perhaps 30% of your population, making it very difficult to have one health care system really be responsible for the health of the entire community. So that puts the health department, I did a lot of work trying to bring together the major health care systems in Pittsburgh, I had some luck. I'm not going to tell you, I succeeded 100% you know, business strategies get in the way people don't want to share that level of information.
We were able to look at data, for example, for oral health. We were able to look across data for four different health systems to try to understand what were the gaps and what were some of the strategies? But what I couldn't do is I couldn't get them all together to really come up with a consensus and to invest in particular strategies. And that was that was challenged. But as a health department, we were the neutral party that we could bring them all together and work with them as a group. And I think that that's been echoed through a lot of health departments across the country. None of them were neutral, right? So you couldn't expect one of them to bring all four together, but we had that position, and from our perspective, we wanted everyone to have opportunity and access to get the health care that they needed, right? We were not a we weren't a regulator of health care, because I think that brings a whole different discussion as well. But you know, you also have situations like in rural communities where there's like, one health care provider, there's no public health department, and that health care provider ends up sort of having to pull take up that role Absolutely, because there's no one else around.
And I think then you've got the State's got to get involved to really help that health care system figure out what's feasible, because it's not going to serve anybody purposes if they go under. And I think that we have to recognize that health care is a business, and so we understand that they have to be able to survive. They're highly regulated, and there's a lot of complexity to it, but that, I think, becomes really challenging when you're talking about communities where they are under resourced in general, like I said, rural communities, but I would also argue the same is true in communities where there's high poverty levels, things like that.
Hohman: Absolutely Okay. Last question for you, why is it important to also enable people to self manage chronic conditions, and what role do providers of community and clinical services have to play in that?
Dr. HackerL So I think that there's so much going on, for example, in the tech world now, and so much being offered that's outside the healthcare system, that I think that the area of self management is going to boom. It already is booming, and that we have to really be cautious that we don't see gigantic disparities as a result of that, right, that we get the people who figure it out, they've got the money, they can buy, the equipment, they can go to, you know, they can pay for other services, alternative care, whatever it is that they want, versus people who don't necessarily have those options. Right? I think that understanding your own health and making decisions that are right for you is really critically important.
But I also want to make sure that people are getting access to the services that they need. The health care system right now is having its own challenges, right? I mean, we have a very large demographic shift that's going on in this country, and that's the population that's over 65 right? They're living longer. They, many have chronic diseases. You know, the biggest risk factor for chronic disease is age, right? So, and they've spent their lives working, and they're going to use that health care system, right? And I can't, I'm one of them, exactly. But then what happens in terms of prevention? And so I think people are faced more and more with trying to figure out, well, what am I able to do for myself? We want to make sure that they get the accurate tools. You know, if they're we, we're really big on self monitored blood pressure, for example, right? So, but do they know how to take their blood pressure? You know? Do they know how to monitor it? Are there the strategies to get that information from them to a provider, so that they're working together.
There's a lot going on with home health, for example, so people don't have to make the trek to the health care system Park and do all the other kinds of things. How do we bring it into their homes? I think there's some fascinating things going on in that arena. And I think for us, we're very interested in what's going to be happening in the tech world, but also what's happening in the space of self management. You know this, we have a whole program on self management for diabetes, for example, and we do not think it's getting utilized in a way it should be getting used utilized, right? I think that the whole question of understanding, what should I be eating for me personally. But again, you get back to great, but if I can't get access to it, and if it's not affordable, then it doesn't help me, right? And I feel like those are some of the dilemmas that we're faced with at this point in time, in terms of thinking about, what can we in public health do? What can the clinical delivery system do? But more importantly, how do we actually work together? Because, like I said, I don't think that the clinical delivery system wants to become the public health system, right. I really don't, right. But at the same time, they're now collecting all this new data. How is that data available to the public health system so they can figure out, well, what else needs to be going on here? And unfortunately, we don't, no, honestly, we don't always work as well together as we could.
Hohman: Yeah. Well, always opportunities to improve and also celebrate those successes that we've had. Most certainly, I really enjoyed this conversation, and could continue it for much longer, but I would like to thank my guest, Dr. Karen Hacker, for being with us today at the summit and on the podcast as well. That brings us to the end of another episode of the Health Disparities podcast from Movement is Life. I'm Sarah Hohman. Until next time, be safe and be well.