As mayor of Kansas City, Kan., Joe Reardon is justifiably proud of the University of Kansas Medical Center, which has trained several generations of physicians and nurses for more than 100 years. After all, the medical center is consistently rated as the best hospital and treatment center in the state, according to a popular ranking of health institutions. So when Mayor Reardon—who heads the government of both the city and Wyandotte County, in which it sits—first learned that Wyandotte had come in dead last among the state's counties in a rigorous analysis of health measurements in 2009, he was shocked. “We have great access to excellent health care in a state where some counties have essentially no access,” Mayor Reardon says. “And we're ranked last out of 105 counties? My first reaction was, ‘How could this be?’”

The answer, Mayor Reardon discovered as he delved into the statistics behind the claim, is that proximity to fine hospitals and first-rate doctors is only one of many factors—and not always the most important—determining how long people live and how vulnerable they are to serious illness. Evidence collected by public health experts over the past few decades repeatedly shows that less obvious forces, including proper diet and exercise, higher levels of education, good jobs, greater neighborhood safety, and underlying support from family and friends, provide a powerful, and often unappreciated, boost to a community's health and well-being. By the same token, studies demonstrate, a poor showing in any of these areas can sink the health of individuals or of communities—even if they have access to topflight medical facilities.

The goal of the County Health Rankings project, which has given Wyandotte County low marks for health but high praise for its commitmennt to change, is to bring these hidden health factors to light and thereby help elected officials, civic leaders and community groups take concrete steps that can improve the health of local residents. The initiative originated at the University of Wisconsin–Madison, covering solely that state in 2003. A similar project began in Kansas in 2009, and in 2010 the Robert Wood Johnson Foundation in Princeton, N.J., provided funding so that the University of Wisconsin could expand its investigation to include within-state comparisons of counties in all 50 states.

Among the biggest lapses identified in Wyandotte County, for example, were much higher than average rates of smoking and obesity, lower than average rates of high school graduation, a distressing number of babies who weigh too little at birth, and a relative scarcity of fresh fruits and vegetables in grocery stores compared with the rest of the state. Mayor Reardon says these measurements have already transformed his approach to budget priorities. Changes include earmarking money for the addition of mentoring programs for high school students, new parks and sidewalks, and the opening of more and better supermarkets and community gardens in impoverished neighborhoods. And that is just the start, Mayor Reardon says. “The measure of our success as a city is not just how many jobs we create but also the health of our citizens.” He believes that potential employers who want to stay competitive in today's global marketplace are more likely to settle in communities where workers are both highly skilled and relatively healthy.

Public Health Strategy has Deep Roots
The notion that government officials can use public health statistics to improve policy decisions is not new. In 1854 physician John Snow, one of the founders of modern epidemiology, traced a cholera outbreak in the overcrowded London neighborhood of Soho to a contaminated public water pump by noting how many cases of illness clustered around the pump. (The pump was later found to be too close to a leaking cesspool.) Snow convinced officials to disable the pump, which helped to stop the spread of disease.

Today's health statisticians still search for instructive patterns of behavior and illness in communities, although they have moved beyond simply tracking infectious disease rates and deaths. Nowadays, says Julie Willems Van Dijk, a researcher at the University of Wisconsin Population Health Institute who helps county leaders figure out what to do with the data, public health officials also monitor quality of life and trends in chronic, noncommunicative disorders, such as depression, diabetes and heart disease.

The trick for researchers, Willems Van Dijk says, is to sift information from broad studies of large populations to identify behaviors and other influences on health that can be modified. The next step is to see how those factors play out at the level of the city, county and town, where many of the policy decisions that most directly affect people's health are often made. Individual cities started enforcing smoking bans in restaurants, Willems Van Dijk notes, after studies showed that secondhand smoke increased the number of heart attacks and cases of asthma in nonsmokers. The County Health Rankings project, now updated annually, is an attempt to provide reliable health statistics on a scale and in a format that public officials can use to take action, such as altering zoning rules to allow for beneficial placement of grocery stores, bike paths and parks.

Four Broad Categories
In comparing the counties within each state, Willem Van Dijk and her colleagues at the University of Wisconsin gather no new data. Instead they base their ratings on public information scoured nationwide from various sources, including the National Center for Health Statistics, the FBI and the U.S. Census. Their aim is to identify robust, reliable indicators that are measured the same way from county to county within each state for four broad categories—behavior, clinical care, socioeconomic status and physical environment—that research shows shape health.

Within these groupings, some of the most influential factors—such as smoking (behavior)—come as no surprise. Others include education level attained by most of the population (socioeconomic status), the relative number of sexually transmitted diseases diagnosed each year (behavior), and the number of car crashes related to drunk driving (behavior).

Researchers analyze a host of patterns in the data to help community leaders spot where improvements are most needed. For example, Wyandotte County scored particularly low on education in 2011. Part of the reason for that result is that just 60 percent of its ninth graders graduated from high school within four years, and only 42 percent of adult residents aged 25 to 44 had spent some time in college. Mayor Reardon hopes the high school internship and mentoring programs he has helped establish within the city government and within some of the county's high-technology firms will help turn around those low scores on education. Students need to see the link between college and a good job, he says, and to imagine themselves following that path.

Not Everyone Believes
Not every Kansas official has responded as enthusiastically as Mayor Reardon has. At a 2009 public meeting in Shawnee County (home to the state capitol, Topeka), then County Commissioner Vic Miller dismissed Shawnee's low health ranking (78 out of 105) as misleading. “Frankly, I can't imagine what argument you're going to promote that dropout rates in schools relate to public health,” Miller was quoted as saying in the Topeka Capital-Journal.

Willems Van Dijk says that Miller's skepticism is understandable, but the evidence that socioeconomic factors like education play a major role in health is solid and growing. For example, high school dropouts tend to die earlier than graduates. Further, their children are more likely to be born prematurely, robbing another generation of a healthy start. Every year of additional education improves those outcomes. “Research is now showing that many health effects once attributed to racial differences are actually tied to educational and economic disparities,” she says.

When Political and Health Priorities Collide
No one expects a county's overall ranking to improve overnight. “Where you are on the curve isn't as important as which direction you're moving,” Willems Van Dijk says. Wyandotte County was rated at or near the bottom of Kansas rankings for three years in a row and is likely to be there again when the state's latest numbers are released this spring. Yet Mayor Reardon is hopeful that the measures he is taking will ultimately shift the course. County planners must now consider the needs of pedestrians and bicyclists as well as drivers when designing road improvements, he notes. And a newly remodeled supermarket has doubled the amount of fresh fruits and vegetables that are available downtown. “There are a lot of polarizing issues in Kansas City,” he says, “but I've been pleasantly surprised to see that doing all we can to improve the health of our community isn't one of them.” That mapmaking visionary of epidemiology, John Snow, would be proud.

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