On the Human Condition
Volume XXVIII Number 2
Photo courtesy Indiana University
Taking Hoosier Health to Heart
Read the phrase "diseases of poverty," and what comes to mind? Rickets? Malaria? Malnutrition? In some places and at some times, yes. But in Indiana, in 2006, the big health threats that disproportionately plague the state's poorest citizens are obesity, diabetes, tobacco addiction, and cardiovascular disease.
As a professor in the Department of Applied Health Sciences in Indiana University's School of Health, Physical Education, and Recreation, Millicent Fleming-Moran has devoted her research to clarifying the relationship between poverty and susceptibility to these conditions. And as an expert advisor to state legislators and policy-makers, the Bloomington professor has spent decades fighting to improve all Hoosiers' chances to lead healthier lives.
Fleming-Moran recalls her tenure in the 1970s as an evaluator of state-run medical and safety agencies. "I realized that I could report back to legislators about whether these agencies and programs were fulfilling their statutory mandates. I could tell them how much money they were spending per person to do various regulatory activities. But I couldn't tell them a whit about whether they had actually changed anyone's health status," she says.
Fleming-Moran sensed this problem most keenly when she examined the state's Medicaid operation. "It was very difficult to tell to what extent Medicaid was working," she says. "Were some hospitalizations avoidable? Were some health outcomes--such as diabetics needing amputations--too frequent? Were there things that the Medicaid program could be doing to help people stay a little healthier?"
In pursuit of answers to some of these questions, Fleming-Moran entered a Ph.D. program in epidemiology at the University of North Carolina. She studied hypertension in working women from an economically depressed mill town in the state.
"Like Indiana, North Carolina is in the 'stroke belt,'" she says. "And not only does the state have an elevated stroke rate, but African Americans in such areas have an even higher rate of hypertension and stroke."
Fleming-Moran's study bore out the findings of other researchers that minority status, like low socioeconomic status, is a risk factor for high blood pressure. "People respond to hostility, to anxiety, to racial discrimination with increased blood pressure levels," she says.
Back in Indiana after earning her doctorate, Fleming-Moran was conducting patient outcome studies at the IU School of Medicine's Regenstrief Institute, located atop Wishard Hospital, which has a largely urban, low-income patient base. "It was really apparent that a number of the diabetes and coronary patients were far younger than one would expect," she says. "Even though these people were covered by Medicaid, they just were not able to use health resources the way other people would. I began to wonder what makes a difference in whether people get health care when they need it, what kinds of interactions they have with their health-care providers, and whether their treatments are appropriate."
Fleming-Moran is intensely aware of the difficulty of these issues. As an example, she cites a memorable conversation she once had with a physician who treated mainly low-income patients. She asked how many newly diagnosed diabetics under that doctor's care might be able to control their condition with dietary restrictions and oral medications, instead of insulin therapy. "The doctor told me," she recalls, "'I don't think you're going to find anyone on dietary management here. These patients are going to have trouble with any kind of compliance. We put them all on insulin.' I thought, 'This is prescription by labeling.' It was like we'd given up on them before we'd ever started to treat them."
As a member of the Indiana Public Health Association's board and head of its policy committee, Fleming-Moran is helping to change such attitudes, not only in clinical and scholarly circles, but in the public at large. Recent IPHA policy recommendations include practical solutions such as more healthful school lunch and snack options, increased cigarette taxes and smoke-free public spaces, and reducing the barriers to health care for underserved groups such as low-income, rural, or non-English-speaking Hoosiers. And Fleming-Moran unofficially ventures the opinion that a major reform of the health-care system may be more acceptable to Americans than ever before.
"I really think the country is at a stage where we have to do something," she says. "The current system is too much of a patchwork, too many people are left out. We all need a minimal level of access."
Karen Grooms is a senior editor for the IU Office of Creative Services in Bloomington.