For the past five years, Suzanne Mineck’s team at the Mid-Iowa Health Foundation has been working to develop, fund and expand initiatives to identify and address negative social determinants of health that contribute to and perpetuate disparities in health outcomes for children in Central Iowa. 

The foundation’s work has become particularly relevant in 2020 as social justice organizations have sought to raise awareness of racial inequities that are built into many American systems. Among those inequities, health experts say the evidence has become clearer that disparities in health have contributed to greater death rates from the COVID-19 pandemic in communities of color than the U.S. population as a whole. 

“If we are really going to get at the core drivers of health outcomes, we as a community need to peel back the layers,” Mineck said, “and the social determinants of health are clearly the predominant drivers of those barriers and opportunities for health.” 

As defined by the Kaiser Family Foundation, social determinants of health include factors such as socioeconomic status, education, neighborhood and physical environment that can create disparities in health and access to quality health care. It’s a recognition that someone’s ZIP code can be one of the biggest determiners of how healthy they will be. 

Among recent reports that comprehensively document the local disparities in health outcomes that are part of a nationwide pattern is the One Economy initiative that was updated earlier this year by the Directors Council. 

An additional report that was released in August by an organization known as the City Health Dashboard provides extensive data that shows marked disparities between the health in communities of color compared with white residents and the population as a whole for several Iowa metropolitan areas. 

A number of initiatives — many of them being spearheaded by organization leaders who have received financial and planning support from Mid-Iowa Health Foundation as part of the Health Connect Fellows program — are actively addressing poverty-related health disparities that have been exacerbated by the pandemic and subsequent economic recession. 

Other programs are part of efforts developed by startup companies that have recognized opportunities to develop apps and solutions to help health and social services providers to bridge gaps in filling community needs. 

Companies that are emerging in this area include Greater Des Moines startups such as telehealth provider Certintell, as well as firms like New York City-based Unite Us, which is expanding into Iowa as part of a nationwide rollout. 

Several broad efforts to address socio-emotional aspects of children’s health are also emerging in Central Iowa, including a recently announced initiative to bring Sesame Street in Communities to Greater Des Moines. 

Multiple barriers to equitable health 

Poverty and a lack of safe, affordable and healthy homes are two top health issues and powerful determinants of health that “continue to be addressed very minimally in Iowa’s health improvement plan,” according to the 2020 Healthy Iowans Progress Report released in June by the Iowa Department of Public Health. 

“The percentage of low-income children living in supportive neighborhoods continues to be much lower than for all Iowa children (45% versus 62% in 2018)” state health officials noted in the report. 

Additionally, infant mortality continues to trend upward in Iowa, especially for Black/African American, non-Hispanic infants, the report stated. 

At the same time, the death rate for children ages 5-9 has nearly doubled in Iowa since 2016, and the 2018 rate for youths ages 15-19 was more than 17% higher than 2016’s rate. Most of these deaths were from unintentional injuries (45%) or suicide (25%). 

Nearly two-thirds of Iowa adults report experiencing at least one type of adversity growing up, according to the 2020 ACEs 360 Report: Healing Iowa. 

One in six Iowans report four or more adverse childhood experiences. At least five of the top 10 leading causes of death are associated with ACEs, according to the U.S. Centers for Disease Control and Prevention. 

The research has generated a number of systemic changes in Iowa’s education, health and government institutions in recent years, among them legislation in 2018 requiring annual training on ACEs be provided to educators statewide. 

It’s now well-documented that the more adversity someone experienced as a child, the more likely they are to suffer from depression and to smoke, have heart disease, miss days at work due to poor health or face many other challenges in adulthood. Not all people with ACEs have equal access to care, the 2020 report noted. 

“Our world has created policies and institutionalized systems that perpetuate oppression and prevent access to resources. Black and Indigenous individuals, people of color, and those living in poverty are among the most impacted. 

COVID-19 has especially elevated the need to change our systems as we see the impact this crisis is having on our communities,” according to the report.

Where there is one barrier to good health outcomes in a family, there likely are more present, Mineck said. “It’s similar to what the ACEs 360 study has revealed to us, that if you have one adverse childhood experience, then it’s likely that you have had several,” she said. 

“For instance, there is a whole range of barriers that exist for our families in maternal health,” Mineck said. “It’s not just about literal access to an OB clinic. [Other considerations include]: Is the housing the family lives in stable? Is the mom part of a stable relationship where she feels safe and valued? What kind of racial discrimination has she faced; has she faced an amount of toxic stress that would drive her not to trust different systems? When you get into social determinants of health, the complexity and intersection of determinants is at times overwhelming.” 

According to “Race in the Midwest,” a research report published in October 2019 by the Iowa Policy Project, the Black infant mortality in the 12 Midwestern states studied is more than 2.5 times higher than white infant mortality due to health disparities. Nationally, the rate of Black infant deaths, 11.3 deaths per 1,000 infants, is more than twice the rate for white infants. 

Olivia Samples, a women’s health advocate who works on the front lines of maternal health for Black women like herself, launched a community-based doula system focused on providing an alternative supportive service for expecting Black women. 

A graduate of Simpson College, Samples is currently the membership and training coordinator for the Iowa Coalition for Collective Change, an anti-violence coalition supporting survivor services organizations statewide. She was also selected by Mid-Iowa Health Foundation for its Health Connect Fellows program, which prompted her last year to train as a doula. 

Samples said reading a New York Times article about the role of doulas inspired her to provide that service to women locally. 

“There is lots of evidence that working with folks who look like you has lots of positive benefits,” she said. To her knowledge, she was one of just three Black doulas in the state a year ago; now there are six. She has her own startup doula business, Kismet Services, and she also provides volunteer doula services for the Young Women’s Resource Center in Des Moines. 

“It is massively important to me,” she said. “I’ve been advocating for [social] issues since college. … Just the idea of Black women dying in childbirth — this is 2020 and people are still dying in childbirth. That made me so sad. Black families have been under attack in America, and I think it’s something we really need to protect. Making sure that we have rights to our reproductive experiences is hugely important to freedom.”

In her role as a doula, Samples takes a holistic approach with expecting moms to find out about their nutritional resources, exercise and access to health resources. “What are you eating, where do you get your food from, where is the nearest grocery store?” she said. “It’s thinking about the places we live, work and play.” 

From her perspective, poverty is not a barrier in and of itself that adversely affects people’s health. “It’s what other people put in place that keep you from services,” she said. “Like the lack of affordable birthing centers in Iowa. It’s more the systemic factors that end up affecting folks.” 

Because of those systemic factors, the barriers are not an individual problem, but families are still suffering because of it. “So I take the approach of working with families individually to access resources and quality care,” Samples said. 

At the same time, she advocates through her involvement in systems like the Iowa Department of Public Health, where she serves on the Health Equity Advisory Committee, as well as on the Young Advisory Council for UnityPoint Health and other community organizations “to address and eliminate systemic barriers which are upheld by racism and paternalism.” 

Unite Us seeks to unify health, social service agencies 

Often, health care providers don’t have access to the full picture of their patients’ lives beyond clinic and hospital walls, said Taylor Justice, co-founder of Unite Us, a New York-based health coordination tech company that’s expanding into the Midwest. 

Justice, a military veteran, partnered in 2013 with another veteran to launch a technology platform addressing veterans’ needs as they were transitioning out of the military. Realizing a wider need, they broadened the business model to improve connections between health systems and social services agencies for patients. 

“Our business model really focuses on the larger institutions that have a vested interest in improving connections,” Justice said, “as well as well-capitalized nonprofits such as health information exchanges.” Those organizations fund the access, which is then made available at no charge to social services agencies and community organizations. 

Unite Us claims its accuracy in connecting individuals with best-fit organizations is about 94%, and touts an 88% rate of improvement in efficiency in connecting people with social and community services. 

“We’re seeing specifically due to COVID stress on social services agencies there is a high uptick in demand for these services,” Justice said. “When that happens you also see a high drop-off in supply. When you don’t have that coordinated network, you could be sending someone to an organization that doesn’t have capacity.” 

Unite Us recently entered into a partnership with Nebraska’s health information exchange, the Nebraska Health Information Initiative. Working with NEHII, Unite Us is also developing partnerships with organizations in six surrounding states, including Iowa. 

Unite Us currently has state-level contracts or network relationships in 42 states. Health information exchanges, which in Iowa is the Iowa Health Improvement Network, allow health care professionals and patients to appropriately access and securely share a patient’s medical information electronically.  

“The burden shouldn’t be on just one sector,” Justice said. “I think what we’ve been able to do is create the glue and the mesh that brings them together, bringing everybody to the table and giving them a voice.” 
Health equity is a priority for Unite Us, Justice said. “In and by ourselves, 

we’re not going to remove all of the challenges,” he said. “Our role is to remove barriers to access, by allowing anybody to engage with organizations. If there are gaps for certain populations, how do we fill those? We help organizations make better decisions in real time.” 

A snapshot of Iowa’s health equity status 

To better understand health and equity trends in small and midsize cities, researchers at New York University’s Department of Population Health and NYU’s Wagner Graduate School of Public Service examined data for 719 small and midsize metropolitan areas with populations between 50,000 and 500,000 residents across the United States, including Iowa’s nine largest cities.

The study built on earlier work by NYU researchers for an ongoing data comparison tool called the City Health Dashboard that includes community-level health, social and economic data for more than 750 U.S. cities. The new report, released in August, compares “City Types” like Des Moines (a Working Town, one of 10 types classified in the report) with cities having similar profiles — with the idea that cities can gain insights and synergy by learning about programs and initiatives that are proving successful for their peers. 

Across all cities, the researchers found evidence of widening disparities in health outcomes, and that as racial and economic disparities have increased over time, so have health disparities. Not surprisingly, wealth and better health outcomes are concentrated in city types that are predominantly white. 

The two city types with large low-income and large Black populations (Regional Hubs and Small Industrial-Legacy Cities) had the highest burdens of 
disease and mortality. 

The researchers also used the city types framework to better understand COVID-19 infection risks’ relation to demographic factors, and found that the city types with high risk for COVID-19 also have higher rates of child poverty and shorter life expectancies. 

Among the findings for Iowa cities: Dubuque and Cedar Rapids have some of the largest household income disparities between Black families and their white counterparts. In those two cities, Black households’ incomes are, on average, 30% and 40% of white households’ incomes, respectively, in Dubuque and Cedar Rapids. In the remainder of Iowa’s seven other largest cities, including Des Moines, Black household incomes range from 50% to 60% of what white households bring in annually. 

As identified by cost-of-living studies conducted by the Iowa Policy Project, about 1 in 5 working families in Iowa do not earn enough income to meet basic needs of food, shelter and clothing, and existing programs for food, child care, health and utilities assistance often barely fill the gaps. 

The Mid-Iowa Health Foundation’s Mineck noted that uneven socioeconomic factors that have existed before the pandemic could likely be worsened, both directly from the impact of unemployment on low-income families and indirectly in terms of education that could help children to complete high school and postsecondary education to help them escape poverty. 

Notably, third grade reading levels — a data point that economic development officials have been addressing at the local and state levels for the past several years, could suffer due to limitations on face-to-face programs during the pandemic. Reading proficiency by third grade is a key determinant of children’s ability to read for learning and to graduate from high school. 

According to the City Health Dashboard, 60.2% of Des Moines third graders read proficiently, compared with 46.2% nationally. “I’m worried about how that data point may get dramatically worse in the next few years,” Mineck said, “and the ripple effect that that would have.” 

Overall, the pandemic has spotlighted the stark differences in incomes among families and the significant needs, Mineck said. 

“From the beginning [of the Mid-Iowa Health Foundation] 50 years ago, the trustees of this foundation understood that if you’re hungry, it’s hard to be healthy,” she said. “If you don’t have stable housing, it’s hard to be healthy. So some of our earliest investments were around the barriers that exist in our community for all members who don’t have the chance to be healthy. 

“I think this pandemic has brought a magnifying glass to those social determinants of health, and it has really elevated how critical they are to our opportunities to be safe and healthy.”  

Business Record intern Sarah Bogaards contributed data analysis for this article