By Maria Grusauskas
July 29th, 2014
Santa Cruz just received a high ranking among California counties. But it may be hiding some of the biggest health dangers facing our area
Santa Cruz County is a mecca for the health conscious, the active and the energetic. Our oceanic backyard, 29 miles of beaches and redwood forests surround our working lives with a virtual playground for decompression and physical exercise. Five farmers markets in any given week and over a dozen different health food stores keep our plates loaded with organic produce, and menu options at a vast majority of county restaurants bend to fit the latest dietary restrictions and health trends, even before they hit the mainstream.
So it’s not a huge surprise that Santa Cruz was ranked the 11th healthiest county in California this year by County Rankings, an extensive annual report by the Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute. Compiled from a vast amount of public data pertaining to 34 different measures, the rankings assess 58 counties for both health outcomes—the length and quality of our lives—as well as health factors such as our lifestyle behaviors, education, socio economics and physical environment.
We do have a lot to be proud of; the county’s 10 percent smoking rate, for instance, is one of the lowest in the nation. Our teen birth rate has continued to decline over the past five years. And the quality of the air we breathe, thanks in part to the offshore air currents, is in the nation’s 90th percentile.
“But if you peel back the curtains, you see that in this very same county, the statistics sort of hide the fact that we have a lot of the conditions that make people die young, conditions that make people sick and conditions that make people not fulfill their human potential,” says Mary Lou Goeke, executive director of United Way of Santa Cruz County.
Even as working professionals jog along West Cliff, stretch into triangle pose in yoga class and towel the salt off their fit bodies after a good surf, a contrasting scene plays out, with negative impacts on county health as a whole: migrant laborers stoop over crops that are often soaked in pesticides, and about one in 10 of their children will graduate high school. Meanwhile, 3,536 residents were estimated to be homeless as of 2013. And while a major economic disparity leaves 18 percent of children living in poverty, the affluent are not exempt from the county’s other major health issues: one in three of our children are obese, 21,000 above the age of 12 are estimated to be living with substance abuse disorders, and upper- and middle-class parents are opting out of immunizing their school-aged children from dangerous diseases.
There’s no guarantee that we can maintain our high health ranking, which has already slipped from No. 8 in 2010. And if we want to move in the direction of No. 1 (a spot occupied by Marin County for the past five years), then we have some work to do.
WHEN WEALTH EQUALS HEALTH
More than in any other country, health in America depends largely on one’s individual wealth and resources. “It’s the strongest relationship you’ll find anywhere, that wealth pretty much equals health,” says Dr. Anthony Iton, senior vice president for Healthy Communities at the California Endowment, in the PBS documentary Unnatural Causes: In Sickness and in Wealth.
Both Goeke and Santa Cruz County Health Officer, Lisa Hernandez, attribute Marin County’s first-place health ranking in California to high education levels and high income. In Santa Cruz, these two factors are no less important.
“Our county’s health is definitely a tale of two cities,” says Goeke. “Particularly in northern county, and particularly in the Anglo population, we are highly educated, we have high income, we live in safe neighborhoods, and we have good jobs. And that’s why we rank No. 11.”
But in South County, “We have people who are poorly educated, not proficient in English, working physically demanding jobs in hospitality and on farms for very low wages,” says Goeke.
Though the county’s 18 percent of children living in poverty are certainly not exclusive to South County, the disparity between north and south is undeniable, with Watsonville’s most recent estimated mean household income of $47,442 in 2012 significantly lower than Santa Cruz’s $63,884.
But Goeke points out that how long you live and how healthy you are throughout your life depends on “education, above anything—above income and above race.” So, fortifying the health of Santa Cruz County by addressing the inequities in our population means placing much of the focus on education.
While the county’s high school graduation rate of 86 percent is an improvement on 2012’s 77 percent, Megan Joseph, director of community organizing at United Way of Santa Cruz County, says that for the Latino population it’s 73 percent. Of course, high school dropouts are 12 years in the making, often beginning with an early childhood education that’s behind schedule. The most endangered sector of the population are children of migrant laborers, who are often forced to change schools halfway through the school year, and the San Jose-based Migrant Education Project estimates that only 10 percent of migrant laborers’ children will actually graduate high school.
For Joseph, the answer is simple: “We need to rebuild opportunities for our youth,” she says. For the past year, United Way’s Youth Violence Prevention Strategic Plan has been working in South County to do just that. Reducing youth violence is about increasing opportunity, says Joseph, and the multi-organizational approach includes everything from increasing family engagement in schools, to providing social after-school activities and making sure there are enough jobs for youths.
WORKING AGAINST A CURE
Proper medical care—especially preventive, is another crucial determinant in the health of a community. With the help of vaccinations and education, diseases like diphtheria that once ravaged the county (in 1876 and 1878, causing many deaths, especially among children) have been controlled. Which is why Santa Cruz Health Officer Lisa Hernandez’s biggest worries for infectious disease in the county come as a surprise: syphilis. Over the past four years, the number of syphilis cases has increased, with 32 cases reported in 2013, and eight already in the first quarter of 2014. Luckily, if syphilis is caught early enough it can be treated and cured before the disease’s severe complications—meningitis and paralysis—set in.
Hernandez also worries about other preventable diseases that were supposed to be eradicated in the last century. The county saw 54 cases of pertussis (also known as whooping cough) last year, the highest number of cases since 2010, when there were 87. So far this year, there have been 12 cases and one death from the highly contagious respiratory disease caused by the bacterium Bordetella pertussis. Measles has also reared its ugly head, with three cases reported last year—a seemingly low number, but after an outbreak of measles in the county in 1990, cause for some concern.
So how are these diseases of old seeping into our present-day lives? This time, it may be North County that’s falling short: one contributing factor that is very unique to Santa Cruz, says Hernandez, is a high number of parents opting out of vaccinating their children.
“Vaccines are one of public health’s successes, we’re able to get rid of diseases that killed people in certain instances,” says Hernandez.
But 9.54 percent of parents are waiving their children's immunizations—a rate much higher than the state average of 3.15 percent and surrounding counties, like Monterey at 1.6 percent and Santa Clara at 1.7 percent.
“One of the things that we know, especially for parents of younger kids, is that they feel like there’s too many vaccines given at one time, and they don’t want to give all those vaccines in the schedule that the CDC recommends," says Hernandez. "The other thing is these are diseases that are thought to be of olden times, so they don’t think that it’s going to affect the health of their child, and don’t realize the serious complications that some of these diseases have.”
She believes that opting out of vaccinations could have also contributed to the nine cases of influenza in 2013—severe enough to cause death or ICU care—and five more in the first quarter of 2014.
It was only four years ago that Andrew Wakefield’s widely published study linking vaccinations to autism and bowel disease was discredited as a hoax with a profit motive. Hernandez is hopeful that targeted community outreach and a new law that requires parents to consult a health professional before opting out of vaccinating their children will help bring the “personal belief exemption” rate down in the county.
It’s no secret that obesity, responsible for skyrocketing rates of diabetes, cancer and heart disease, is the most troublesome health epidemic facing our nation today. And as active as the average Santa Cruz resident is, the county is far from exempt: one in five adults is considered to be obese, reports County Rankings. While this 20 percent rate (which matches the state’s) may be relatively low compared to the national average of 28 percent, an additional 31 percent of us are considered overweight.
But County Rankings failed to report on child obesity rates—which is really what we should be worried about: 37 percent of county children are considered to be obese, says Hernandez.
“That’s an area of concern, because we know that 70 to 80 percent of children that are obese grow up to be obese as adults,” says Hernandez. “So, not only is it a tragedy that our children are obese, and it’s impacting their health, but if we look at how it’s going to impact the future health of the community, three quarters of them are going to be obese.”
And it gets worse: “When you go to the Pajaro Valley you see that our Latino [obesity] rate is around 50 percent, and that’s due to a lot of different factors,” says Joseph.
It’s counterintuitive that our county would be prone to obesity, when the salad bowl of the world is Salinas Valley, says Hernandez. Again, wealth disparity may play a role.
“I think one reason that rate is so high in Santa Cruz County, again you can trace to a higher prevalence in low-income communities,” says State Sen. Bill Monning. “We have a high number of the population in Santa Cruz who are an immigrant workforce and who are targeted because they don’t have the education or the money to stretch limited dollars to buy more healthful foods.”
“It’s expensive,” says Hernandez. “When you go to the grocery store and you look at the price of fruit and vegetables, it’s a lot more expensive than getting some of the low-cost prepared options.”
But a weekly supply of fresh fruit and vegetables is not totally out of reach: the Santa Cruz County Farmers Markets accept Electronic Benefit Transfer (EBT) cards at all five of its markets. Nesh Dillon, executive director of SCCFM, reports that they saw about $90,000 in EBT sales last year.
“And that’s a direct infusion of money right into farmers’ hands,” says Dillon, who praises the program for being efficient and seamless.
For the past three years, the Live Oak and Felton markets have also offered an incentive program called Market Match, where individuals who swipe their EBT cards for more than $10 get an additional $5 in buying chips—a program that could see a significant increase in funding next year.
“It’s had a really powerful effect, because it’s brought a lot of people into the market that maybe wouldn’t typically use their EBT card there because they’re at that income bracket where every dollar counts,” says Dillon. “So it’s driving a lot of the dollars toward the market and away from more unhealthy options.”
Although Monning’s recent soda warning label bill, which proposed adding the warning “State of California Safety Warning: Drinking beverages with added sugar(s) contributes to obesity, diabetes and tooth decay” to all beverage containers with added sweeteners, did not pass—“a disappointment but not a surprise”—he remains adamant that sugar is a major factor driving child obesity rates.
“The reason we focus on the sugar-sweetened beverages is because it is a unique driver in converting the sugar to fat,” says Monning.
“The pancreas, the liver—when it comes in liquid form, the infusion is so fast, the body goes into defense mode, and it converts that sugar to fat as a way of protecting the organs. The liver can’t process that sugar, so it converts it to fat, and then the fat becomes a leading contributor to diabetes.” Kids who drink two cans a day of soda increase their risk of becoming pre-diabetic or diabetic by 50 percent, Monning adds.
Another important component for battling obesity, according to research by the CDC and RWH Foundation, is making sure that the environment of the community is healthy and safe. United Way’s almost 10-year-old program Go For Health is taking a multifaceted approach that’s brought 150 different organizations together to address childhood obesity—everything from ensuring that babies are breastfed (data shows that they are less likely to be obese later in life, says Joseph) to ensuring safe routes to school, access to bike and pedestrian lanes, and safe parks. And the results are showing: in 2013, 33 percent of Pajaro Valley children were walking to school—which is well above the rest of the county, and 51 percent of people in the Pajaro Valley reported shopping at farmers markets or local produce stands—up from 39 percent just two years prior.
It’s not just the adults who are contributing to these encouraging trends: United Way’s Latino youth group, Jóvenes SANOS—a group of teens mostly from Watsonville High School—has been hard at work passing policy in Watsonville around healthy eating. In 2010, they passed the Healthy Restaurant Ordinance, which requires restaurants to offer healthy menu options. In 2013, they passed a Healthy Vending Ordinance which requires all of our bus stations to provide healthy options, and most recently, they completed the Healthy Corner Markets project, which transformed two corner markets in downtown Watsonville to carry healthy options.
OUR DRINKING PROBLEM
Another unhealthy habit that’s on the rise in Santa Cruz is excessive drinking, with an estimated 21 percent of residents partaking in heavy or binge drinking—up from 14 percent in 2010. Though alcohol is the number one drug of choice, Bill Manov, director of the Santa Cruz County Alcohol and Drug Program, says the problem extends well beyond it.
In 2012, the number of Santa Cruz County residents over the age of 12 with a diagnosable substance abuse disorder was 21,000, according to the State Department of Health Care Services—roughly 7 percent of the population. And 3,200, or 15 percent, of those people were estimated to be seeking treatment, says Manov. Compare that to the number of people the county was able to serve that year: 1,288.
“There’s a huge gap between the number of people who need treatment and the number of folks who are able to get treatment. That’s probably been one of the most striking findings,” says Manov, who says the SCCADP is now finalizing the findings of a year-long data gathering phase in order to put together the county’s Substance Abuse Strategic Plan.
“It’s a little hard to track trends to the county level, but if you look statewide and nationwide, the pattern of usage is shifting, and we’re seeing more prescription opiates and heroin and a slight drop in methamphetamine,” says Manov, who says the county is also seeing similar patterns.
Untreated substance abuse drives costs up in every public sector, says Manov. County Rankings reports that 31 percent of fatal driving accidents in 2013 were due to alcohol impairment. Currently, the county spends more than $200 million annually on substance abuse impacts in the county, while only $7 million on treatment and prevention.
But Manov insists that money spent on treatment and intervention of substance abuse is well worth the investment. “There are many research studies on the return on investment for substance abuse disorders treatment, and depending on the study and population and type of treatment provided, they typically show anywhere from $4 to $7 return on investment for every $1 spent on treatment,” says Manov, noting that most of the cost savings are in health care and the criminal justice sectors.
“We’re going to be spending money on substance use, that’s inevitable, but we need to look at what’s the smartest way to spend our money to protect our quality of life,” he says.
A draft of the Strategic Plan will be available to the public in September, says Manov.
Based on the County Ranking’s measure of premature death—people dying before the age of 75—Santa Cruz lives 451 years longer, altogether, than the average California community, and our death rate (614.7 deaths per 100,000 people for 2012) is relatively low.
"Our death rate is generally much lower than the national rate, and among the lowest in the nation, but not too different from the statewide rate,” says Will Forest, epidemiologist and chief deputy registrar at the Santa Cruz County Office of Vital Records. “For many years, our death rate was significantly lower than the statewide rate, but while our death rates have been dropping steadily, the statewide rate has been dropping faster.” He says it’s unclear why that is happening.
Still, the average age at death was 74.89 in 2013, which doesn’t exactly make Santa Cruz County a “Blue Zone” as much as we’d like it to be.
“Although Santa Cruz County has very low death rates, the major factors that determine our longevity are not particularly different from those in any other American county," says Forest. "We have very low smoking rates; that's hugely important. We have very high physical activity rates and low obesity rates; that's huge, too."
But Goeke reminds us that the death rate and average lifespan of today’s Santa Cruz resident are largely dependent on health behaviors of the past—which is why focusing on the present is so important for improving the quality and length of life in our future. And despite the challenges facing Santa Cruz County, Goeke sees reason for optimism.
"As I look to the future, I want to see even more of our kids graduating high school and going on to college. I want to see even more of our adults having a higher wage. I want to see more opportunities for healthy eating and active living. I want people to feel like they're safe in their home and safe in their community,” she says. “Which means we have to address the perception of gang violence, youth violence, bullying, drug-related crimes. All of these things we've got to work on, on all fronts and at one time, but I feel like we have a lot of very talented people working on it."