Poverty among many factors blamed for low health ranking

YAKIMA, Wash. -- Upon learning last year that she and her husband were expecting their first child, Juanita Cervantes enrolled in the First Steps program at the Yakima Valley Farm Workers Clinic.

The program pairs new moms-to-be with a team of health care providers to ensure proper nutrition and optimal physical and mental health during pregnancy until two months after birth.

For Cervantes, the services have been critically important because miscarriages run in her family. The 22-year-old Union Gap resident found herself stressing over every little unfamiliar change in her body.

"If the baby wasn't moving, I'd be on the phone. If it was moving too much, I didn't want to move," she said. "I was really, really nervous."

But monthly home visits and expertise that was just a cell phone call away calmed her nerves, and she now awaits delivery in two months.

Programs like First Steps have been available in the Yakima Valley for nearly two decades and have measurably improved the health of babies and their mothers, according to experts.

Yet despite First Steps and programs like it to help improve the health of all residents, Yakima County remains one of the sickest places in the state. A recent national survey ranked Yakima 32nd of the 39 counties in Washington in premature death and reports of physical and mental illness.

Yakima County ranks even lower -- 34th -- in the kinds of factors that influence health. These factors include behaviors as well as the social and economic conditions under which people live.

Unhealthy behaviors include unsafe sex, binge drinking, smoking, poor diet and lack of exercise. Social and economic conditions -- which are heavily weighted in the survey -- include poverty, income inequality, community safety, education levels, lack of a social support system and the number of single-parent households.

Yakima County doesn't reflect poorly in all unhealthy behaviors. For example, the rest of the state has a higher incidence of binge drinking.

But in teen pregnancy rates, deaths from motor vehicle crashes and the incidence of the sexually transmitted disease chlamydia, the county does worse than the rest of the state.

When it comes to social and economic conditions, Yakima ranks dead last among Washington's 39 counties.

The rankings for more than 3,000 counties across the country were published by the Robert Wood Johnson Foundation and the University of Wisconsin's Population Health Institute. The organizations hope the data will serve as "a call to action" to local communities to pursue programs that encourage healthier outcomes.

While Yakima's poor performance surprised no one on the local health scene, it's worth asking: Why does the county rank so low?

The short answer, health experts say, is the county's high rate of poverty coupled with the prevalence of violence and drug abuse.

Although several indicators of poverty are used in the rankings, especially startling is the number of children living in poverty in Yakima County. The rate is nearly twice that of the rest of the state.

In Yakima County, 28 percent of children under age 18 live below the federal poverty level, which for a family of four is about $22,000 in annual household income. The statewide rate is 15 percent.

Add to that lots of single-parent households, high dropout rates and rampant teen pregnancy, and the conclusion is sad and inevitable.

When it comes to health, there are simply a lot of strikes against the people of Yakima County.

"Bluntly, the measures are quite low in too many areas," said Dennis Klukan, administrator of the Yakima Health District.

Each county is scored in eight different categories, each of which are assigned a statistical value to reflect their varying impact on health.

The report is based on the notion that geography is destiny when it comes to health. Data on access to healthy food, air pollution, crime, obesity and liquor store density go into the rankings.

But the report has limitations. The authors don't recommend state-to-state comparisons because data collection methods vary by state.

Another shortcoming: While the prevalence of liquor stores is part of the "physical environment" category, researchers didn't look at bike paths, hiking trails or parks and recreation outlets.

Even so, Yakima County ranks high in physical environment -- No. 5 in the state. But while residents are surrounded by opportunities for healthy outdoor activities, turning those opportunities into healthy behavior is another matter.

Local public health leaders say that while the report provides little that is new, it reinforces the reality that much work lies ahead.

Klukan said he wants to start a community conversation, using the rankings as a tool for planning a response.

"This bears further study and some action in the future," he said.

He said the health district, which already partners with schools and other agencies to tackle obesity and tobacco use, will give a presentation on what the data mean to the general public sometime in the next few months.

Authors of the county-by-county health rankings recommend that counties compare themselves to their neighbors for the best perspective.

But the news isn't much better for Yakima County compared with the other 19 mostly rural counties in Eastern Washington. Among counties east of the Cascades, Yakima ranks 18th in "health factors" that contribute to poor health.

The county ranks 16th in "health outcomes," which includes the number of men and women who don't reach their life expectancy, the number who report physical and mental illness, and low-birth-weight babies.

Handily beating Yakima in health outcomes are counties with similar demographics and economies: Grant, Franklin and Benton.

The Hanford nuclear reservation and Pacific Northwest National Laboratory in Richland drive up Benton County's ranking because of the high number of well-paid and educated workers who live there.

Franklin County, which at 49 percent has a higher percentage of Latino residents compared with nearly 40 percent for Yakima, showed somewhat better health behaviors, including lower rates of adult smoking and fatal car crashes. The violent crime rate is also lower in Franklin County.

Health officials are at a loss to explain such things as why Franklin County residents smoke less than people in Yakima County or why they go on fewer drinking binges.

But Dr. Larry Jecha, health officer for the Benton Franklin Health District, cautioned against reading too much into the differences in rankings.

"Nobody should be patting themselves on the back, because if you look at obesity, everybody's in bad shape," Jecha said. "You could be good in a number of factors. But if your obesity rate is high, you're still in trouble."

Experts say Yakima County takes a hit in another way.

Being near an urban area tends to boost a county's ranking, primarily because wages are higher in cities, which correlates with better health.

But while Yakima has definite urban characteristics -- within the city of Yakima and the prosperous nearby "suburbs" of Selah and the West Valley -- the overall high poverty rate brings everyone down.

"You don't benefit as much from your urban areas because you have so much poverty," said Mary Small, associate administrator and longtime public health advocate in the Chelan Douglas Health District, which ranked seventh overall in health outcomes.

Local health leaders say they know improving children's economic well-being will lead to improvements in their health. They believe programs like Ready by Five, an early learning project aimed at Yakima's youngest and poorest children, will make a difference.

"We've known for some time that we need to cross these lines between educational achievement and health," said Vickie Ybarra, director of planning and development for the Farm Workers Clinic, a registered nurse and chairwoman of the Yakima school board.

For example, Yakima Neighborhood Health Services, a community health center, addresses the relationship between poverty and health with dental and medical outreach programs for the homeless. Law enforcement is tackling the gang problem, which discourages people from leaving their homes to jog or recreate in the neighborhood.

Still, it's hard to budge the low ranking, especially with state funding cuts that took effect in July and more likely on the way. Residents now on the state's Basic Health Plan, which faces steep cuts, could be forced into the ranks of the uninsured, which are already higher in Yakima County than the rest of the state.

"The hope is we have a lot of great people and organizations doing a lot of great work," Ybarra said. "What's scary is what's happening with the Basic Health plan. We have a disproportionate number of enrollees."

Yakima County shouldn't despair over its ranking, said Jessica Athens, senior population health assessment analyst at the Population Health Institute at the University of Wisconsin-Madison.

She said one of Wisconsin's poorest counties -- Juneau -- ranked last in a state survey three years ago but has been able to inch its way up through a collaborative effort and by setting realistic expectations. For example, the county received a grant that it used to open a much-needed dental clinic.

"You will see benefits, but the payoff may come down the line, 10 years or so. Match your programs to your expectations," Athens said.

* Leah Beth Ward can be reached at 509-577-7626 or lward@yakimaherald.com.