Neighborhood Vitals
The Rekebisho Centre is a bright and colorful building in the Mukuru slum in Nairobi, Kenya. In the dirt yard between the Centre and the neighboring houses is a barbell, which was made by pouring concrete into two five-gallon water bottles. It does the day shift as a balancing beam for children during recess and in the evenings, is the start of the gym for older boys.
You will see a constant flow of children, parents, aspiring artists and sometimes ducks crossing this yard. For a while, you would also see an Access Afya Nurse with a white coat and a health backpack passing through every day. The Rekebisho Centre was an Access Afya Healthy School.
The Rekebisho Centre combines youth activities and preschool in Nairobi’s Mukuru slum
The Healthy Schools Approach
The Healthy Schools program I built at Access Afya created health hubs in community schools surrounding our clinics. The goal was to make healthcare accessible and engaging by bringing health products, preventative services, environmental assessments and education directly to communities with high child mortality rates. Schools subscribed classrooms to this program for $1 per child per month. The schools bought into the program because it covered regular nurse visits and treatment for the children when needed. (“School Nurses” are not common in schools for low-income Kenyans.)
When schools signed up, we took their subscription revenue and invested it into toilet and ventilation assessments and upgrades, monthly soap deliveries, regular deworming and health lessons for children through community health advocates. We did this in addition to providing healthcare services for the children including first aid, check-ups, diagnostics and medication for illnesses that they had.
Children reminded their peers to wash their hands. They missed up to 50% less school. At the Rekebisho Centre, the number of children with health conditions reduced by 40 percentage points over the course of one year. Although we did not track long-term impact, we know anecdotally that children discussed their “health report cards” at home, and taught their parents about nutrition, germs and more.
We were able to eke out a small profit margin on those $12 per year subscriptions because of the extensive work we did making the school a healthy place that prevented expensive healthcare visits.
It seems common sense that our environment affects our health, but why doesn’t our health system take this into account? Health systems should start looking at what I call "Neighborhood Vitals” in addition to patient data. These would include air pollution levels, noise, access to food and social services, green space coverage, electricity and water sources.
Health assessments primarily center around individual patients. An individual’s symptoms, the history of these symptoms, family members, medication history, and more. The linchpin of every visit is looking at a patient’s vitals: blood pressure, respiratory rate, temperature, pulse. These are considered vital to contextualize the rest of the medial encounter.
But they are only one part of the picture. I believe that additional data points about neighborhoods and communities could contextualize the information that healthcare workers are getting from patients.
These data points could create an index for neighborhood health. They could help treat patients, neighborhoods and cities.
Mounting Evidence of the Impact of Environmental Factors
We have increasing evidence on the correlation between where people live and their health outcomes. This week Sidewalk Labs, a prominent voice in the future of cities, wrote about groundbreaking US based research from the journal Housing Policy Debate on the link between our zip codes and our health. This research found that:
“Children whose families received housing vouchers to leave high-poverty areas had hospital admissions rates 36 percent lower for asthma and 30 percent lower for mental health conditions than children who didn't receive such vouchers.”
This is not surprising to me as a healthcare veteran. There must be other studies like this one. There are studies linking air pollution, noise and green space individually to people's health. What is missing is a systematic way of getting accurate, recent environmental health data into the hands of healthcare providers and neighborhood residents. Local governments also need to look at Neighborhood Vitals when crafting healthcare policy.
Doctors Know the Importance of Environmental Factors
A physician on the Navajo Nation will ask about electricity and water sources while taking a patient’s social history. These data points have immediate implications on care plans. How will the patient change a wound dressing daily without running water? A Clinical Officer at Access Afya’s community health clinics in Nairobi, Kenya will ask how a family cooks their food to better understand possible air pollutants during a respiratory visit. (Air pollution is the fourth largest risk factor in driving disability and death in Kenya.)
Doctors are doing this intuitively. But Neighborhood Vitals would still help. It would make understanding a patient’s living environment vital, not optional. It would lead to more attention and questions. This would build a codified framework to work with, and show them the answers to questions that some might not even think to ask.
I would like to build an open source diagnostic for neighborhood health that can be used by healthcare practitioners and governments alike.
Building a Neighborhood Vitals framework would take the following steps:
Identify the right city-level data: Air quality would always be important. Uranium exposure might only impact some communities. Noise is important especially in cities.
Set risk thresholds for each data point: When you get outside of the recommended blood pressure ranges you work with your healthcare provider to get back on track. When environmental factors get out of range, we need to put pressure on governments, the private sector and citizens to get it back on track.
Focus on data points that are easily measurable: Measuring vitals regularly can track progress back to a recovery.
Remember the micro and the macro levels: An ideal tool could be scaled-up to a city level, and down to blocks and potentially even houses.
I’m laying out the bare bones of a framework, but to build this I believe we need an open source and collaborative approach with healthcare people, data scientists, patients and urbanists.
Patient vitals like temperature can signal that there is a problem.
It is not the end all and usually not the diagnosis. Neighborhood Vitals will similarly be able to signal potential problems. By making this a vital and showing it on every visit, healthcare providers will start thinking about it, and asking questions about it. Neighborhood residents should have a right to see their Neighborhood Vitals. Local governments could use them to manage and advocate for projects.
If we pay more attention to it, societally we might just spend more time working to improve it. When we take into account the environmental risk factors that individuals and communities face, we can start to shift our focus from illness care back to prevention, wellness and even vitality.