How wealth drives health — and what we can do about it

By Daniel Weintraub

California is a land of health extremes, and to see what that means, you need only travel a few miles from the state Capitol.

Placer and Yuba counties border each other about a half hour’s drive north of downtown Sacramento. Both places are largely rural. But the similarities end there.

Placer’s residents are, on average, much healthier than their neighbors across the county line. A person living in Yuba County is much more likely to suffer from chronic disease and die at an early age than someone living in Placer. In fact, Placer’s residents are among the healthiest in California, while Yuba’s are among the sickest by many measures.

The easiest explanation for the difference is wealth. Health and wealth are connected, here and almost everywhere in California and across the country. No one is sure exactly why they go together, but the answer is more complicated than the fact that people with higher incomes also tend to have better access to medical care. Even when access to care is the same, health disparities remain, because a large share of a person’s health is determined by things outside a doctor’s office or hospital room.

More likely, the disparities in health outcomes are linked to a combination of other factors that often move in tandem with wealth: employment, education, housing, transportation, access to healthy food and outdoor exercise, and leisure time. Also playing a role, perhaps a pivotal one, is an issue that is tied to all of the others: stress. All of these factors can drive behaviors that shape our health or even affect our bodies directly.

A look at Placer and Yuba counties sheds some light on how stark these differences can be and how difficult they will be to overcome — even if the federal health reform known as the Affordable Care Act works exactly as its supporters hope.

The two counties share a history dating back to the Gold Rush, when Placer’s foothills were the site of much of the mining and the Yuba County seat of Marysville was a gateway for settlers and supplies heading into the Gold Country.

But their paths diverged sharply toward the end of the last century when technology companies, sparked by Hewlett Packard, began to move and open operations in Placer County, igniting a boom that has since turned it into one of the wealthiest places in the state.

By contrast, Yuba seems almost stuck in its past. Marysville, which once boasted a population larger than Sacramento’s, is now a tiny fraction of the size of the Capital City with a boarded up downtown and a moribund economy. More than one-fourth of the jobs in the county are tied to a single source: Beales Air Force Base, and government at all levels accounts for more than 40 percent of the county’s non-farm employment. The county’s economic growth is hindered by its vulnerability to flooding and by the fact that Yuba City, across the Feather River from Marysville but in Sutter County, is the node of much of the region’s growth.

That divergence between Placer and Yuba is now reflected in a host of economic and social statistics. Median household income in Yuba County is about $41,000, compared to $69,000 in Placer County. Yuba County’s unemployment rate of 14.5 percent is twice that of Placer’s, which stood at 7.1 percent in March. Placer County’s high school graduation rate is among the highest in the state at 91 percent while Yuba’s is at the statewide average of 81 percent. And while more than three-quarters of Placer County adults have attended college, barely more than half of Yuba County’s residents have done so.

Yuba County residents face other problems that can lead to ill health and shortened lives. They are more likely to struggle with high housing costs and overcrowded conditions. And they are far more likely than Placer County residents to be a victim of violent crime.

All of this adds up to what researcher Dale Ainsworth calls “ambient stress.” Ainsworth, who has studied health patterns in Yuba County and elsewhere in Northern California, says people struggling for survival on a daily basis are more prone to illness.

“Living in a continual state of stress,” Ainsworth says, “as result of constantly worrying about resources, about where your next meal is coming from, how you are going to keep the lights from being turned off, how to keep a bill collector from harassing you on the job, living in that ongoing state of stress will manifest itself in the physiology of the body, with hypertension, with heart disease, a number of other health outcomes.”

In Yuba County, that stress may be magnified because many residents lack a network of family and friends on whom they can lean for help, and public institutions are not as strong as they are in other places. In fact, twice as many people in Yuba County as in Placer report that they suffer from inadequate social or emotional support, a crucial but often overlooked factor in shaping a person’s health.

Family support, contact with others and community ties all are linked to health and longevity, according to University of Wisconsin researchers who annually compile a ranking of the health outcomes in nearly every county in the country. The health risk associated with social isolation, the researchers say, is similar to that of cigarette smoking, and people lacking a strong social network are more likely to make unhealthy lifestyle choices.

Indeed, Yuba County residents are twice as likely to smoke as those in Placer, alcohol-related drivers’ deaths are far more common in Yuba, the rate of sexually transmitted disease is far higher, and teen-age girls in Yuba are more than three times as likely as those in Placer County to have children of their own.

Yuba County residents also report worse access to healthy food and exercise, and not surprisingly, their obesity rate is a third higher than the residents of Placer County. Obesity has been linked to diabetes, heart disease and other chronic illnesses.

Placer County has enormous advantages due to its wealth and the education levels of its population. But the county also has a long history of cooperation among the public, private and non-profit sectors, which work together to try to ensure that as few people as possible fall through the holes in the safety net.

Much of that work is driven by two collectives – the Placer Collaborative Network and the Community Collaborative of Tahoe-Truckee. The two organizations serve distinct regions of the county and knit together an impressive network of local support.

“Placer County does have a value that we should really work with each other to accomplish the many goals we have for the community,” says Maureen Bauman, co-chair of the Collaborative Network and director of the county’s Adult System of Care. “We need not just the county to solve problems, but partners in the community. Lots of complex social problems need to have multiple people trying to work through solutions together.”

The network Bauman chairs draws on more than 40 community organizations, including Latino, faith-based, and homeless groups. The network receives financial support from both the Kaiser and Sutter health organizations, as well as many grant sources.

One of its greatest successes is Health Express, a transportation system that helps the elderly and disabled reach appointments as far away as Sacramento. The network also provides the homeless with transitional housing via grants from the Department of Housing and Urban Development.

Then there is hip-hop. At first blush the music and its surrounding culture might not seem connected to health. But the non-profit Hip Hop Congress received a grant from the Placer Collaborative Network to support at-risk youth with artist development programs, writing classes and other assistance including teachers, field trips and supplies. Youth and mentors provide workshops, conferences and assemblies that seek to reduce the stigma and discrimination associated with mental illness, fight substance abuse and curb bullying.

“The leadership in Auburn and Placer county are open to new ideas,” says Natalie Pohley, who leads the local chapter of the Congress. “The collaborations here are fantastic. Through using music and art we are able to bring the community together and reach people in fun and non-threatening ways.”

To be sure, Yuba County has its share of civic and community organizations, but its leadership doesn’t always exhibit the same zeal for public health initiatives that marks Placer County, despite Placer’s reputation as a bastion of conservatism.

Mary Jane Griego, a Yuba County supervisor who has made improving public health a cornerstone of her career, fought for years to try to get the county to officially recognize obesity as a serious health problem. Yuba has the highest rate of adult obesity in the state.
The board even resisted Griego’s suggestion that they model healthy eating habits at its public meetings.

“Philosophically, we have some board members that don’t think we should be in the business of telling people what to do,” Griego said while in the midst of that battle.

Still, she managed to create a forum to address childhood obesity and safety issues, which helped lead to the elimination of junk food and soda at schools, the addition of salad bars and fresh fruit at campus cafeterias and the construction of sidewalks and bike lanes to make it safer for county residents of all ages to move around without a car.

Dr. Michael Kinnison, Yuba County’s interim public health officer, says county leaders recognize they have not done enough to improve health conditions. They are working to have their public health department gain national accreditation, and the county plans to implement an aggressive program to fight and manage chronic disease and improve wellness.

The chronic disease program will borrow from a successful effort in San Diego, known as 3-4-50 because changing three behaviors can reduce the incidence of four diseases that cause 50 percent of deaths. In Yuba County those diseases — diabetes, heart disease, lung disease and cancer — cause 65 percent of deaths.

Kinnison said county officials are well aware that Yuba is annually ranked toward the bottom of California’s 58 counties on the health status of its residents.

“We want to improve the health of the people of Yuba County,” he said. “We also want to change those stats. Everybody knows about them. And everyone is tired of looking at them.”

Daniel Weintraub is editor of the California Health Report at California Health Report correspondent Matt Perry contributed to this article. Email Weintraub at

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