A Tucson Checkup

New data shows that the health of Pima County residents is decidedly mixed

For the past year, residents of Pima County—like all Americans—have been inundated with talk about our health-care system, its flaws, proposed reforms and its philosophical underpinnings.

However, much less has been said about how healthy we are as a community.

The absence of such conversations does not involve a lack of information. There are plenty of up-to-date statistics out there, including a Robert Wood Johnson Foundation report released in February that provides data for counties across the nation.

For Pima County, the latest health figures show decidedly mixed results, clashing with the century-old image that Tucson is a destination for wellness.

Back in 1890, a former assistant surgeon of the U.S. Army, Dr. C.L.G. Anderson, wrote: "I believe that the climate of Arizona presents every degree of elevation, temperature and humidity necessary for restoration and maintenance of health."

By 1922, Tucson's Sunshine Climate Club was using the community's healthy profile as an economic-development tool. It sold this area as a rejuvenating place for, among others, "the business man who is overworked, needs outdoor recreation, hunting, horseback riding, motoring and fresh air."

Gone are those idyllic days.

While the local cancer rate is relatively low compared to national figures, the overall premature-death rate is quite high; we have a somewhat low incidence of teen pregnancy, but one of the highest infant-mortality rates in Arizona.

We're not as troubled by adult obesity as some counties; on the other hand, a high number of people commit suicide here each year.

Alarmingly, the number of deaths in adults older than 45 due to lower-respiratory illnesses puts the kibosh on Pima County's longstanding reputation as a healing destination for those suffering from tuberculosis and asthma.

Despite these mixed health results, according to the Robert Wood Johnson Foundation study, most Pima County residents feel upbeat about their physical condition. Between 2002 and 2008, on average, only 14 percent of those surveyed considered themselves in "poor" or "fair" health.

Sherry Daniels, director of the Pima County Health Department, appreciates the community's positive attitude, but says she's disturbed about some aspects of the county's checkup, including our high suicide rate, our high rate of premature death and our high infant-mortality rate.

"I don't know all the reasons (for Pima County's figures)," Daniels admits. "Some you can postulate on, and some, not so much."

Daniels is particularly puzzled by the Robert Wood Johnson Foundation finding that Pima County is tops in the state regarding a combination of figures made up of four quantifiable criteria: health behaviors, clinical care, social/economic factors and physical environment—yet for health outcomes like length of life and quality of life, Pima County ranks sixth out of 15 counties, trailing Yuma, Santa Cruz and Maricopa counties, among others.

"That's sort of a conundrum," Daniels says. "You'd think they'd be closer together."

She's also concerned that the economic downturn is only going to make things worse across the board.

The Robert Wood Johnson Foundation report can be used to compare and contrast Pima County with other Southwestern communities.

On the minus side, one of the most disturbing local statistics is the rate of premature death, which is defined as number of deaths from 2004 to 2006 for those below the age of 75 per 100,000 people.

When compared in this category with six other Southwestern counties centered around major cities, Pima County placed fifth, with fewer deaths than only Las Vegas and Bakersfield, Calif.

An e-mail from Pima County Health Department division manager Diane Kerrihard says that Pima County's high minority population contributed to the numbers.

"In Arizona in 2008, Asians were on average eight years younger than white non-Hispanics when they died. Hispanics were 10 years younger. African Americans were 16 years younger, and Native Americans were 19 years younger," she wrote. "... Thirty-nine percent of Pima County's population is comprised of ethnic and racial groups with less than the 77.0 average lifespan."

Nancy Johnson, the chief operating officer of the El Rio Community Health Center, which has primarily served minority clients for decades, has a somewhat different vantage point on the issue.

"You need to look at health disparities when considering premature death," says Johnson. These factors include the percentage of uninsured people in a community, along with their education level, economic status, native language and health literacy.

Johnson points out that lifestyle also plays a key role in longevity. "What do people do to keep healthy?" she asks. "Who they hang out with is important. Are they exercisers or doughnut eaters?"

Dr. Luis Escobedo, regional medical director for El Paso with the Texas Department of State Health Services, says proximity to the border may help explain his border community's low number in the premature-death category: Because of close cultural ties to Mexico, people with terminal illnesses could cross the border, and thus wouldn't appear in El Paso's premature death figure.

"The statistics may underestimate results," Escobedo says.

In her e-mail, Kerrihard highlights a number of favorable Pima County statistics. For example, the area has a relatively low rate of both sexually transmitted diseases and vaccine-preventable diseases such as hepatitis A.

                                                 Arizona     Pima County   Maricopa County

Overall cancer death rate
(per 100,000 population)

145.5 154.3 142.3
Rate of hepatitis A 
(per 100,000 population)
1.81 1.38 1.78
Respiratory disease deaths
(45 years old and above, per 1,000 people)
122.4 125.2 119.1
Infant deaths 
(per 1,000 live births)
6.3 7.2 6.1
Prenatal care in first trimester of pregnancy 79.40% 70.80% 83.10%
Pregnancies per 1,000 15- to 17-year-olds 34.6 31 36.8
Source: 2008 County Profiles Monitoring Progress Toward Healthy Arizona 2010 Objectives, Arizona Department of Health Services (azdhs.gov/plan/report/ahs/ahs2008/pdf/6b1_10.pdf)

On the other hand, 2008 health statistics for Arizona counties published by the Department of Health Services reveal the local infant mortality rate is high—7.2 deaths per 1,000 live births. This figure exceeds the state average and places Pima County ninth out of 15 counties.

This statistic bothers Daniels. "Too many babies are dying," she says, adding that she can't explain this disturbing and ongoing trend (see "Lost Angels," June 5, 2008), although she knows that fetal deaths are often related to a lack of prenatal care.

The same 2008 figures show that the proportion of women receiving care during the first trimester of pregnancy was low in Pima County—less than 70.8 percent, compared to 79.4 percent statewide, and 83.1 percent in Maricopa County. Not surprisingly, Phoenix had a lower rate of infant mortality—6.1 deaths per 1,000 live births.

"I don't know why we'd be different than Maricopa County," Daniels says, "and I'm surprised we haven't done better."

For Kathi Ford, who manages the county's Child Care Nurse Consultation Program, the situation is less opaque.

"Prenatal care is accessible depending on where you are, who you are and how much money you have," Ford says. "If an expectant mother is here illegally, she most likely doesn't feel safe seeking prenatal care from the government."

Ford also points out that a number of women are uninsured, yet make too much money to qualify for government health care. "We try to get these women plugged into low-income health insurance, but there are limits to that," she says.

So why does Maricopa County come out ahead of Pima County on a number of important health benchmarks?

"I really have no good answer for such questions," replies Dr. Bob England, director of the Maricopa County Department of Public Health. "I have no funds to look into the root causes (of these sorts of questions)."

According to England, his department is grossly under-funded for the number of people it serves. Local money, as opposed to state and federal funding, is the key to addressing health issues, he says.

"There, the national average is $15 per person, and Maricopa County receives $2," he says.

Pima County reportedly invests more generously, coming in at $7 to $10 local dollars, per capita. (However, Daniels points out that her department performs some functions, such as animal control, that the Maricopa agency does not.) Given that Pima County dedicates more local money to public health, shouldn't Pima County be doing better than Maricopa County?

Not necessarily, replies England. He says he's skeptical of statistics, regardless of their source. He considers the Robert Wood Johnson 2010 county rankings report as "low-hanging fruit" and encourages people instead to review the source data.

"You need to look at the confidence level. ... Unless every case is being counted (i.e., with death certificates), you might be seeing a random sampling that frequently gives you no better than a 95 percent confidence level.

"What I hate about the County Rankings Report," England continues, "is that often, there's very little difference between a county that ranks the best on something, and the county that comes in almost last. That gives a negative impression."

Like his counterpart in Pima County, England agrees that inadequate funding is the bane of his job, and he doesn't see that changing in the near future.

"Because we don't have near the funding we need, we network a lot and try to create community-based organizations that can then spin off and stand on their own," he says.

Under the rubric of Family Health Partnerships (FHP), Maricopa County has done just that. Rose Howe, manager of the program, recalls how one particular partnership started seven years ago.

"I remember how we were assessing the state of health in Maricopa County," says Howe, "and noticed that women, specifically Latina women, were not getting prenatal care."

As a result, they brainstormed and reached out into the community for volunteers and mentors to help alleviate the problem—and there was a strong outpouring of support from the Maryvale neighborhood.

"We partnered with the community," Howe says, "and today, they are a 501(c)3 nonprofit and affiliated with a national initiative called Healthy Mothers, Healthy Babies.

"The group is trusted by the community and can do a much better job than we ever could have," Howe continues. "It's all about helping people to access the health care that they need."

What Howe has seen in Maryvale makes her confident that once women realize the importance of first-trimester prenatal care, they'll be willing to spend some money and change their lifestyles to ensure healthier babies.

A few years ago, the Maricopa County Department of Public Health also became concerned about another issue: the rising incidence of premature death in a particular segment of the community.

"We helped to start a group called Center for African-American Health," says Howe. "The impetus for this effort was a high rate of premature death in that population, including an increase in many chronic and disabling diseases."

Today, she credits the group with expanding its mission and offering health education and awareness to all residents, regardless of ethnicity. But Howe is fully aware that the effort is a patchwork endeavor.

"The center depends on lots of volunteers and grants to augment what funding they receive from the state and county," she explains.

Dr. England has nothing but praise for the community groups that have been fostered by the Maricopa County Health Department.

"We'd like to have a lot more of these in the future," he says. "We're focusing now with a group called Healthy Weight that is trying to come up with policy changes that might counteract the obesity trend. They are looking at simple things we can do, such as bike paths or leaving school playgrounds open after hours. These sorts of changes have more of an impact on health than all the health-education programs that we try to initiate."

According to the Johnson Foundation study, in 2008, Maricopa County had a slightly higher obesity rate in adults than Pima County.

England echoes a sentiment also expressed by Sherry Daniels, Pima County's health director.

"So much about health is out of our control," he says. "We do as much as we can."

Using statistics from various sources, the comparison of seven Southwestern counties that contain major cities reveals that Tucson generally falls somewhere in the middle of the data.

The local suicide rate is higher than that in some other places. Tyler Woods, who leads the support group, Survivors of Suicide Tucson, thinks there are two main reasons.

"First," Woods says, "we are a snowbird community, and the elderly suicide rate is pretty high. When someone looses a spouse, they might not choose to go on.

"Second," Woods continues, "our social-service network doesn't have great programs, and funds for mental-health care are constantly being cut. So we don't have the funding to help people and get the word out there."

Poor or fair health  (1)
Premature death (1)
Adult obesity (1)
Heart disease (2)
Suicide (2)
Uninsured (3)
Albuquerque 15% 7,816 20% 175 17.6 17.8-23.2%
Bakersfield   24% 8,677 29% 303.4 11.1 17.8-23.2%
El Paso 26% 6,375 24% N/A N/A 30.0-46.9%
Las Vegas 18% 8,346 25% 238.5 17.9 17.8-23.2%
Phoenix 15% 6,978 23% 184.3 14.1 17.8-23.2%
Salt Lake City 13% 6,230 23% 164.4 15.5 13.9-17.7%
Tucson 14% 8,019 21% 181.2 16 17.8-23.2%
1. County Health Rankings, 2010, University of Wisconsin Population Health Institute for the
Robert Wood Johnson Foundation. Premature death figures are per 100,000 population.
2. www.worldlifeexpectancy.com. Figures per 100,000 population.
3. “Health Insurance Coverage Estimates, Percent Uninsured, 2006,” map produced by U.S. Census Bureau.

With the knowledge that some key indictors in Pima County appear to be heading in an unhealthy direction, what can we do to work toward better checkups in the future?

"If expenditure trends (budget cuts) continue, health education will be the first piece to go," Daniels says. "In some respects, that's the most important piece."

In March, the county was awarded a two-year, $15.75 million federal grant. The application was prepared by the UA College of Public Health, and according to a press release, the money will help "promote the adoption of healthy eating and active lifestyles, as a way to combat obesity in Pima County."

Daniels, like Dr. England in Phoenix, points to partnerships as the wave of the future.

"There are many advocacy groups and a strong connection with educational institutions ... and there is a growing link to places like the UA Medical School, the College of Public Health and the College of Nursing," she says.

Neither administrators at the UA nor the Pima County Health Department officials returned calls requesting specifics about health partnerships similar to those implemented in Maricopa County.

A story put out last year by the UA media-relations arm reported that two university programs were "providing training for promotoras, or community health workers, in the areas of environmental health and science, including asthma and allergies, fundamentals of toxicology, air quality and water infrastructure and sustainability."

Don Proulx, with the UA's Arizona Area Health Education Center Program, sees Pima County as a "resource-rich area with lots of services, educational and social." He focuses primarily on rural areas, "to teach neighbors how to care for themselves."

Across the board, people involved with health care in Pima County emphasize the importance of working together and integrating services.

"We need to work with a more integrated care system, including community health workers," says El Rio's Nancy Johnson. "To get our arms around the community, we need more (health-care) integration."

However, fiscal realities are bleak. In 2008, Pima County's rate of tuberculosis—a disease that once brought many people to Tucson for a cure—was below the state average. The Health Department's reward for doing so well was a decrease in state tuberculosis funding over the past few years.

"It's difficult, because sometimes when you do well in an area, you get less funding," Daniels says.

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