How you see a problem drives how you create the solution.
We are not a healthy country. And while health reform focuses on coverage, cost, access and care, this is simply triage to a system that fails to ask the question "Why aren't we healthier in the first place?" Our health reform debate is focusing on where health ends (with medical care) and not on where our health begins (where we live, learn, work and play).
This month, the Robert Wood Johnson Foundation Commission to Build a Healthier America released a report about all of those other things. This report comes out of a bi-partisan commission created to look at the factors that affect Americans' health in our homes, our work environments, and our communities. In wonky terms, we call these factors "social determinants of health." In plain English, the Commission's purpose was to look for ways beyond medical care that could improve our health.
What do we mean by "beyond medical care?" There is a ton of evidence that shows where and how people live, learn, work and play has a tremendous impact on our health. And while this link may seem intuitive to most, the extent of the relationship is not reflected in either the way we consider our own health or the way we go about creating solutions to make us a healthier nation as a whole.
Let us consider just a few facts:
• Evidence now suggests that medical care accounts for only 10 to 15 percent of preventable early deaths.
• Some Americans will die 20 years earlier than others who live just a few miles away because of differences in education, income, race, ethnicity and where and how they live.
• College graduates can expect to live five years longer than those who do not complete high school.
• Middle-income people can expect to live shorter lives than higher income people, even if they are insured.
• And people who are poor are three times more like to suffer physical limitations from a chronic illness.
In other words, as it relates to our health, our zip code may be more important than our genetic code, our school files may be more telling than our medical files, the time spent in our office at work may be more relevant than the time spent at our doctor's office and the places we play may be more crucial than those where we get treated.
Even when we do consider these social factors, we too often place an unfair burden on personal responsibility and ignore the obstacles that stand in the way for some to make healthier choices. Consider that Detroit, an area of 139 square miles and over 900,000 citizens has just five grocery stores. An apple a day may help keep the doctor away but that assumes you can find an apple in your neighborhood.
As we begin to explore new ways to improve this country's health, we should look for inspiration from innovative programs around the country that are finding sensible, sustainable solutions at the intersection of health and daily life.
Take for example a program like Bonnie CLAC (Car Loans and Counseling), which is built on the premise that how you get around affects your ability to live a healthier lifestyle. Reliable transportation can mean the difference between keeping and losing your job, being able to take your kids to the doctor and make it to a grocery store that sells healthier food. Bonnie CLAC is helping the working poor purchase fuel-efficient cars at great prices and low interest rates, while providing them with crucial financial counseling. This counseling not only helps them make the payments but also show how changes, like quitting smoking, can help their financial bottom line and be good for their health. If only our banks had taken a similarly responsible approach to home lending, we could have avoided the sub-prime mess that has had a devastating domino effect in creating more Americans who are vulnerable to financial difficulties and subsequent poor health.
As we consider health reform in 2009, let's think about the neighborhoods and towns in which we all live, and ask ourselves: What are the barriers standing in the way to better health and how can health reform change the places we spend our lives to make them healthier places in which to live?
Take a look around you and ask yourself "where does health really start?" Is it in the hospital or the home? Is it with insurance company or your employer? Is it with an ambulance driver or an urban planner?
Only when we answer these questions honestly and see our health problems more clearly in this broader context, will we begin the real work to create and invest in solutions that help us all live as long and as healthy as we can.
Dr. James Marks is currently the Senior Vice-President, Director of the Health Group at the Robert Wood Johnson Foundation and is former Assistant Surgeon General, Director of the Centers for Disease Control's National Center for Chronic Disease Prevention and Health Promotion.
The Commission's report is a wonderful milepost, filled with evidence and stories of hope. Also wonderful is an open question: Will anyone listen? (This was actually overheard as a candid aside between Commissioners at one of RWJF’s public hearings.) We might add, Why or why not? These invite a deeper inquiry that must unfold if we are to begin the real work of profound, sustainable change.
As we inquire after the societal, structural and contextual conditions that lead to poor health, we must also consider what ways of thinking and acting and being led to these conditions in the first place. As Churchill said, “We shape our buildings, then our buildings shape us.”
The good news is that coming together to consider questions that matter is intrinsically healthy. In coming together we re-connect with what is most important. We create inclusive environments where every voice can be heard. And we begin to see that the exterior conditions in which we live and work are manifestations of our collective interior conditions, and that means we can change them together.
We are exploring this approach now in a growing number of communities (www.communitiesofhealth.org), and we welcome participation by all.
Detroit, which Dr. Marks references, has been on the Health & Human Services list of Medically Underserved Areas since 1994, and each year the measured factors decline further. A child raised in Detroit has a greater chance of dying from lack of access to care than in most other areas of the country, including remote rural areas. Many other urban areas show similar statistics. Unfortunately, the statistics are argued as though they represent nothing more than a spreadsheet total.
The human cost of failing to address these issues has caught up with us. Our health as a nation is comparatively worse than that of persons in Europe. It can be seen in the trail of crippled lives from elementary schools to the prisons where urban residents are a disproportionate sector of that population. Outdated laws in many states prevent the establishment of health care facilities in areas where they are most needed. Some states prevent competition between health insurers, which results in higher premiums. Bravo, to Dr. Marks and to RWJF for endorsing policies that do more than simply add to the bottom line of a balance sheet.
These nurses can tell you that by the 8th grade, kids in poor neighborhoods have decided that they have a future or that they have no future. The ones who feel that their lives will be nasty, brutish, and short don't take care of themselves -- not only that, they often actively sabotage their own health with tobacco, junk food, alcohol, sex, drugs, and violence.
Let's focus the lens on childhood as we think about ZIP codes and health. Let's get in and get working as soon as we can, however we can. All kids count.
How you see your life and yourself drives how healthy you are.
In rural New England we see our clients struggling to reach needed health care, grocery shopping and job opportunities because they lack reliable, affordable transportation. Our program serves as a catalyst for lasting financial and health well-being changes in their lives.
For those who want to learn more about Bonnie CLAC, please check out our new Promise Story video:
http://www.rwjf.org/vulnerablepopulations/product.jsp?id=41548
- Terri Steingrebe, CEO Bonnie CLAC
Thanks for your post and your excellent questions. I think the first step toward increasing the financial resources towards the places where health begins is helping both the private and public sector see the value and importance for doing so. Everyday, we are learning more about the economic and societal value of early intervention and prevention programs. Too often, we end up “paying later” to repair our health instead of investing earlier to make good health easier and to have it last as long as possible. For our part, at the Robert Wood Johnson Foundation, we purposely look to find programs, like Bonnie Clac, which are working upstream to build the pathways to better health that should have been there in the first place.