This week’s blog was originally posted by The Pump Handle on September 21, 2015. In this post, HIP Co-Director, Jonathan Heller, reflects on how collective efforts are necessary to improve our health and well-being.
The dominant narrative in the United States is that, as individuals, we hold the key to our own success. We are told to pull ourselves up by our bootstraps and that if we just try hard enough, we’ll succeed. Read more…
This blog post was first published by the Detroit Wayne County Health Authority on Feb 9, 2015.
Too many babies are dying in Detroit – just as in my town, Oakland, California. Too many people are dying earlier than they should be. Heart disease rates are soaring. None of these facts are in dispute. But when we ask why or what can we do, we get some different answers.
Some say we need to improve the health care system. But while health care is important, it does not address the reasons people are getting sick. Most of us go to the doctor’s office when we are already sick.
Others attribute it to personal behaviors, saying that if people ate better and exercised more, their health would be better. That’s true, but if we examine why people don’t have healthy behaviors, we quickly find that healthy options are limited – particularly for those living in low-income communities. Healthy food is scarce. Parks aren’t safe. Streets aren’t walk-able. Good jobs are scarce, so stable housing in neighborhoods with high performing schools remains only a dream.
At the root of all of these, however, is a tragic reality: The most important reason health outcomes in Detroit are so bad is that we have created public policies that mean parents can’t get good jobs, our kids go to inadequate schools, and many members of our communities are isolated from opportunity. We have created policies that mean kids don’t have the healthy food, stable housing, and good education they need to thrive. They live under constant stress because these policies have resulted in difficult family conditions and community violence. The way they live each day is simply not conducive to good health.
The good news is that change is possible. There are many things those of us working in health can do. We can use our individual and collective voices to advocate for policies that get at these core issues – policies that promote full employment and higher wages, integrated communities with affordable housing, and a strong educational system. And we can use the resources our organizations have to address these underlying determinants of health.And we should do all this recognizing that the communities suffering from poor health outcomes bring their own expertise that should be respected.
Because we are all in this to improve people’s health, we must use the power and resources we have to work for that change. For example:
We know this approach works. In the early 20thcentury, child mortality rates plummeted as a result of new child labor, sanitation, worker safety, and zoning laws passed by our government and implemented in the face of opposition from those who were profiting from the lack of regulation. This all happened before penicillin was invented or immunizations were available.
So, why not get involved in policy decisions that are being debated right now? Both Governor Snyder’s proposed sales and gas tax increase and Detroit Future City will affect the health of huge numbers of people. Health must be part of the debate.
There are many excuses we can give for not doing this work, including that it makes us uncomfortable and it feels alien. But if we are serious about improving health in Detroit, these are the kinds of actions that are required of us.
Jonathan Heller is, Co-Director of Human Impact Partners, and will be the keynote speaker at the 2015 Population Health Forum on March 2.
The Ebola outbreak in West Africa is an unambiguous reminder that social and economic conditions, like the lack of reliable public infrastructure in Liberia and Sierra Leone, are at the heart of many public health problems. In such an extreme case, public health and medical officials agree that once the epidemic gets under control, we must focus on improving these root conditions to prevent future crises. But even in the United States, where most places have reliable public infrastructure that protects people from such heart-wrenching scenarios, social and economic conditions lie at the heart of most serious public health issues and the inequities that result.
A new book, Expanding the Boundaries: Health Equity and Public Health Practice, released by the National Association of County and City Health Officials (a collaboratively written document with primary authorship by my friend Bob Prentice), focuses on the importance of social and economic conditions as keys to public health. Its central thesis is that “Health equity practice should consider the underlying social inequalities that are the root causes of health inequities, rather than only their consequences.”
Expanding the Boundaries begins by tracing the history of public health in the United States. Public health today takes a biomedical science approach – vaccines, laboratories, clinics, screening for disease. But many of public health’s most important advances were part of social reform movements responding to industrialization and urbanization. Reforms in sanitation, urban planning, food safety, child labor, and other areas resulted from public health advocates working with reformers in labor, women’s rights, housing, and other social movements.
The book argues that we must return to such collaborations to truly address the social determinants of health and health inequities:
The notion of an expanded health equity practice that can directly confront the sources of social inequalities is not a wistful claim to a romanticized history of public health. It is, rather, an argument that a public health that uses its resources, perspectives, commitment, and savvy to challenge the structures of power that create and maintain social inequalities and unhealthy living conditions is grounded in its own history.
It examines the root causes of health inequities – class, racism, gender inequity and heterosexism – and the structures that perpetuate these inequities. Disaggregating data, improving clinical management, and health education for specific demographic groups are all necessary, but not sufficient if we want to address inequity. “An expanded health equity practice,” NACCHO writes, “. . . asks how these [populations] came to be the way they are, and how public health might influence the forces that shape them rather than contend only with the consequences.”
Inspiring case studies – from Alameda County and San Francisco in California, Ingham County in Michigan, and the State of Minnesota – show how this can be done. Public health agencies in these places have been tackling such issues as goods movement, foreclosures, displacement, public transit, minimum wage, and planning and zoning.
Expanding the Boundaries identifies seven elements of health equity practice. For me, one resonates most and reflects where HIP is heading: “Some health departments have learned how to participate strategically in campaigns initiated and led by others, which might not be primarily about health but nonetheless advance health equity goals.”
This approach to public health is far from commonly accepted today and far from what is possible now in many places. But as the book concludes, “Developing health equity practice … is best seen as a movement-building strategy. It is a long-term process that requires a transformation of organizational culture and practice, and the larger public understanding of what most influences health.”
I admit it. I used to be a professional victim-blamer. I didn’t realize it at the time and I always meant well. But as a public health educator, I sometimes contributed to people blaming themselves for their own poor health – because I didn’t mention to them how hard it might be to do the things I was telling them to do, or that there might be other things that could be done to improve their chances. This probably left them thinking that if they didn’t succeed, it was their fault.
An overwhelming majority of Americans blame people, and people blame themselves, for being fat because they don’t eat right or get enough exercise. We in the public health community tell them about all the ways obesity will harm their health. Then our society, from the medical establishment to reality TV, perpetuates this message (even though the relationship between weight and health is more complicated than that). In my days as a public health educator, I toed the party line and supported efforts to encourage individuals to change their eating and exercise behaviors to maintain a healthy weight.
When people live in neighborhoods that lack safe sidewalks, bike paths, parks, or public transit they can walk or pedal to, they’re naturally less likely to be physically active. And when people don’t have easy access to affordable healthy food, but are surrounded by corner stores, gas stations, fast-food places, and food industries pushing cheap unhealthy food, guess what? They’re less likely to make healthy choices. While the public health community is now supporting some neighborhood and policy interventions, most of our messages about food and exercise still focus exclusively on the individual without information about the influence of the environment, which probably contributes to a lot of the blaming mentioned above.
Victim-blaming can also result from the way we talk about sexually transmitted diseases. I cringed when I heard an NPR story reporting that when people are told how bad STDs such as herpes are, they are less likely to want to get tested and find out if they’re infected. I used to be one of those people who did condom demonstrations on plastic bananas and then handed out brochures with scary pictures of what might happen if they didn’t use them.
These messages, like the ones about healthy eating and exercise, were focused exclusively on the actions individuals should take, without any context about how the environment might influence their choices. When we use messages that talk about the bad or scary things that can happen to people in an effort to motivate them to change, the underlying message can easily become if you don’t do these things to protect your health, you deserve it if you get fat or get an STD – leading people to blame themselves, and others to blame them as well.
But again, look at the neighborhood. If you live in a neighborhood where there’s nothing for teens to do after school, a neighborhood where there aren’t enough jobs so people resort to selling drugs, a neighborhood saturated with alcohol advertising, you have a higher chance of contracting an STD. Neighborhood factors can create a vicious cycle. In some urban neighborhoods more than half of the young men have been in prison, most often for selling drugs. Prison gives them a higher exposure to STDs. With so many of them locked away, people in the neighborhood have fewer partners to choose from, so those who have STDs are more likely to share them with others.
There was even some level of victim-blaming when I taught stress management, though perhaps this was more subtle. For nine years, I taught patients in an outpatient clinic of a hospital that primarily served a low-income African American population how to manage stress. I offered them guidance in different forms of meditation and ways to change their thoughts. It was deeply rewarding on one level – I loved hearing things like “My family says I smile more now!” – but I worried that people would not be able to sustain the benefits long-term, and eventually I came to see it as putting a Band-Aid over a bigger, deeper problem.
The fact is that poverty and racism are stressful. Learning how to manage your own stress does nothing to get rid of the root causes, and when you are surrounded by root causes that never go away, you must continually swim upstream to take care of yourself, and may blame yourself if you don’t succeed. Meanwhile, policies that work to reduce the impacts of poverty, such as minimum wage laws and wage theft ordinances, are a different way to tackle stress at the population level.
I’m not saying we should stop talking about the importance of physical activity, healthy food, safer sex, and ways to manage stress. And I’m not saying messages directed at individuals are inherently victim-blaming. But I am saying that when we know neighborhood and policy factors influence individual behaviors and we only tell people about the individual behaviors they should change, it can lead to moralizing about those behaviors and to victim-blaming.
In the systems thinking world, some might call victim-blaming an unintended consequence of individually-focused prevention messages. It’s time to recognize and address this unintended consequence by complementing those messages with information and advocacy for public policies that promote health and well-being. It’s time to stop fanning the flames to blame the victim and work together to change the conditions that lead to poor health.
Why do some workers get paid sick leave, while 85% of food preparers have to choose between coming to work sick or losing a day’s wages? Why do fewer than 1 in 10 African Americans live in a census tract that has a supermarket, compared to almost one-third of whites? Why do we send drug offenders to jail when it’s cheaper and more effective to send them to treatment? How do these inequities affect health for all of us?
As HIP and others conduct innovative research that highlights the health issues inherent in all policy decisions, we are seeing an emergence of new public health professionals who are interested in Health Impact Assessment (HIA) and Health in All Policies (HiAP) research as tools to advance health and equity. In the first two years of HIP’s Health and Equity Fellowship, we have had 90 applicants from across the country, and with a diverse range of personal and professional backgrounds.
We asked Fabiola Santiago, who recently completed our first Health & Equity Fellowship: What advice do you have for emerging public health and HIA practitioners who are interested in health & equity research?
Fabiola:
HIP’s Health and Equity Fellow is responsible for initiating and leading a new and innovative HIA or HiAP project that aims to advance the consideration of health and equity in decision-making. For my primary project, I led an HIA focused on proposed legislation to address wage theft, the nonpayment or underpayment of wages rightfully owed to employees.
In working on the wage theft HIA, I found that health and equity are still relatively new concepts for many organizations. Throughout this experience, I was simultaneously learning and teaching these concepts and the HIA steps. Patience is key. As someone with a strong background in social justice issues and an ardent inclination towards public health, the link between social determinants of health and health outcomes is evident to me, but it’s not necessarily explicit in research. Extra research is often needed to form predictions in areas where a health lens is not available. Budget additional time for each HIA step, and still expect delays.
During my fellowship, I also worked on a Health in All Policies project – the Local Control Funding Formula. This project involved a broad set of partnerships. I learned that each organization and individual may have a different agenda, some will be more equity focused, others more on health, and still others on other issues. Being mindful of these differences, yet staying focused on the overall goal can reduce confusion, but innovative ideas can emerge from the conversations. Communicating findings will generate more partnerships and garner more support in issue areas. Not everyone may use the same language, but the goals may be similar. Paying attention to these nuances has the potential to create new relationships.
For all the projects I worked on, I found it important to be flexible yet firm. As you embark on your project and especially while working with people and organizations you’re close to, it’s important to be flexible to their needs. But it’s also important to make sure that the project does not fall too far behind. Respect their feedback, incorporate their suggestions, but remember to value your professional expertise as well. As an emerging professional, it can be hard to make executive decisions, but it’s important to your development as a leader.
The purpose of the HIA is to first and foremost increase the consideration of health and equity in decision-making. However, if the HIA does not succeed in influencing decision makers, it does not mean it failed. Hearing, “Thanks so much for your work. I can’t believe we haven’t looked at how wage theft impacts health” is a sign that the overall purpose of the HIA is heading in the right direction. Additionally, when I conducted focus groups, seeing how candid participants were, and creating a space for them to vent was also a sign of success because it illustrated how much their working conditions impacted their daily lives.
Social determinants of health and community are key. Addressing health problems from their root causes will inevitably take longer, but in the long run will have a much greater effect. Changing the social determinants that influence people’s health has the potential to prevent and alleviate the most pressing health problems. Additionally, the field of public health must lead in elevating community voices—especially from those whom are most affected.
Spike Lee calls it “the Christopher Columbus Syndrome” – the “discovery” of lower-income, racially diverse urban neighborhoods by a richer, whiter influx of new residents who drive up the cost of housing, squeezing out working-class folks, and transforming the neighborhood. The debate over gentrification rages among academics, cultural critics, and of course, to those of us who find ourselves living it. (I’m a twenty-something who has recently moved to the San Francisco Bay Area, gentrification ground zero.)
But what about the perspective of the people being displaced? In a new report, Causa Justa :: Just Cause provides much-needed insight from the perspective of the residents of Bay Area communities most heavily impacted, providing vivid evidence that gentrification is not just an amoral process of change but a public health problem – as sociologist John Joe Hickman says, “the most pressing issue as we become an urban world.”
The report – Development Without Displacement: Resisting Gentrification in the Bay Area – defines gentrification as
a profit driven race and class remake of urban, working class communities of color that have suffered from a history of disinvestment and abandonment. This process is driven by private developers, landlords, business, and corporations and supported by the state, through both policies that facilitate the process and funding in the form of public subsidies. Gentrification happens in areas where commercial and residential land is cheap relative to other areas in the city and region, and where the potential to turn a profit, either through re-purposing existing structures or building new ones is great.
The pace and scope of gentrification in the Bay Area is alarming. Causa Justa :: Just Cause’s analysis shows that there are no remaining neighborhoods in Oakland that are not already gentrifying, susceptible to gentrifying, or already wealthy. Working-class communities of color in San Francisco are in a similar position, especially in the Mission district, where no-fault evictions are at the highest levels since the dot-com boom of the early 2000s.
Displacement has been linked with a myriad of stressors, including financial hardship, disruption of social networks, loss of access to health services, even homelessness. Stress, in turn, is linked with poorer health outcomes. The fact that gentrification literally makes residents of displaced communities sick is not an inevitable effect of morally neutral market forces, but a fundamental injustice.
But gentrification is not inevitable. The report provides specific policy recommendations that can prevent displacement from beginning and halt its progress in areas where it is already occurring. Health impact assessments can help local governments and public health officials to promote economic development without displacement. Causa Justa :: Just Cause says the key factor in turning the tide is honoring the voices of communities as partners in development and planning processes that affect their future. Only then will current residents stand to benefit from the renewed wave of investment coming to the neighborhoods they call home.
This blog post was originally published at The Pump Handle on February 18, 2014.
The quality of public housing is a key determinant of health among low-income populations. Substandard housing – where mold, pest infestations, fire hazards, or other health risks are present – is associated with a wide range of health problems, including respiratory infections, asthma, lead poisoning and mental health issues. Nor is illness the only concern: Each year millions of Americans are injured, and tens of thousands killed, by accidents in and around their homes that may be linked to housing conditions. Access to safe and affordable housing is not just an economic issue, but a major public health issue.
However, much of the public housing in the United States is in disrepair – unhealthy, unsafe, even uninhabitable. The federal Department of Housing and Urban Development (HUD) has been working for many years to fix the problem, but with the cost of bringing public housing up to standard estimated at more than $20 billion nationwide, it’s a daunting task. (It doesn’t help that HUD’s budget, especially the portion for maintenance and renovation, which was inadequate in the first place, has been repeatedly slashed for the last 30 years.)
In 2011, Congress passed the Rental Assistance Demonstration Project (RAD), a pilot program providing for the purchase and renovation of some 60,000 units of public housing by nonprofit organizations or private entities. A linchpin of the program is the requirement that for 15 to 20 years the new owners must continue to make the housing available to the same populations that currently live there.
Public housing has received increasing attention from the field of Health Impact Assessment, which evaluates multiple health impacts of proposed policies and projects. HIAs have been conducted on housing inspections in Ohio and in Marin County, Calif., and on the HOPE VI program in San Francisco. Currently the Health Impact Project is in the midst of an HIA done in collaboration with HUD about changing the rules for elderly and disabled public housing. In 2011, Human Impact Partners released an HIA of the RAD proposal.
Recently San Francisco, where soaring rents are forcing increasing numbers of low- and medium-income renters out of the city, was awarded a grant from HUD to rehabilitate its public housing stock – enough to renovate three-fourths of all units. In order to qualify for renovation, the units must be sold to private or nonprofit owners who get tax credits. The units then become Section 8 voucher properties (where low-income tenants pay 30 percent of their rent and vouchers make up the difference to the landlord), and the owners sign a contract to keep them as such for 20 years.
Human Impact Partners’ HIA of the RAD project predicted that the program would lead to improved housing quality, decreased stress among residents and decreased crime around renovated housing. But the devil is in the details. We also predicted that RAD, if not done well, could lead to poor health due to potential evictions, displacement, lack of authentic resident inclusion in decision-making, and stress from not knowing whether one’s housing is secure over the long term.
Here’s what we believe San Francisco must do to avoid those potential negative impacts:
Affordable housing is not only vital for low-income populations, but to the community at large. We’ve seen what happened when the mental health system that helped those who could not live without support was dismantled. Homelessness and incarceration shot through the roof. We don’t want that to happen if public housing goes away. The bottom line: We just aren’t sure that the RAD program offers enough protection to ensure that private interests wouldn’t eventually win out over the public good.
Think about it: You’re a developer who can afford to buy hundreds of units of public housing, get tax breaks from the government for improving them. All you have to do is agree that for 15 to 20 years you will keep them available for low-income populations. After that, you must consider keeping them available, but you’re free to sell them at market rates. In markets such as San Francisco, where even modest units have no shortage of takers eager to rent or buy at prices unthinkable until recently, would you think about public health, or your own opportunity to profit?
Policymakers must consider ways to require or incentivize the continued availability of affordable units. Policymakers who want to consider health and quality of life for their most vulnerable residents must assure that safe, well-maintained housing continues to be available for low-income residents.