Tag Archives: Social determinants of Health

Expanding Access to Preschool Could Improve Health and Equity in Cincinnati, August, 2016

One of my favorite things about doing HIAs and other projects at Human Impact Partners is the unexpected “Aha!” moments that occur, when we find something in the research that surprises us.

Today, Human Impact Partners and our partners from The AMOS Project are excited to release a report that examines the health and equity impacts of expanded access to preschool for children in Cincinnati. Our study concludes that expanding access to preschool would benefit the health and equity for children, families, and other residents of Cincinnati. That’s actually not an “Aha!” for me. I expected that improved education would have benefits to health and equity. But I didn’t exactly expect all of the connections we found.

To me, it makes sense that if children get a better chance at high-quality education earlier on in life, they will do better in school later on. What I didn’t expect was how far those ripple effects would reach. It makes sense that high-quality preschool education could improve reading and math scores in third grade. But interestingly, those impacts don’t always continue over time. By the fourth grade, children who had access to high-quality preschool don’t always show significantly different reading or math scores from those who didn’t. But, they are less likely to be held back to repeat a grade in school, and they are less likely to require special education services. Essentially, they are able to keep up. And this ability to keep up allows them to remain connected and engaged in the school system, which means that they stay in school. They graduate. And if they graduate, they have better job options with higher wages. Which means they are not as likely to become involved in the criminal justice system.

Higher wages and less crime because of preschool. Those are some far-reaching ripple effects!

Figure 1

And guess what else? I really didn’t expect this one, but it makes sense to me. Family relationships are better. Being a parent of a young child can be stressful. When parents don’t have resources to deal with that stress, a small proportion of the time it can unfortunately manifest in child abuse and neglect. But research suggests that high-quality preschool has some pretty impressive protective factors for this. High-quality preschools not only give parents a break from the stress of parenting, they give children an opportunity to learn social and emotional skills when interacting with other children, and they give parents structured and guided ways to interact with their children. In our study we predicted that nearly three out of ten children in Cincinnati who would have experienced abuse or neglect would not experience it if they were sent to preschool. And improved family relationships last over time as well. Forty-year-old adults who attended preschool as children are still more likely to say their family relationships are better than those who did not. Again – those are some far-reaching ripple effects!

Of course, increased education, improved wages, less crime, less stress, and better social relationships can all lead to improved health. And that’s a wonderful, amazing thing. But it turns out that preschool could also be a key factor in breaking the cycle of generational inequities. Due to multiple forms of structural discrimination, growing up in poverty, in a single-parent household, or with a parent who is incarcerated are all more common experiences for children of color. These experiences increase the odds of negative physical and mental health outcomes and lead to a vicious cycle that continues through multiple generations, further contributing to ongoing inequities. When preschools and the school systems that they feed into have a trauma-informed approach to discipline, focusing on the root causes of the problem behaviors, rather than zero-tolerance suspensions and expulsions, preschools could help break that cycle.

Figure 2

This is especially important for communities like Cincinnati, where many of these risk factors are nearly double the national rate.

Figure 3

Thus, based on our findings, our study recommends the following actions:
1. Expand access to high-quality preschool programs to all children
2. Prioritize to reach those most in need, such as children living in poverty
3. Assure high-quality preschools and teachers through adherence to preschool program and training features that research has proven to be successful
4. Utilize a trauma-informed approach to discipline that incorporates an understanding of the source of the behavior problem, in preschool and beyond, rather than zero tolerance policies such as suspensions and expulsions
5. Assure that high-quality preschools are geographically distributed throughout the city

This Health Impact Assessment was produced in partnership with our Advisory Committee members from Cincinnati Children’s Hospital, StrivePartnership, Interact for Health, Mercy Health, and United Way’s Success by 6.

The Long Road Home: Decreasing Barriers to Public Housing for People with Criminal Records

For individuals with a criminal history, finding affordable and stable housing becomes extremely difficult in a place like the Bay Area, with high cost and limited supply. People with a criminal history can legally be excluded from housing. In a survey from the 2015 Ella Baker Center for Human Rights and Forward Together report, “Who Pays? The True Cost of Incarceration on Families,” 79% of people who had been incarcerated were either ineligible or denied public housing as a result of criminal history. More than half of those released from jail or prison have unstable or nonexistent housing.

Safe and affordable housing is a fundamental basis for success in all areas of life, and without stable housing, an individual’s health, employment and education opportunities, family reunification and social networks are compromised. In Alameda County, California, nearly 20,000 people are at risk of residential instability because of having a recent criminal history.

Having housing improves health directly and indirectly, decreases recidivism, improves the chance of becoming employed and having more income, and helps with family reunification. These factors, known in public health as the social determinants of health, create opportunities to succeed and are known to be important for health and wellbeing. For example:

  • Moving often affects recidivism. The odds of recidivism increase by at least 70% for every time someone who is formerly incarcerated changes their residence.
  • Six randomized control trials analyzed supported employment in public housing against other approaches to help residents find jobs, and found 58% of public housing program participants obtained employment compared to 21% in the control group.
  • More than 70% of those leaving prison indicated that family is an important factor in keeping them out of prison, and up to 82% of people leaving prison or jail expect to live with or get help from their families.
  • Having stable housing upon leaving jail or prison decreases a person’s chance of having their probation revoked.

It’s clear from the research; the lack of stable and affordable housing forces families to frequently move and live in unhealthy and crowded environments, increases stress and depression, and can lead to homelessness. Homelessness brings higher rates of infectious diseases; substance use and mental health disorders; exposure to violence; overexposure to cold and rain; and suicide. Studies show that 25% to 50% of people who are homeless have histories of involvement with the criminal justice system.

Public housing admissions screening policies play an important role in creating the conditions for successful reentry of people who were incarcerated. HIP recently released a report called, “The Long Road Home: Decreasing Barriers to Public Housing for People with Criminal Records” done in partnership with Ella Baker Center for Human Rights (EBC). I worked closely with EBC staff starting in September 2015 to complete this Health Impact Assessment (HIA), as part of my Health & Equity Fellowship with HIP. We studied the Oakland Housing Authority (OHA) as a case study to understand the impacts of screening policies on health.

To fully understand OHA’s admission and screening policies, HIP met with two staff from their office. We learned that OHA denials due to a criminal history in the first round of screening have decreased significantly from 12% to 0.8% between 2010 and 2012. Of those who were screened out by OHA due to a criminal history, 75% request an informal hearing, and 64% of those have the decision reversed, allowing them to continue on in the application process. This is a powerful statement for the presentation of mitigating circumstances; at OHA, when people are allowed to tell their story and present supporting documentation, it often results in a reversal. We know that historical policies have created racial inequities in housing and health outcomes. However, data on race and ethnicity is not being recorded or reported, making it impossible in OHA’s case to analyze inequities in screening practices.

While more people with criminal histories are able to move forward in the screening process when OHA allows them to present mitigating evidence, there are additional changes OHA and other public housing authorities can make to improve housing stability for individuals with criminal history:

  • Allow mitigating circumstances to be presented in the initial application for public housing
  • Ensure proper implementation of policies that allow individuals with criminal history to join their family in public housing, and eliminate any practices of evicting existing residents from public housing for allowing a family member returning from prison or jail or denying admission if there is no valid reason for doing so
  • Collect, track, and publicly report the race and ethnicity of applicants and those screened out due to their criminal history to examine the potential impact of screening policies on people of color with a criminal history

Read more of the findings & recommendations in the full report.

A Framework Connecting Criminal Justice and Public Health

HIP has been doing a lot of research about how criminal justice policies and practices affect health. As our work to understand these impacts has evolved, we are more and more convinced that it is a public health imperative to use the power of public health to re-envision and change our justice system and virtually all its component parts.

As conveners of the National Criminal Justice and Public Health Alliance, we’ve also been thinking a lot about how the determinants of health are more or less the same as the determinants of justice system involvement. Others are also thinking about criminal justice as a public health issue by: changing behaviors related to violence; addressing the traumas that victims face and how those perpetuate crime; reducing Adverse Childhood Experiences; ensuring those leaving prison sign up for Obamacare; and working to reinvest savings from criminal justice reform back into our hardest hit communities.

All these approaches are necessary to addressing the health and social needs of those who are justice involved. It’s useful to also think about how these individual and community level interventions tie together into a criminal justice and public health framework. This diagram represents a way of thinking about these relationships and how change in any one domain might affect change in another domain.


First, let me give examples of what is included in each element of the diagram:

  • Community Conditions – Social, Economic, and Environmental Determinants of Health includes employment, housing, and education; exposure to environmental contaminants like lead as well as access to healthy food; and poverty, racism and other forms of oppression, and empowerment.
  • Physical and Mental Health Outcomes includes chronic disease (e.g., cardiovascular disease, diabetes); infectious disease (e.g., AIDS, hepatitis); developmental issues; stress, anxiety, depression, and trauma; and preterm birth, infant mortality, and premature mortality.
  • Behaviors include substance abuse, theft, and violence as well as eating a healthy diet and getting exercise.
  • Criminal Justice System Involvement / Criminal Justice Policies includes involvement in system as well as policies that govern all aspects of the criminal justice system including school discipline and the school-to-prison pipeline; policing; pre-trial, prosecution, defense, adjudication, and sentencing; incarceration; and release and re-entry.

Here are some examples (though not a comprehensive list) of how elements of the framework shown in the diagram simultaneously interact with each other to generate poor health and justice system involvement.

Examples: How factors that shape health affect justice involvement, behaviors, and health outcomes

Determinants of health can affect criminal justice involvement, behaviors, and physical and mental health outcomes through:

  • Homelessness and poverty are criminalized, leading to justice system involvement
  • Both structural and institutional racism lead to over-policing of black communities and disproportionate punishment of people of color throughout the justice system.
  • Lead exposure in childhood leads to developmental delays, behavioral issues, and crime.
  • Unemployment can lead to a host of behavioral issues: drug use, involvement in the underground economy, theft, and various forms of violence.
  • Conditions that lead to Adverse Childhood Experiences, such as exposure to violence in the community, homelessness, or incarceration of a parent, can lead to behavioral issues in school and beyond, substance abuse, as well as mental health disorders.


Examples: How justice involvement affects factors that shape health and health outcomes

Criminal justice involvement and policies can affect determinants of
health, behaviors, and physical and mental health outcomes through:

  • People re-entering society face collateral consequences of justice system involvement, such as difficulty finding employment and housing.
  • Experiences while incarcerated, including traumas from physical, sexual, and mental abuse, and from isolation, can lead to drug use and further violence.
  • The presence or absence of rehabilitative programs while incarcerated influence recidivism upon release.
  • Restorative justice practices as an alternative to incarceration influences


Examples: How health outcomes affect justice involvement and factors that shape health 

Physical and mental health outcomes can affect criminal justice involvement and determinants of health through:

  • Physical or mental health issues can lead to unemployment and housing instability.
  • Mental health crises can lead to arrest.
  • Debt from health care expenses can lead to inability to pay bills, poverty, and arrest.




How can this framework be used?
This framework provides public health and criminal justice reform advocates a common basis for talking about work to create a more just criminal justice system that creates the conditions necessary for people to succeed and therefore healthy and safe communities. Those seeking change in any element of the framework should recognize that their efforts are linked to other elements and therefore a) consider the relationship and consequences of their work on those other elements and b) build relationships with others working on other parts of the framework to think about how all efforts can reinforce one another. The less our work is isolated, the better the outcomes we will realize.

For example, many proposed criminal justice reforms can be analyzed using this framework. Our Health Impact Assessments ask how these reforms – in policing, sentencing, access to education in prison, for example – influence physical and mental health outcomes directly, and through changes in the other two elements – behaviors and determinants of health.

As we continue work with the National Criminal Justice and Public Health Alliance, we’ll make sure we represent the different aspects of the framework in our discussions and continue to strengthen relationships between the groups doing this work. We have already collaborated to create a vision for a criminal justice system that operates from public health principles. Should this vision be realized, it would improve upon virtually all elements of the framework and lead to improved health and justice system outcomes.

We hope the framework is useful to others doing work at the intersection of criminal justice and public health. We’d love to hear your thoughts!

Dismantling the Bars on the Birdcage

The recently released Coming of Age in the Other America by Stefanie DeLuca, Susan Clampet-Lundquist, and Kathryn Edin asks the question: why do some kids in the poorest neighborhoods thrive and meet their potential despite overwhelming odds when others don’t?

As summarized in an excellently in-depth Atlantic article, which I am leaning on until I get my hands on a copy of the book, two separate factors stand out for those who thrive: their neighborhood or having an “identity project”, meaning a strong passion such as music, art, or a dream job. But there are important caveats to underscore. Living in a safer neighborhood or having an identity project can help, but either of these alone is not a 100% guarantee that a person meets his or her potential. According to authors, other factors can simultaneously pull down and overwhelm even promising students – things like the absence of a parent, living in overcrowded homes, or living in blighted neighborhoods. As The Atlantic article powerfully notes, “A journey from poverty to the middle class or beyond is a birthright of many of these kids, their shot at the American dream. But the research indicates they can’t just get there themselves. Like anybody, they need a little help.”

But what can that help look like?

Help comes in different forms and at different levels – but what is central is putting the emphasis on supporting people. For example, it comes at a policy level by society enacting incarceration policies that focus on uniting adolescents and parents rather than separating them. It comes at a resource level by investing in housing and public services for neighborhoods deeply and historically overlooked. And it comes at a personal level by providing individual support. One example of the latter is a promising program profiled in a two-part series in The New York Times. Thread is a Baltimore-based program that brings together teams of volunteers to support at-risk teenagers, through unconditional support 24 hours a day for 10 years, and by providing increased access to community resources.

Thread Program Model 


(source: Thread.org)

But there’s a larger idea also at work here. A colleague of mine wisely suggested, “structural problems need structural solutions.” When we look at structural solutions, focusing separately on schools, family, policing – one of these alone is not enough. It’s too easy to fall through cracks if you focus on only one. This same concept came up at a staff meeting recently. Looking at an article on structural racism by Andrew Grant-Thomas and john a. powell, there is a metaphor borrowed from Iris M. Young who borrowed it from Marilyn Frye. (Still with me?) In talking about racism the article says the following – and I include the full excerpt because it’s important language:

“If we approach the problem of durable racial inequality one ‘bar’ at a time, it is hard to appreciate the fullness of the bird’s entrapment, much less formulate a suitable response to it. Explaining the bird’s inability to take flight requires that we recognize the connectedness of multiple bars, each reinforcing the rigidity of the others. In confronting racism we must similarly account for multiple, intersecting and often mutually reinforcing disadvantages, and develop corresponding response strategies.”

So in thinking about the work you do and the structural challenges you are working to confront, consider: how are you working on dismantling multiple bars on the birdcage, and not just one?


Strategic Questions to Ask To Explicitly Address Racism and Power in Your Public Health Practice

A few months ago, I wrote about the need for public health practitioners who want to advance equity to explicitly address race and power in their work. I received positive feedback, but also found that people are interested in how to actually do this. I recently created some materials for a training and it went well.

So, here goes an attempt to share it with a broader audience…

Let’s say you and your team – a team that hopefully includes people with a variety of skill sets and perspectives, including people from communities facing inequities – are working on a project on a particular social determinant of health in a particular location. As an example, let’s use policing, and mass incarceration more generally (i.e., the determinant), in Cincinnati and Akron, Ohio (i.e., the location). (Disclaimer, these examples stem from a recent HIA HIP released).

Questions about Underlying Issues

As you begin thinking about your project, here are a set of strategic questions that you can discuss with the team that get at the underlying issues of racism and power that are at play for virtually all social determinants of health:

1. What is your long-term equity goal, as it relates to the issue in that place?
2. What is the historical and current racial context for the issue, at the structural, institutional, and interpersonal levels?
3. What is the historical and current context with regard to other forms of oppression (class, gender, age, sexual orientation, disability, etc.) for the issue at the structural, institutional, and interpersonal levels?
4. Have race and/or other forms of oppression been used as political tools in decision making around the issue? If so, how?
5. Do you have the votes or other measures of buy-in to advance your equity goal? Explain.
6. Do you have a network of organizations and individuals strong enough to advance your equity goal? Explain.
7. What is the current societal narrative as it relates to your equity goal? Does it work in your favor or against you?

Example: Here are some quick and oversimplified answers for policing in Ohio:

1. Long-term equity goal? Eliminate the use of policing and incarceration as a form of control of black communities. Invest in necessary jobs, housing, education, etc. instead.
2. What is the racial context for the issue? FDR’s compromise with southern Democrats, who were segregationist (interpersonal racism), led to housing policies at HUD that have allowed whites to build wealth and simultaneously led to white flight and disinvestment from inner cities (institutional racism). Many communities of color, like those in Cincinnati and Akron, now suffer from lack of opportunity – in jobs, housing, education, etc. – and high crime rates (systemic racism). This has led to excess policing and incarceration. Listen to this NPR piece, for example, for more details.
3. What other context and forms of oppression are important to consider? The following populations have also been over-policed in communities of color and other communities: youth, men, LGBTQ, those with mental illness, and low-income whites.
4. How have race and other forms of oppression been used as political tools? Think of who the language of “tough on crime”, “war on drugs”, “super-predators” was really about (dog-whistling). Think about how heroin addiction – which is thought to be used more by whites – is treated as a health issue, in comparison to crack addiction – which is thought to be used more by blacks – which is criminalized.
5. Do we have enough votes or buy-in to advance our equity goal? No! Most people – including people of color – consider policing to be the best solution to addressing public safety needs in inner-city communities of color.
6. Do we have a network of organizations strong enough to advance our equity goal? No! This issue is just beginning to bring people together and a movement is starting. But still, policing and incarceration are seen as separate issues from jobs, housing, and education. We are still too siloed in our work.
7. What is the current narrative? It includes “Be afraid of black people”, “us vs them”, “individuals are at fault – they choose to commit crimes and are bad people”, “punishment deters crime”, and “we are protecting the innocent”. We see these themes everywhere – in the news, on TV, and in the movies. There is a lot more that could be said about this, but the way crime and policing are now thought of, we will have a difficult time achieving significant reforms.

After going through this exercise, your team will most likely have a better and a common understanding of the barriers you face in achieving your equity goal. That understanding should inform the approach you take.

Questions to Overcome Barriers Identified

If your project includes conducting research, like a Health Impact Assessment, a next step is to think about how you can use your research process to overcome these barriers. For example, your team could discuss the following questions.

How can you use your research process to:

1. Bring attention to the current and historical context regarding racial and other forms of oppression around your issue?
2. Unite people across the boundaries of race and other forms of oppression?
3. Diffuse the ability of opponents to use race or other forms of oppression as a political tool to block your ability to move your equity goal?
4. Build your ability to advance both your short-term and long-term equity goals by:
a. Winning enough votes or other measures of buy-in?
b. Building relationships and infrastructure to change what is on the political agenda?
c. Changing the dominant narrative related to your issue?

Example: Again, here are some quick and oversimplified answers for policing in Ohio:

1. How can we bring attention to the current and historical context of oppression? We can: discuss these with our steering committee; reflect them in our recommendations (e.g., recommend that communities come together to talk about this history); and have a section in our report that discusses this history.
2. How can we unite people across boundaries? We can discuss how both black communities and the police are negatively impacted by current forms of policing. And we can use the steering committee to start bringing people together and build trust.
3. How can we diffuse the ability of opponents to use oppression as a political tool? We can discuss approaches to overcoming dog-whistling during our research process. We can make recommendations about further and broader discussions about the use of race as a political tool as it relates to policing. We can also share information about how unconscious bias plays out today in terms of policing.
4. a. How can we build our ability to win enough votes or gain buy-in? We can use the HIA process to engage communities most impacted and help our partners build their leadership and sense of agency.
b. How can we build our relationships and infrastructure? By developing and engaging a diverse steering committee.
c. How can we use the research process to change the dominant narrative? This is hard! We can start to change the “us vs them” mentality by discussing that we are all impacted. We can humanize everyone. We can talk about wanting to have policies that improve everyone’s health and that address underlying social causes.

As you can see, these are difficult questions and advancing equity by addressing race and power is not easy. But this work is necessary and it is worth struggling – together – to figure out how to do it.

Tools You Can Use

In case it is useful, we’ve pulled these questions together as a worksheet to use with your team. And for HIA practitioners, after you go through these questions, you may want to use the Equity Metrics for HIA Practice as a planning tool for your project.

Let us know if you use these tools and, if so, what feedback you have for us! Thanks!

Our Politics are Killing Us

Today’s blog post is written by Dr. Rajiv Bhatia, a physician, health scientist, Principal of The Civic Engine, and co-founder of HIP. The post was first published on December 18, 2015 by Medium

Doctors train to find the diseases behind the symptoms and signs. But, social diseases, like poverty, are usually hidden behind the ones that afflict our bodies. It’s something that medicine doesn’t often talk about it. And, our politics is what keeps these social diseases alive. Read more… 

If we want to advance equity in public health practice, we must address race and power

This week’s blog post was originally posted on The Pump Handle on January 7, 2016.

Most public health practitioners, and those who work on health impact assessment specifically, want to improve the health of vulnerable populations. Most efforts to do so are well-intentioned, yet they often don’t lead to significant change. What do we need to do differently? Below is an analysis we at Human Impact Partners put forward. Read more…

The Greater Health Impacts of the Affordable Care Act

My son had an accident and broke his leg and I found a lump for which a routine biopsy was needed.

When these things happened to my family, I was relieved I had health insurance to help meet our medical needs. But it’s been an expensive and confusing experience – even quality health insurance coverage (procured through my partner’s employer) is proving inadequate at sparing my family the negative health effects of high medical bills. It made me wonder – how has the expansion of health insurance through the Affordable Care Act impacted peoples’ economic security? How much farther do we have to go to ensure that people can access health care without significant financial stress?

While our health issues were serious enough to require treatment, they were not unusual. I had to spend $1,500 (after insurance paid what they would) to discover my lump was, thank goodness, totally fine from a cancer perspective. Not so, from a financial perspective. Then recently, my son was playing with his cousins, fell, and broke his leg. Not sure what the total bill for this is going to be yet, but I’m guessing it also will be around $1,000 after insurance. In the health insurance world, these are probably considered moderate costs for a “consumer” who also pays health insurance premiums every month. But for a household with a tight and perpetually stretched budget like ours, this extra expense causes a great deal of stress.

This financial stress has a number of additional impacts to our family’s health and well-being. My partner and I have to make decisions about the things we will forgo in order to pay these bills. These are not fun conversations and I could see how over time they might end up putting too much stress on a relationship. For couples that separate, there is a cascade of health effects that happen: isolation, depression, anxiety, and negative impacts on children are well documented in the research.

There’s also research that looks at the long-term “economic scarring” that happens (such as during a recession) when families have to make tough choices about spending money on basic needs and medical bills, rather than on things like educational achievement, investments, or starting a small business. When scores of families are forced to make these trade offs (such as during a recession) our whole economy suffers. Our current system of health insurance not only does not protect people’s right to be healthy and productive, but when one of us gets sick or injured in the current system, we all pay.

In HIA, we seldom look at the health impacts of health care policy. We usually focus our policy efforts more upstream, and think of health care as a safety net after upstream efforts have failed. Health care becomes relevant when we aren’t able to change the unhealthy places where we live, work, go to school, and play. Yet through my personal experiences with the financial burdens of health care, I am gaining a different perspective on the greater health impacts of inadequate health insurance. It’s informing my research on the health impacts of financial stress through a new HIA project in our Economic Security Program that I’m leading with our partners, ISAIAH, in Minnesota.

Although the ACA represents a leap forward, we still have a long way to go towards ensuring everyone has health care that doesn’t come with a heavy dose of financial stress. I believe that health care could and should be considered a human right rather than a commodity, as it is now. We should all have the ability to be healthy and lead productive lives, without living in fear of having an accident, or being stricken with an unwanted illness and not being able to afford diagnosis and treatment. We are still far from this ideal.

Was “Race Together” Wrong?

Starbucks’ short-lived “Race Together” campaign, in which baristas wrote the phrase on coffee cups, generated lots of conversations – and lots of controversy.

Was it a good idea, but poorly implemented? Did it succeed, however slightly, in nudging the nation to talk about racism? Or was it a marketing move that prompted more talk about Starbucks than racism, and was not grounded in a plan for more significant action?

Whatever you think, it’s an opportunity to reflect and learn. Public health practitioners wrestle continually with this question: Should we talk about racism? If so, how?

In an open letter, Race Forward offers smart ideas on what we can learn from Starbucks’ campaign in the movement for racial justice. Their thoughts, as well as recent conversation with the Public Health and Equity Cohort that HIP has blogged about here, prompted some of my own thoughts, illustrated with examples gathered from public health colleagues.

  • Keep the dialogue – it’s how we reach hearts and minds and come to understand our role in serving the public.

Health departments and agencies nationwide are hosting public screenings and conversations around the Raising of America documentary, about how improving the social and economic conditions that shape childhood and childcare can create a safer, healthier, and more equitable future for our nation. The Kansas City, Mo., screening and conversation brought together multiple health departments, an organization that advocates for racial and economic equality, educators, legislators, clergy, and the public. The conversation ended with more than 90 people committing to take action.

  • Productive dialogue, particularly between people with different levels of power, is often accompanied by discomfort. But done in a supportive setting, it can be valuable for moving forward.

Since 2005, the Ingham County, Mich., Health Department has hosted Health Equity / Social Justice Workshops that use facilitated dialogue to have structured, strategic conversations among the health workforce and with interested community members. The dialogue builds the capacity of participants to talk about differences like race, class, and gender and their impacts on community health, as well as strategies to engage other individuals on these issues.

  • Beyond dialogue are structural solutions that require commitment to a larger, coordinated, long-term strategic plan that involves staff across levels and community partners.

In 2006, the Alameda County, Calif., Public Health Department launched the Place Matters initiative to address the social factors that shape health. As described in Public Health Reports, three factors created a strong foundation for the initiative: senior leadership dedicated to ensuring strong government-community partnerships and to building employees’ skills in advancing health equity; identifying inequities at the neighborhood level; and a strategic plan to achieve health equity that included policy change.

That strong foundation has translated into action. Alameda County Place Matters staff have provided testimony locally to successfully protect tenant housing rights. They have provided findings from data collection and suggested policy solutions to federal agencies, including U.S. Housing and Urban Development and Health and Human Services. And they continue to partner with community organizations to identify policy solutions to persistent problems of landlord retaliation, displacement, and deportation, as well as a lack of affordable housing that force people to live in unsafe and unhealthy housing.

Like Starbucks, public health practitioners are advancing conversations about race – hopefully, in more comprehensive and strategic ways. One place where we agree with the Starbucks campaign is in being impatient. We can’t wait for change.

An Uncomfortable Truth – Our Failure to Address Racism

This blog article is a re-post of an open letter to the public from Dr. Muntu Davis, who is the Health Officer and Director for Alameda County Public Health Department in California. Dr. Davis offers the kind of public health leadership we love, linking common health issues with their social determinants like racism. 

Dear Alameda County residents, partners, colleagues, and friends,

Everyone should live in conditions that support and foster living a healthy, fulfilling and productive life. These conditions include clean and safe environments, good education, good quality housing, stable employment, an income to pay for basic daily goods and services, such as food, shelter, clothes, and healthcare, among others – all of which should be free from discrimination, whether explicit or not. Read more…