Perspectives

Intervening at the Community and Policy Levels to Address Persistent Health Gaps

When I was in medical school in east Baltimore, in the midst of some of the worst slums in North America,I quickly learned the limits of the medical model for intervening in the health of a community. The medical model we were learning is based on ridding the world of disease one person at time. People trained in that model are wedded to the notion that health is largely about behavior, about what people do to themselves. It stops at the individual.

But all around me I could see entrenched poverty, unsafe housing, fear of violence, young people who had dropped out of school and had no vision of their future. I could see the health toll these community conditions exacted and I began to learn that social and economic power is at the root of health disparities.

The medical model is blind to community, treating it as if it’s irrelevant. We talk as if individuals live in a vacuum. But we don’t live in a vacuum. Our society lays down patterns of illness and death in the same way we distribute education, income and employment. A community’s rates of poverty, high school graduation, unemployment, home ownership and percentage of nonwhite residents can predict life expectancy for residents.

High school graduation rates, for example, tell us so much about the social context of a community that we can predict how soon people will die on average in that community based on that one variable alone. Education affects people’s ability to plan for a future, to have hope for the future. And without hope for the future, people tend to make short-term decisions. They are more likely to smoke, to drink to excess, to engage in high-risk behavior, because they aren’t thinking about the future. Their future is today.

Poverty is another thief of hope for the future and another predictor of life expectancy. Poor communities have schools that contribute to “unlearning,” few jobs, rampant crime, segregation by race and income and low-quality housing. They are places we dump our garbage and toxins. How much individual responsibility can a kid growing up in such a community have? How does the medical model help that kid today? In the San Francisco Bay area, where I live, every additional $12,500 in household income ‘buys’ a year of life. And, closer to home for Minnesotans, mortality rates in Hennepin County follow the same gradient as in Alameda County, with the number of deaths steadily increasing as the poverty rate increases. This is the true poverty tax: the cost of being poor is earlier death.

In the face of persistent health gaps based on race, income, neighborhood, education and other social factors, we must stop acting as if individuals live in a vacuum. Looking at the neighborhood and community conditions in which we live our lives, at social inequalities and the power of institutions, will allow us to intervene in the physical and social environment — in the prevalence of pollution, liquor stores, smoking billboards in poor neighborhoods, for example, and other issues that are outside the control of individuals — in ways the medical model, with its emphasis on the individual, does not.

How do we intervene? Some of the best ideas come from people working on the front line in communities. They have been doing this work for so long, helping to build the culture and capacity of communities without necessarily recognizing the critical health impact of their work. They know that leadership matters and that effective, sustainable leadership means working across sectors and holding the system accountable.

 But community-level work must be complemented by work at the policy level to address biases such as racism, classism and sexism that lead to ‘diseased’ societal decisions. The home mortgage interest deduction, for example, is a federal subsidy, with those earning $500,000 and above receiving the biggest subsidy. Compare the $81 billion this subsidy costs in 2008 to the $30 billion that would support a high-quality, two-year preschool program for poor families. These are policy choices we are making and can make differently if we so choose.

Perhaps most important, we must recognize that change is possible. As Nelson Mandela said, “Like slavery and apartheid, poverty is not natural. It is man-made and can be overcome and eradicated by the actions of human beings.” The point is not to understand theory or to acknowledge bias, but to change what we do.

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