7
Closing Comments

Before providing closing comments, Roundtable Chair Nicole Lurie opened the floor for discussion. Members of the Roundtable and of the workshop audience discussed sustainability of interventions, the link between spirituality and health, education of the next generation of physicians, and the need for a social movement to bring everyone together and address health disparities nationally.

OPEN DISCUSSION

Sustainability

Roundtable member America Bracho said that comprehensive interventions are needed in order to improve the health of our children. All of the elements discussed during the workshop converge to influence health outcomes. Including the community in the development of strategies brings not only common sense to the process, but also accountability. An engaged community will not allow a program to stop simply because the funding is gone, she said. One of the issues with developing comprehensive interventions is how the funding system works. Funding may be short term or categorical, or funders may only see value in new programs and may not continue to fund established programs. Bracho said that we need to work on place, bringing different designs to the communities, working with city engineers and health departments.

The models discussed during the workshop show how community involvement can lead to positive health outcomes, offered Roundtable



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7 Closing Comments B efore providing closing comments, Roundtable Chair Nicole Lurie opened the floor for discussion. Members of the Roundtable and of the workshop audience discussed sustainability of interventions, the link between spirituality and health, education of the next generation of physicians, and the need for a social movement to bring everyone together and address health disparities nationally. OPEN DISCUSSION Sustainability Roundtable member America Bracho said that comprehensive inter- ventions are needed in order to improve the health of our children. All of the elements discussed during the workshop converge to influence health outcomes. Including the community in the development of strategies brings not only common sense to the process, but also accountability. An engaged community will not allow a program to stop simply because the funding is gone, she said. One of the issues with developing comprehensive inter- ventions is how the funding system works. Funding may be short term or categorical, or funders may only see value in new programs and may not continue to fund established programs. Bracho said that we need to work on place, bringing different designs to the communities, working with city engineers and health departments. The models discussed during the workshop show how community involvement can lead to positive health outcomes, offered Roundtable 69

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70 FOCUSING ON CHILDREN’S HEALTH member David Pryor, but he fears we will still be discussing the same issues about funding and sustainability 5 or 10 years from now. His recommenda- tion was to have greater emphasis on developing an economic or political model that could produce sustainable change over a larger portion of the country, not just for isolated cities and isolated projects. We need to create a national platform so that, 10 years from now, we have moved beyond isolated successes to improvement in overall health indexes, Pryor noted. Roundtable member James Krieger agreed, noting that we do not have the mechanisms to put programs in place beyond a boutique-type of approach, where there is a small amount of grant funding or a government program that may only last for 2 or 3 years. While communities may rise to the challenge to save a program, we cannot pass the responsibility to the communities who may also be victims of economic discrimination. We need to look for sustainable funding sources. About 90 percent of health related expenditures in this country are invested in the medical care sector, Krieger said, with the remainder going to support community-based projects and public health. In contrast, most of the determinants of disease, in particular determinants of health disparities, are not going to be addressed in the med- ical care sector but in the communities. Krieger suggested the Roundtable consider what could be done at the policy and financing levels to transfer resources from the medical health care sector to the public health and com- munity sectors, so they have an ongoing sustainable resource base. Another member of the Roundtable, Winston Wong, pointed out that no one addressed the myth of the “American Dream,” that everyone has an equal chance for success in this country. There is a perception that if you are in despair in an economic or health sense, it is essentially your responsibility to pull yourself up by your bootstraps. Such countries as France, Sweden, and the United Kingdom have much more progressive understandings of the roles of communities, government, and organized groups with regard to accountability. Our programs are constructed based upon the flawed concept that Americans have some unique quality that enables us to be able to make personal progress toward this ideal of attaining wealth and fortune, or in this case, health. Total Health: Spirituality and Education Roundtable member Jennie Joe cited a recent research project involv- ing the Native American community for whom spirituality is very impor- tant, and is not simply a religion, but something that provides a sense of cultural strength. It is a way of life and provides a sense of identity that is very important for the children. Many of us conducting research, she said, do not do justice to such cultural issues. Separation of church and state is ingrained in us, but the communities we work with are redefining spiritu-

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7 CLOSING COMMENTS ality in a very different context. Joe said she hopes for a future where the definition of who is healthy includes elements of spirituality. One participant, who said she was a child care provider, agreed that the spiritual aspect of health deserves more attention. She also raised a concern about government takeover of child care, observing that before free programs were in place, children were well prepared when they entered kindergarten. But now, she believes that because of the poor quality of the free programs that are available, many children are entering special educa- tion kindergarten programs because they are not ready for school. Roundtable member Alicia Dixon noted that another key factor that was not discussed in depth during the workshop was the importance of educating the health care workforce to be able to diminish or eliminate health disparities. We need to be training a different kind of physician. We can’t keep training people in the same way, she said, and expect any kind of significant change in the systems that perpetuate the problems. Creating a Health Movement Workshop keynote speaker David Satcher expanded on the idea of creating a “movement.” When enough people are moving in the same direc- tion, he said, it draws the attention of policy makers. People involved in the movement, even though they may suffer, gain hope for change. Those engaged in a social movement change their own behavior and the behavior of others. He mentioned the WHO Commission on Social Determinants of Health, which is working to build a sustainable global movement to eliminate health inequities by targeting social determinants. He cited a program being undertaken in Chile to invest in early childhood education for the lowest 10 percent of the population in terms of socioeconomic level, providing day care and then education for children from 3 months of age onward. Such a program allows a parent to work, or a teenage mother to continue in school. The program also models good nutrition and fosters physical activity. How then, he asked, do we invest in a movement whereby we could really effect change in the United States? We need to develop a strategy to pull all of the people and groups engaged in this issue together, and to spread the message where it is most needed and where it will be most effective. Roundtable member Mildred Thompson concurred with Satcher regarding the need for a movement, and suggested that in order to create a movement there needs to be a common vision about how this is a problem for all of us, and that solving it benefits all of us. The issue needs to be carefully framed and communicated, using language that does not create a perception of “us and them.” As long as we see health disparities as being

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72 FOCUSING ON CHILDREN’S HEALTH “their” problem, people are not going to see themselves as being part of the solution. Workshop attendee Marian Dennis followed up by noting that health disparities are the result of socioeconomic determinants of health, driven in large part by poverty. With regard to framing the issue, disparities in health are not limited to ethnic and racial minorities, but also affect a significant number of people in the United States who face poverty. She suggested that there is a currently a window of opportunity to start a movement because many people who didn’t think of themselves as vulnerable are now becom- ing more vulnerable. Many people who have viewed themselves as middle class are worried about losing their jobs and homes. The struggles facing immigrants were raised by another participant, who said they want the best for their families but often cannot afford health care or insurance, or education beyond public school. CONCLUSION In closing, Lurie noted that the impending recession has the potential to make disparities much greater. With the many current discussions about race and gender and politics, Lurie said that disparities in health are not about Republicans and Democrats, or men and women. It is, in part, a gen- erational issue. It is about what our country and the world are going to be like for our children. That is really the theme of the workshop, she said. The way we invest in our children has incredible implications for the health of our country, the well-being of our citizens, the productivity of our country, global competitiveness, and America’s place in the world. What happens in the womb, and in the early years of life, have a great impact on lifelong health. Lurie noted that it behooves all of us to bring these issues into the public discourse. She cited the PBS video series presented by Thompson as an important step in this direction. Lurie urged participants to be active in their own communities, including bringing up these issues with local candi- dates, regardless what level of office they are running for. Challenge people to think about creative solutions, she said. Let people know that there is a movement coming and that they need to get on board.