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 recommendation 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 medical 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 community 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 involving the Native American community for whom spirituality is very important, 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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