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2
Changing the Conditions of
Communities Where People Live
Three of the four coauthors of the paper commissioned by the Round-
table, A Time for Opportunity: Local Solutions to Reduce Inequities in
Health and Safety, Tony Iton, Rachel Davis, and Larry Cohen, each pre-
sented descriptions of different aspects of the paper (the full text of the
paper can be found in Appendix A). The three presentations were followed
by questions and discussion with members of the Roundtable and work-
shop participants.
USING DATA TO DOCUMENT HEALTH DISPARITIES
Tony Iton spoke of the importance of having data to document the role
of social determinants in health status. The availability of data allows the
correlations between policies, institutional practices, and health disparities
to be examined.
Death certificates are among the most comprehensive data sets avail-
able to public health researchers. For example, in California a death is not
officially recorded until the local registrar of vital records, the county health
officer signs the death certificate. Death certificates contain a great deal of
useful information for researchers, including cause of death, age at death,
race/ethnicity, and place of residence. These data reveal a narrative about
the distribution of life and death across a community (Alameda County
Public Health Department, 2008).
Iton used the data from over 400,000 death certificates from over a
45-year period in Alameda County, California, and compared life expec-
tancies for whites and blacks. In 1960, whites had a life expectancy that
5
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6 POLICY INITIATIVES TO REDUCE HEALTH DISPARITIES
White
7.8 years
4.9 years African American
2.3 years
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
FIGURE 2-1 Health inequities by race and ethnicity in Alameda County, California.
Figure 2-1.eps
redrawn
was longer by about 2½ years. By 1980, that difference had doubled to a
life expectancy that was almost 5 years longer for whites than for blacks.
By 2005, that life expectancy difference had increased to nearly 8 years
(Figure 2-1).
These data can also be mapped geographically according to where the
premature deaths cluster at the county level. Looking again at the data from
Alameda County, the neighborhoods with the longest average life expec-
tancies (census tracts depicted in green) also had high rates of high school
graduation, low rates of unemployment, relatively low rates of poverty, and
high rates of home ownership. In Alameda County, neighborhoods with
long life expectancies are about 50 percent white and 50 percent nonwhite
(Figure 2-2).
Figure 2-3 shows that the neighborhoods with a middle to long average
life expectancy (census tracts depicted in yellow) have relatively high rates
of high school graduation (81 percent) and low rates of unemployment, and
about half the residents of this census tract are homeowners. This area is
slightly less diverse, at nearly 60 percent nonwhite.
Figure 2-4 shows the neighborhoods in the county with the shortest
average life expectancy (census tracts depicted in red). These neighborhoods
also have relatively low rates of high school graduation and higher rates of
unemployment, 25 percent of the residents live in poverty, and 90 percent
of the residents are nonwhite. The West Oakland neighborhood pictured
in Figure 2-4 reveals a heavily industrial area adjacent to a residential area.
By mapping census tract data showing poverty levels on top of these
data, it is possible to conduct a simple bivariate analysis (looking at life
expectancy on one axis and poverty on the other axis). This is what Iton
calls “the true poverty tax.” This shows the true cost of being poor mea-
sured as the likelihood of premature death in Alameda County. Every level
of income has a corresponding average life expectancy. In other words,
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CHANGING THE CONDITIONS OF COMMUNITIES
Life Expectancy by Tract
High school grads: 90%
Unemployment: 4%
Poverty: 7%
Home ownership: 64%
Non-White: 49%
FIGURE 2-2 Neighborhoods in Alameda County with the longest average life
expectancy.
Figure 2-2.eps
bitmap w masks & vector type added
income is a fairly good predictor of how long a person will live, because
every level of income has a corresponding average life expectancy. This
phenomenon holds not just for the poor, but also for the middle class.
In the San Francisco Bay Area of Northern California, Iton calculated
that $12,500 buys an additional year of life. This so-called social gradi-
ent allows one to calculate the cost of a year of life in many U.S. com-
munities, including New York City, Philadelphia, Cleveland, Los Angeles,
Minneapolis–St. Paul, and Baltimore. In Baltimore, $10,000 buys an addi-
tional 3 years of life.
Using the Alameda County data, Iton and his colleagues in the county
(Alameda County Public Health Department, 2008) produced a report
concluding that the most important drivers of the differences in life expec-
tancies were not related to access to health care. Rather, the social determi-
nants of health lead to differences in life expectancy and other important
health outcomes. How poor a person is should not determine how long
that person lives.
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8 POLICY INITIATIVES TO REDUCE HEALTH DISPARITIES
High school grads: 91%
Unemployment: 6%
Poverty: 10%
Home ownership: 52%
Non-White: 59%
FIGURE 2-3 Neighborhoods in Alameda County with intermediate to long average
life expectancy.
Figure 2-3.eps
bitmap
High school grads: 65%
Unemployment: 12%
Poverty: 25%
Home ownership: 38%
Non-White: 89%
FIGURE 2-4 Neighborhoods in Alameda County with the shortest average life
expectancy.
Figure 2-4.eps
bitmap
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CHANGING THE CONDITIONS OF COMMUNITIES
Iton concluded by noting the importance of differentiating “health
inequities” and “health disparities.” Health inequities are unnecessary,
avoidable, and therefore, unjust, whereas health disparities are merely
differences in health outcomes divorced from the context in which they
are produced. One cannot properly understand health disparities without
examining health and social inequity.
THE TWO STEPS BACK FRAMEWORK
Rachel Davis next spoke about the importance of understanding the
cumulative impact of living in a stressful environment and its long-term
effects on health, particularly for population groups already experiencing
inequities. She suggested a model to address the causes of the stressors;
strengthen the social, economic, and physical environments of those neigh-
borhoods; and empower those groups most affected by inequities. Invest-
ments in communities and efforts to learn to work across government levels
and across sectors within a government are needed. In turn, this will lead
to a sustainable system for promoting health equity.
Davis’s interest in creating and sustaining systems arose from her pre-
vious experience as a social worker. She told a story about working in a
residential treatment facility for emotionally disturbed children. One day,
an underdeveloped 4-year-old boy came to the facility, accompanied by
paperwork saying that the boy had “failed” 14 foster placements in the past
year. How can a 4-year-old fail in foster placement? In reality, the system
is failing him, rather than the other way around.
Davis outlined a set of policy principles to guide efforts to reduce
health disparities (see Appendix A). These principles were adapted from the
Alameda County Public Health Department report (2008) described earlier
by Iton. Related to these policy principles is the Two Steps Back frame-
work (Figure 2-5). The model begins with a consideration of medical care.
FIGURE 2-5 Two Steps Back framework.
Figure 2-5.eps
bitmap
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10 POLICY INITIATIVES TO REDUCE HEALTH DISPARITIES
Clearly, access to high-quality and culturally and linguistically appropriate
care is critical to improved health outcomes. A wealth of data, including
data from the Institute of Medicine (IOM) report Unequal Treatment: Con-
fronting Racial and Ethnic Disparities in Health Care (IOM, 2003), docu-
ment the disparities between people of color and whites in health outcomes
that occur because of a lack of access to health care for people of color.
However, taking a step back, access to medical care alone is not enough
to eliminate health disparities. Exposures and behaviors also need to be
addressed. A wide variety of research indicates a set of nine behaviors and
exposures that are linked to major causes of premature death: tobacco,
diet and activity patterns, alcohol, microbial agents, toxic agents, firearms,
sexual behavior, motor vehicles, and inappropriate drug use. Reducing one’s
exposure to these behaviors reduces one’s risk of injury and illness.
Taking a second step back, the model suggests that exposures and
behaviors are shaped by the environment in which a person lives. This
offers an opportunity to prevent injuries and illness before their onset by
considering the root factors (for example, poverty, racism, and other com-
munity factors). A focus on changing exposures and individual behaviors
cannot begin until the root causes are addressed and the ways in which
they play out in communities are altered. Quoting an earlier IOM report,
Davis noted that “it is unreasonable to expect that people will change their
behavior easily when so many forces in the social, cultural, and physical
environment conspire against such change” (IOM, 2000, p. 4).
Looking more specifically at policy issues linked to negative outcomes
in the environment, Davis suggested a number of examples: criminal justice
laws, hiring practices, redlining in residential areas, and more recently, the
subprime lending fiasco that disproportionately affected low-income com-
munities and people of color.
Violence is another environmental stressor and more often occurs in
low-income communities of color. For some young people, violence is a per-
vasive part of life. The National Center for Post Traumatic Stress estimates
that as many as one-third of young people living in the United States are
direct victims of violence (U.S. Department of Veterans Affairs, National
Center for PTSD, 2011), and that as many as 43 percent of youth experi-
ence at least one form of trauma (for example, a school shooting, violence
in the community, or physical or sexual abuse). Of those youth who have
experienced a traumatic event, between 3 and 15 percent of girls and
between 1 and 6 percent of boys will develop posttraumatic stress disorder
(U.S. Department of Veterans Affairs, National Center for PTSD, 2011).
Targeted marketing of unhealthy products such as cigarettes and other
forms of tobacco, high-alcohol-content malt liquor, and fast food is also a
problem in low-income communities. A related problem is a lack of healthy
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CHANGING THE CONDITIONS OF COMMUNITIES
food options, for example, a lack of supermarkets in predominantly African
American census tracts.
All of these policy issues shape the environment and have an impact on
health. This means that a key means to affect health inequities is providing
increased economic and educational opportunity to all, as well as access to
health care in low-income communities.
Davis concluded her presentation by speaking about the relationship
between health care, health care institutions, and community. The Allina
Backyard Project is one such example. A second example is Kaiser Per-
manente’s efforts to start farmers’ markets to bring healthy food into low
income communities. It is possible, then, to create a system that brings
health care, health care institutions, and the community together in support
of better health outcomes.
SPECIFIC RECOMMENDATIONS
Larry Cohen, the final presenter and author, described the 32 recom-
mendations from the paper (see Appendix A, page 61, for the complete list),
but they can be clustered into four groups. The first is community recom-
mendations. As previously discussed, this means looking at the community
environment as a whole, understanding how the root factors that lead to
health inequities play out, and emphasizing participation and feeling a sense
of ownership and leadership at the community level. An example of this is
a housing director who realized that by paying attention to issues like mold
and lead paint in the housing stock, she could have an enormous positive
impact on health. Similarly, having access to high-quality supermarkets,
farmers’ markets, walking paths, and safe places to play makes a difference.
The second group consists of health care recommendations (Appendix A,
p. 61). These include affordable and accessible health care that is available
where people actually live. Technology can also be used to a stronger
advantage; for example, cell phones have a 97 percent market penetra-
tion in most communities. Cell phones, then, could be used to provide a
reminder about a health care appointment or to access health information.
Promoting the medical home model is another recommendation.
The third group is systems recommendations (Appendix A, p. 61).
These include recommendations such as using community mapping tech-
niques and making health equity a component of every type of new pol-
icy, from transportation (providing reliable public transportation and safe
places to walk) to housing and agriculture policies.
Cohen offered an example of the efforts of the head librarian in Sali-
nas, California, a major source of the world’s lettuce crops. Unfortunately,
Salinas also has a very high violent crime rate. In a unique effort to prevent
violence among children and youth, the librarian went to every school in
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12 POLICY INITIATIVES TO REDUCE HEALTH DISPARITIES
Salinas and gave every child a library card. Library fines were also waived
for a year. Three days later, the number of books checked out from the
library had tripled. This is a very different way of thinking about health.
The fourth and final group consists of overarching recommendations
(Appendix A, p. 61). The nation needs a national strategy, said Cohen,
as well as high-level national leadership on health equity issues. Federal
resources must support what is happening at the state and local levels, he
emphasized.
Cohen concluded his remarks by describing the economics of preven-
tion: According to the Prevention Institute and the Trust for America’s
Health, with only a $10 annual per capita investment, for every dollar
invested in community prevention efforts, by the second year, the commu-
nity gets that dollar back and a return on investment of an additional dol-
lar. By the fifth year, the return on investment is $5.60 per dollar invested.
This provides support to the reasoning that prevention and community
wellness efforts should be included in the 2009 federal stimulus package.
This implies a very different approach to health and also implies that this
is an ideal opportunity to promote health equity as a component of health
care reform.
DISCUSSION
Roundtable member Bill Vega asked whether the real goal is to create
better living conditions for people living in concentrated poverty neighbor-
hoods. Tony Iton responded that in the United States, many other resources
are linked to wealth. In other words, he said, “you can only purchase your
way out of harm’s way with income in this country.” What is needed, then,
are policies that decouple wealth from other critical resources, such as
health care, dental care, and education.
Iton, who grew up in Canada, noted that Canada provides universal
access to health care, universal access to dental care until age 12 years, and
subsidized access to education all the way through college. These are poli-
cies that decouple wealth from access to critical protective resources. Cohen
added that what the paper is really trying to do is promote a different way
of thinking about how to pay attention to the community environment to
keep people healthy.
Workshop participant Anne Kubisch wondered whether there is scien-
tific support for the unique role of health as the driver of the links between
structural issues such as institutional racism and the individual. In particu-
lar, the idea of reframing poverty as a public health outcome is a powerful
one. In response, Cohen noted that health is a concept that really “hits
home” with people. At the same time, the U.S. population does not have a
sense that health is an individual right, although this is not the case in Brit-
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CHANGING THE CONDITIONS OF COMMUNITIES
ain, for example, where health is seen to be an individual right. Iton noted
the effectiveness of using life expectancy data to look at the injustice of
poverty. He believes that using the life expectancy data supports the argu-
ment that poverty, educational attainment, and other social determinants
affect access to health care and overall health status.
The final question referred to the federal health care reform efforts that
got under way in 2009. The participant wondered who will see the savings
when the reform is enacted. Cohen noted that a system to track the spend-
ing is needed, but that some of the savings will go back to the individual,
whereas some of it will go back to the government. This is the thinking
behind the Wellness Trust, which is described in several of the pieces of
legislation. The funding would come into the trust from a variety of places
and would be allocated to a variety of places.
REFERENCES
Alameda County Public Health Department. 2008. Life and death from unnatural causes:
Health and social inequity in Alameda County. Oakland, CA: Alameda County Public
Health Department. http://www.acphd.org/AXBYCZ/Admin/Datareports/00_2008_full_
report.pdf (accessed April 28, 2011).
Institute of Medicine. 2000. Promoting health: Intervention strategies from social and behav-
ioral research. Washington, DC: National Academy Press.
Institute of Medicine. 2003. Unequal treatment: Confronting racial and ethnic disparities in
healthcare. Washington, DC: The National Academies Press.
U.S. Department of Veterans Affairs, National Center for PTSD. PTSD in children and teens.
http://www.ptsd.va.gov/public/pages/ptsd-children-adolescents.asp (accessed May 25,
2011). Washington, DC: U.S. Department of Veterans Affairs, National Center for PTSD.
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