The California Endowment’s investment in community health is guided by the belief that the quest for health is a political “struggle over the allocation of scarce and precious public goods,” according to Anthony Iton, the Endowment’s senior vice president for healthy communities. “In a struggle you have to arm yourself appropriately with data, you have to arm yourself with information, you have to use your relationships, you have to use your people power in any way that you can,” Iton said. The social goods obtained in the projects that the Endowment undertakes in cooperation with low-income communities are amenities that wealthier communities take for granted, such as grocery stores and parks. These gains are accomplished by building capacity within communities to drive change through political, social and economic power; through participation by a broad spectrum of community members; through empowering narratives; and through financial and other resources.
The ingredients described above are key factors in fueling a movement for health improvement and equity, Iton said, because facilitating opportunities for vulnerable populations is critical to assuring equity. Also, as he and several other speakers noted, there is a need to build a “movement narrative” that shapes public recognition of the social determinants of health. “Personal responsibility does matter,” Iton said. “It is necessary, but not sufficient. Access to health care does matter. Necessary, not sufficient. You have to meet people where they are, and you have to expand their understanding of what health is.”
Typical of The California Endowment’s investments was its early support for the national Healthy Food Financing Initiative, whose Pennsylvania model (the Fresh Food Financing Initiative) was described earlier by Thompson of PolicyLink. The project has since drawn broad-based support, Iton said. “What we do is buy down other people’s risk. That allows us to expand and leverage the resources of the private sector.” He added that a national movement for improved health and health equity will also need to leverage diverse forms of capital.
The Centers for Disease Control and Prevention (CDC) defines health equity as occurring when all people have the opportunity to attain their full health potential and no one is disadvantaged from achieving this potential because of his or her social position or other socially determined circumstance.1 In order to achieve health equity, it is not enough simply to define the goal, Iton argued; it is equally critical to understand the roots of health inequity, which can be found in intentional policies and practices. It is also critical that those who have suffered injustices take control of the movement for health equity, he said, recalling Ganz’s assertion that “agency is good for you.” Being in control provides “a sense of help and hope and future” that counteracts stressors and discourages unhealthy behaviors, Iton emphasized.
Maps showing average life expectancy by neighborhood in several urban areas—including Alameda County, California—provide a graphic illustration of health inequities, Iton observed. Understanding how to undo this phenomenon is impossible without understanding the history of how it was created, he said. “You have to have people see the invisible realities that are occurring throughout society. You have to make the invisible visible to people. That is part of changing the narrative.” Low-income neighborhoods struggle with health because policies such as racially restricted covenants—which the Federal Housing Administration supported during the last century—created neighborhoods deprived of resources (Federal Housing Administration, 1938). Medicaid, Social Security, immigration, incarceration, and housing policies have only served to deepen this divide, as have the practices of redlining (the denial of loans or insurance to people deemed to live in risky areas) and predatory lending, he said.
The common factor among these factors—exclusion—creates a narrative of unworthiness for a marginalized population, Iton explained.
1 See http://www.cdc.gov/nccdphp/dch/programs/healthycommunitiesprogram/overview/healthequity.htm (accessed June 13, 2014).
“That narrative traumatizes people and isolates and leads to internalized oppression and self-hate. It leads to sidelining valuable human capital that the country needs to be successful in the 21st century.” Therefore, he concluded, it must be acknowledged that inequity was created by a set of policies that devalued certain populations, which restricted and restrained access to important health resources.
In order to describe the “landscape of opportunity for intervention” for health equity, The California Endowment developed the framework shown in Figure 4-1. The medical “downstream” components of health, shown on the right side of the diagram, are addressed by health care through interventions that attempt to prevent death and reduce the burden of disease; these interventions constitute the vast majority of health expenditures. Meanwhile, the non-medical “upstream” determinants of health, on the left side of the diagram, are being shortchanged, Iton argued—especially in low-income neighborhoods, but also among stigmatized populations, such as gays, lesbians, and the disabled. “The world of health disparities lives downstream,” he remarked, and the situation can only be resolved by intervening to mitigate socioeconomic inequities, the often hidden upstream conditions that underlie more obvious health consequences.
Management of the health consequences of socioeconomic inequity is expensive and potentially unending, Iton said. “We have to figure out how we address some of the conditions and do it in an organized, evidence-based, intelligent, rational way that takes into consideration the historical patterns and legacies.” Although interventions exist to prevent death and disease and change behavior, he said, “we don’t have great interventions for communities that are on life support.”
Identifying such interventions should be a key mission of public health [practitioners and researchers], as it is for The California Endowment, Iton said. Their practice, called “building power in place,” is a multi-pronged effort to demonstrate the socioeconomic causes and consequences of health inequity, to advocate for health in all policies, and to examine and shift the biases and beliefs that underlie the narrative of exclusion. “We need to broaden who is talking about health [beyond] just the guy with the stethoscope around his neck talking about the latest cholesterol drug,” he said.
Returning to the notion of “drivers of change,” Iton described strategic leverage points that the Endowment seeks to address in disadvantaged communities: building a narrative of inclusion and also of sustainability, supporting a health in all policies approach, and creating resilient
FIGURE 4-1 A framework for health equity. Adapted by Alameda County Public Health Department from the Bay Area Regional Health Inequities Initiative, Summer 2008.
SOURCE: Iton presentation, December 5, 2013.
and transformed communities whose residents have hope and opportunities. To fuel action toward these goals, the Endowment hires community organizers; provides opportunities for collective, multisectoral discussion of community needs; attempts to recruit leaders within communities, particularly among the youth; and seeks private funding and investment to support local programs and economies.
“We have 14 sites across the state of California where we are spending about $1 billion over the next 10 years,” Iton reported, but the money is not being spent to build a movement for health equity because that is not the purview of foundations such as The California Endowment. However, he said, foundations can potentiate movements by creating structures that allow people to use their own ideas to improve their communities.
The panel discussion began with a question about how members of the two roundtables might inform the dialogue in the quest for health
equity. Iton suggested that roundtable members could “corral and organize the evidence base,” which could be used strategically by community organizers to advance the cause of public health improvement. “I don’t think public health has applied itself to figure out where the evidence is and how it applies to improving health outcomes,” he said. It is particularly important to support health departments in the difficult task of addressing the policies and practices that create inequity and in contributing to reversing disadvantages by building power within communities.
Given that many rural communities lack a diversified economic base with which to build public–private partnerships, an audience member asked, how might such communities harness their resources or tap into national funding streams to support local efforts in support of health equity? Iton replied that about half of the 14 communities in which the endowment works are rural and that in these settings—while there is indeed a lack of infrastructure and economic diversity as compared with urban communities—it is relatively easily to organize across sectors and to collaborate because local officials tend to wear several hats. “The ability of people to leverage relationships to use resources in the most effective way is something rural communities have to their advantage, that should be essentially taken advantage of,” he said.
Connie Mitchell from the Office of Health Equity in the California Department of Public Health reported that her office, which is charged with defining and describing health inequities, is adopting the “drivers of change” framework Iton proposed. She said that she expects pushback on her office’s report on inequities because it will challenge many people’s personal narratives about choice and personal responsibility, and she wondered what form that reaction might take.
“I encourage you to be provocative, not just to get attention, but because you don’t have much hope of making change unless people feel uncomfortable,” Iton advised. He also encouraged Mitchell to embrace the dominant narrative of personal responsibility and to expand it in order to emphasize that personal responsibility is vested in community responsibility. Tell stories about people who cannot eat healthily because the only food they can easily purchase is junk or who cannot exercise for fear of flying bullets, he suggested. “You have to provoke them a little bit, but you also have to embrace their core understanding that is unshakable. . . . In my experience, people welcome that.”
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