Rachel's Democracy & Health News #898, March 15, 2007


[Rachel's introduction: To improve human health, we can focus on 13 community factors that determine who gets sick and who thrives, and then consider using simple strategies to level the playing field and improve the numbers.]

By Peter Montague

As we saw last week, the Prevention Institute in Oakland, California has identified 13 "community factors" that strongly determine human health and health disparities. As an "environment and health" advocate, they've got my attention.

Health disparities are defined as "differences in populations' health status that are avoidable and can be changed. These differences can result from social and/or economic conditions, as well as public policy. Examples include situations whereby hazardous waste sites are located in poor communities, there is a lack of affordable housing, and there is limited or no access to transportation. These and other factors adversely affect population health," according to the National Association of County and City Health Officials.

To recap, the 13 community-factor determinants of health are:

1. Jobs paying living wages -- low-income equates to poor health

2. Education -- school dropouts tend to have poor health

3. Racial injustice -- tends to widen socioeconomic gaps

4. Social networks and trust -- the glue communities together

5. Participation and willingness to act for the social good -- ditto

6. Behavioral norms within a community (e.g., ideas of manliness)

7. What's sold and how it's promoted (alcohol, fast food)

8. Neighborhood look and feel, and safety.

9. Parks and open space

10. Getting around -- public transit

11. Decent housing -- damp, lead-poisoned homes are harmful

12. Air, water, soil -- toxic sludge is a bad neighbor

13. Arts and culture are conducive to health and safety

These things seem obvious -- yet when was the last time we environment-and-health advocates spent time wondering how our local government is spending its "economic development" dollars, or checking the high-school dropout rate in our town vs. the town down the pike? Our activism for "environment and health" really only worries about SOME parts of the environment and SOME aspects of health -- and we include our own work in this assessment. No wonder some people think we're elitists who don't care about them!

But there's hope. The Prevention Institute's 2006 report identifies 10 disparity-reducing strategies and issues that public health practitioners, advocates (like us), and decision-makers can focus on.

1. Primary prevention.

2. Underlying determinants of health, especially the 13 community factors listed above

3. The built environment

4. Sustainable agriculture

5. Economic development

6. Social norms change

7. Community-based participatory efforts

8. Comprehensive approaches

9. Interdisciplinary collaboration

10. Community resilience

The Prevention Institute's report -- which we recommend strongly, along with their 2003 report on Strengthening Communities -- explains how 5 of the 10 strategies can be used to improve individual health and reduce health disparities by focusing on community health instead of individual health.

The Built Environment

The report say, "For people concerned about improving community health, it is critical to recognize the importance of community health factors related to the built environment and become engaged in changing them. Unfortunately, while some of what is known to many as 'smartgrowth' has flourished, it has primarily been focused -- like many health innovations -- on white, middle-class communities. Unquestionably, issues of design and of what is and isn't permissible use demand the attention of advocates interested in reducing disparities."

The report then describes two important "tactics for transforming the built environment [that] are emerging as important in reducing disparities. One is the building of campaigns to address existing deficits in the built environment in a community. The other is to create mechanisms for the assessment of the health implications of proposed investment that would alter existing infrastructure, such as new transit routes, new buildings, and changes to utility services."

An example of the first is the Ironbound Community in Newark, N.J. that has developed its own urban plan for the waterfront of the Passaic River waterfront as it flows through Newark. The community has envisioned its own future and is insisting on its right to sit at the table as the future of the waterfront is decided. They envision a long narrow recreational park where there used to be nothing but trash and decay. Developers of course envision high-rise condos cutting off access to the riverfront for ordinary people. It's a good fight.

The second tactic is to insist that your local health department undertake "health impact assessments" to try to understand the health consequences of new proposals (such as condos along a riverfront). Traditional environmental impact assessments omit the all-important social environment and thus miss many (if not most) of the health impacts of proposed changes in the natural environment locally.

Sustainable Agriculture

Changing the current food system is an essential part of eliminating health disparities. Ninety percent of children in the U.S. are exposed to at least 13 pesticides in their food. Furthermore, food typically travels 1500 miles by truck -- spewing diesel fumes along the entire route. And, "Despite our agricultural system's emphasis on transporting food, residents of low-income communities have lower access to fresh fruits and vegetables than other communities, and a higher proportion of what is easily available, and heavily marketed, is high-fat high-sugar fast foods. This emphasis on unhealthy food of course affects everyone, but low-income people and people of color even more so, says the Prevention Institute's report. Furthermore, in the U.S., the retail cost of fruits and vegetables has increased nearly 40% since 1985, while the costs of fats and sugars have declined, the Institute's report points out.

The solution to all these problems is a locally-based food system that supports local farmers, keeps food costs low, and offers everyone an opportunity to purchase nutritious produce. Part of a healthy food system is the establishment of decent grocery stores in neighborhoods that presently don't have any. Small corner stores that presently depend on liquor sales to survive can be helped to transition away from junk food and liquor (a key factor in violence) toward healthier fare.

Economic Development

The report points out that, "Long-term poverty and lack of hope or opportunity can be devastating for individuals and communities. Being able to support oneself and one's family fosters self-sufficiency and dignity while reducing the stresses associated with poverty and being unemployed. When adults and youth cannot find appropriate employment, they are more likely to turn to crime and violence and associated illicit activities, such as selling drugs. Individuals and communities without resources are less likely to be able to develop strategic responses to health issues (for example, providing healthy food or eliminating lead from houses and soil). Establishing employment programs that link employees to their community fosters community ownership and connection and can result in positive changes for the neighborhood."

Local ownership businesses is the anchor that protects communities against decay. With the price of gasoline rising, redevelopment of the cities is making more and more sense. But it could be done poorly -- giving control of local businesses to outsiders who continue to siphon money away from urban centers. Economic development needs to focus on creating locally-owned businesses that provide goods and services for which people are presenting sending their dollars out of town. The Business Alliance for Local Living Economies (BALLE), among others, champions this kind of economic development.

Norms Change

A good example of norms change is tobacco. Within a fairly short time, attitudes toward tobacco have changed dramatically and behavior changes have followed.

The "norms change" approach could be used to change gender expectations. As the Prevention Institute points out, "Traditional gender norms of masculinity and femininity encourage a wide range of unhealthy behaviors such as risk-taking and over-consuming among men and limiting physical activity and binge dieting among women. Gender norms affect all races and ethnicities and can exacerbate other risk factors. For example, social norms maintain that men should not need to seek help and can handle problems on their own. Men who have more health problems are more likely to suffer from limited help seeking. Low income men and men of color experience more adverse health outcomes, and gender norms that discourage help seeking exacerbate these effects."

Community-Based Participatory Efforts

"Disenfranchised communities have increasingly recognized that they need to organize and work together to receive equitable services and resources," says the Prevention Institute report. "It's no accident that some communities have fewer resources and services. While a complaining phone call in some neighborhoods might be enough to initiate action, in many low-income communities/communities of color, it takes a mobilized effort to catalyze change."

The report highlights the environmental justice movement as an example of collaboration paying off: "While elements of the physical environment might have the closest connection to health outcomes in the research literature, it seems increasingly clear that the health gap will not be closed without engaging the affected community members -- in identifying the problem, solution, and priorities -- for change. Community based participation not only unlocks the energy and knowledge that exists in a community around a specific issue, it also builds on community networks and capacity to address other issues."

The report goes on to describe how, "In Los Angeles the South L.A. Community Coalition was formed to close liquor stores in the almost exclusively Latino and African American neighborhood. The Coalition represented a broad range of community residents and institutions (including religious groups, journalists, and community organizers) and used a variety of tactics (public hearings, letter writing, media stories, and demonstrations) to close liquor stores. The group successfully closed over 200 stores and documented a 27% decrease in crime within a four-block radius of each store that was closed. Similar strategies have been employed to bring supermarkets into neighborhoods." This kind of on-the-ground base-building work has fallen out of favor with some of the funders of social-change work, in favor of lobbying for policy change. But it's that community-based coalition-building that will reduce health disparities by building community coherence, pride, and stability.

Community Resilience

The Prevention Institute's report says, "Community resilience is the ability of a community to recover from and/or thrive despite the prevalence of risk factors and adversity. A resilient community can be described as having social competence, problem-solving capacity, a sense of identity, and hope for the future. A resilient community provides a triad of protective factors: caring relationships, high expectations, and opportunities for participation. Prevention strategies have focused largely on reducing risk factors. Equally important is building upon and enhancing resilience in communities. Enhancing community resilience can have long-term, positive impacts on individual and community health."

The traditional approach to health disparities has focused somewhat narrowly on "risk factors" -- and they are important, no doubt about it. But eliminating factors that threaten health and safety "does not necessarily achieve the presence of conditions that support health."

The Prevention Institute's report concludes, "Focusing on building community capacity and resilience has three important results:

1) community members are brought into the process and feel a greater vested interest in successful change

2) community members can apply new skills to address other health factors

3) community members gain skills and sense of efficacy that can permeate many aspects of their lives and improve broad life outcomes.

The U.S. currently spends $33 per person per year preventing illnesses and $3300 per person per year treating illnesses.

The "medical model" -- one doctor, one patient -- is unaffordable for tens of millions of people. Community-based prevention programs offer a much better return on dollars invested.

Primary prevention has been the core idea of public health practice for 150 years. We "environment and health" advocates would do well to remember this history.