This post is a submission to the Hastings Center’s Values and Health Reform Connection, a new group blog on American values and why they matter in health reform.
Our health as a nation continues to deteriorate, in part because we have failed to recognize significant influences that account for more than half of what makes us well or sick. These influences – known as the social determinants of health – are largely hidden and unaddressed by current health management efforts. To create more effective strategies, we need an expanded view of health, what influences it, and what can be done to improve it.
Conventional wisdom says that health is the result of individual behavior, genetics, and medical care. Less recognized, however, is that health is also influenced by a range of social and environmental factors in the places we live, work, learn and play. In fact, research tells us that community influences – such as educational quality, economic and employment opportunity, social cohesion, and access to essential goods and services like food and transportation – are the leading causes of illness.
Left unaddressed, these larger influences compromise the impact of health and wellness efforts. For example, nutrition counseling is ineffective if individuals do not have access to affordable healthy food in their residential and workplace communities.
In our Communities of Health work, we are finding that while people intuitively grasp the idea of social determinants of health when shown the evidence, it is difficult to sustain ongoing awareness and attention on these factors sufficient to do anything about them.
A number of barriers exist. First, it is difficult to break from the prevailing frame, which views health primarily as a function of individual behavior and medical care. The individual-medical model of health dominates our systems, beliefs and language, and is continually reinforced in the way our nation thinks about, talks about and acts on health. And, when health is discussed in a broader context, counter-narratives tend to appear, overwhelming the potential for an expanded view of health.
A second challenge has been demonstrating how social determinants impact specific stakeholder groups. For instance, it has been difficult to draw a direct causal linkage between harmful community conditions and the rising costs of health care paid for by an employer.
Finally, even for those who are motivated to act, specific strategies for addressing the social determinants of health may seem elusive, impractical or insurmountable. As more than a few Communities of Health participants have expressed: “This is like trying to solve world hunger – what do you want me to do about it?”
What we are learning is that nothing changes until people have the opportunity to discover for themselves what matters to health, and what we can do about it together. In short, we must un-learn and re-learn “health” as a direct, ongoing and collective experience of it.
This is happening in a growing number of cities around the country where people are coming together to uncover the broad set of factors driving health and illness in their communities. What they discover together forms the basis of collaborative action among an expanding group of stakeholders – citizens, business, government, education, health and other sectors – who realize the collective strengths, needs, and possibilities inherent in their community.
In some communities this is aided by a data-modeling process – the CoH Index – that maps healthful or harmful conditions by neighborhood. The result is a map of community “hotspots” (red zones) that guides business, neighborhood and organizational communities to the most significant and actionable opportunities to improve health. For instance, by overlaying its employee population on the map, an employer can illuminate specific social determinants that matter most to workers living in the red zones.
While every Communities of Health initiative is unique, each is demonstrating that greater collective awareness and change from within can create a profound and sustainable shift in health for all. In addition to generating tangible action, engaged local participation creates “control of destiny,” which is essential to health. Coming together to consider the health of the community is healthy community.