Some Communities’ Strong Structural Approach to Community Health

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November 21, 2014; Stateline

Michael Ollove in Stateline writes about the broad perspective some states are taking toward health. For example, supporters of an increase in the minimum wage in Minnesota have convinced legislators to consider the health impact of the state’s $6.15/hour minimum wage, linking the low wage to rates of infant mortality, inadequate prenatal care, diabetes, and other health outcomes in addition to the lack of insurance. Based on the health impact review, the legislator raised its minimum wage to $9.50/hour, with future increases keyed to the inflation rate.

“That report created a powerful narrative for us, low-wage workers dying eight years before higher wage earners,” said Alexa Horwart, a health equity organizer with the Isaiah faith-based organization nonprofit that was one of the groups pushing for the minimum wage increase. “We thought we were going to win this year, but the question was how high would the new rate be and would it be indexed. The report had the most impact on those two things.”

Ollove reports that other states have made the health connection in analyses of questions of energy, domestic workers’ rights, alcohol sales, public transportation, and even hiring practices that discriminate against applicants with records of criminal convictions. “Health is more than what happens in the doctor’s office. It incorporates everything,” said Kris Rhodes, executive director of the American Indian Cancer Foundation.

However, the underlying concept is not simply health, but structural racism, the presence and power of inequitable policies that, without intent necessarily, consistently privilege white people and create negative outcomes for people of color. For example, Minnesota’s radon detection and elimination program targets homeowners, not renters. But although three-quarters of Minnesota’s households are homeowners, less than a quarter of Minnesota’s African Americans own homes, so the state’s benign, non-racial radon elimination policy ends up benefitting whites more than blacks.

The expanded definition of what might contribute to health, and the states’ understanding of structural policy issues that maintain health disparities among population groups, are important contributions toward improving health outcomes.

When it comes to defining what contributes to health, remember that this is a federal issue, too. For example, Congress has held up approval of Dr. Vivek Murthy, President Obama’s nominee for surgeon general (though President Obama was reluctant to push the nomination prior to the elections), because of Murthy’s observation that gun violence constituted a public health concern. Immigration policy might be another non-health policy with health impacts. President Obama’s executive order on immigration, which protects as many as five million undocumented immigrants from deportation, still leaves them ineligible for health insurance through either the Affordable Care Act or from federal Medicaid dollars. In the handful of states that provide state Medicaid coverage to non-citizens, the executive order could open up desperately needed health coverage for this population. The response, or in many cases, the lack of response to child homelessness has long-term health impacts on children.

Some of this broader appreciation of health has been demonstrated and underscored by health foundations such as the California Endowment, which says that it measures its impact on health outcomes guided by “four big results,” including increasing school attendance and reducing youth violence. The Endowment’s Building Healthy Communities initiative addresses partly on “‘upstream’ social determinants of health—like income, education, and neighborhood conditions—[that] are often at the root of poor health and health disparities.” The foundation’s expansive concept of health explains grants such as its 2009 grant of $237,000 to the Sacramento Housing Alliance to support advocacy for improved regional planning and community design, its 2010 grant of $152,000 to the Long Beach Community Benefits Agreement Campaign, the 2014 grant to Asociacion de Liderazgo Comunitario in San Diego for its healthy homes and improved public infrastructure project, and its 2011 grant of $2,000,000 to Mercy Housing California for its predevelopment fund for housing projects in the vicinity of the Endowment’s 14 BHC communities. We fully suspect that the leadership of health foundations like the Endowment have contributed to a broader appreciation of actions that lead to healthier communities, much like the efforts of states described in Ollove’s report.

The California Endowment’s work, the Minnesota health outcomes study, and others document not only broader conceptions of health, but health disparities that occur by race and persist despite ostensibly benign, non-racial policy initiatives. The research of Yale professor Danya E. Keene has documented how policies affecting housing affordability, residential stability, and exposure to stigma vary by geography and race. In late August, the United Nations Committee on the Convention on the Elimination of All Forms of Racial Discrimination found the “minority communities in the U.S…disproportionately disadvantaged in all areas of life, including education, criminal justice, voting, housing, and access to health care,” according to Laura Carasik, writing for Al Jazeera. An expanded understanding of what contributes to better health outcomes also contributes to an understanding of the “upstream” structural barriers that have to be overcome toward creating healthy communities.—Rick Cohen