1. It's obvious why the poor have worse health than the rich. But why would the middle class? They don't suffer from material want.
DOLORES ACEVEDO-GARCIA: Our position in society matters for health not only because the poor suffer material want, but also because of relative disadvantage. In the U.S., the middle class may not suffer from absolute material want, but there are stressors associated with not having control over one's life and with having a relatively unfavorable position in the social ladder. For instance, some in the middle class may have jobs over which they have little control. These psychosocial stressors also affect our health.
2. As a woman of color, I am affected by many of the disparities you mention. Given that so much is beyond my individual control, what can I do to improve my life chances and preserve my health?
MAKANI THEMBA-NIXON: First, there are the obvious things. It's always good to eat better and to exercise because, as women of color, our lives require us to - in many ways - be even healthier than other people just to survive the daily pressures that we face with racism, sexism, and other forms of oppression. Second, in addition to being prepared for our lives individually, it's important to engage in group activities like organizing and other forms of change work that help us feel like we're making a difference. It's especially vital to have support networks of other folk who are dealing with the same kinds of issues, so we don't feel isolated and crazy. Black Women's Health Imperative, for example, has a number of support networks online. There are a number of organizations of various ethnic groups online and locally for women to come together and support each other. These networks can really make a difference.
MEIZHU LUI: During the women's movement in the ‘60s and ‘70s, when women began to gather and talk with each other about what was going on for them in their relationships with men, they found out that the dysfunction they experienced was not their fault, and the same problems were affecting so many other women. Even just getting together with some of your friends and venting and finding out what you're all going through, in terms of your health, in terms of your social situation, in terms of your job situation, just does a whole lot to make you feel better. Feeling isolated, alone, and self-blaming is truly unhealthy!
I also want to add that – while race, gender, and class do shape life circumstances – one's health should not be pre-destined by the position we were born into. In fact, the whole point of a democracy is trying to overcome rigid hierarchies. We don't want socially constructed categories to determine our children's and grandchildren's futures. So that's exactly the task before us – to dismantle those artificial boundaries.
JACK SHONKOFF: I'd like to add that it's really important for us to understand the difference between population data and individual experiences. Although it's true that there are greater risks for health problems among different population groups based on race, income, social class, and education, it's also true that what individuals do with their own lives still matters a great deal. Making choices for better health is important.
But when we talk about public policy, it's not helpful to put all the responsibility for health on individual behavior, because a lot of the most common health threats are beyond people's control. And when we talk about individual health, it's a mistake to put everything on population, as if individual choices don't matter. So for people who see themselves as disadvantaged as a result of what's being presented in this documentary series, it doesn't mean that what you do and the way you live your own life isn't going to have an important difference.
MAKANI THEMBA-NIXON: I think the most important point to keep in mind is that things do not have to be this way. There are some relatively cost-effective fixes that could make a difference right now. For example, we could invest in more equitable schools, which would make a huge difference in health outcomes in a relatively short period of time. We could help create places where people can walk safely and have access to good food. That would make a huge difference almost immediately. One important outcome of the series, I hope, will be more people will believe that healthy communities for everyone is not some pie-in-the-sky dream. It is something that can happen as soon as there is the political will to do it.
3. With economic inequality among Americans growing, how can we change the wealth structure in the United States and within companies?
MEIZHU LUI: One of the points of the series is that people who feel they have more control over their own lives are healthier. Having been a union activist, I know that – as you start to organize and fight for better working conditions and higher wages – even if you don't win, the struggle is something that gives you hope and that gives you purpose beyond your own individual situation and that is always really energizing and healthy.
We are so isolated in our society right now. Everybody goes into their little cubicle or their little apartment and shuts the door and the TV's on. But organizing activities – where you are working with others to make a change – that kind of civic engagement gives you a sense of connection that is so missing and you don't even realize that you're missing it and that it's something you need until you get involved in it.(3.1, 3.2)
JACK SHONKOFF: There's a lot of research evidence that shows the more social support you have, the better your health and the longer you live. So people who are isolated and disconnected are clearly at much greater risk for poor health. But it's not just the amount of support; it's how helpful that support is perceived to be.
The larger problem is the degree to which inequality is built into our culture. There are many countries where the political and social values are much more focused on people helping each other out. But the dominant social culture of the United States is highly competitive, and that breeds inequality.
That having been said, it's very difficult to change culture. One of our strongest national myths is the Horatio Alger story of pulling yourself up by your bootstraps. So when the question comes up about what can be done to reduce the income of top executives or how we can change the wealth structure in the United States, the honest answer is that nobody really knows how to make that happen — that's really asking us to change a fundamental, core value in our country. The harsh reality is that these social and economic inequalities are partly why we have more illness in this country and why we don't live as long compared to people in other countries, even though we're very wealthy.
MEIZHU LUI: I agree with the challenges that Jack has identified, but I do think it is in our history to reverse these trends as well. We had the Gilded Age and ordinary people revolted and said, "It's not fair! We cannot live with this level of inequality and we have to start taxing the rich." The New Deal era redistributed the wealth and brought about a greater degree of shared prosperity. More recently, even the mainstream media is – finally – paying attention to the dangers of growing inequality, so we might start to see some changes in people's attitudes.
But more education has to be done, and people need help to see how tax structures, in particular, can be used to redistribute wealth. For example, right now we spend hundreds of billions of dollars on incentives for the rich to get even richer – whether it's tax breaks for capital gains, eliminating the estate tax, the home mortgage interest deductions, etc. – but there's nothing for renters. Increasing taxes on wealth would be a good thing.
Taking matters into their own hands, people are creating cooperatives and co-housing, different kinds of business structures, and there have been proposals to enact a maximum wage, which a few companies have done voluntarily. [The ice cream company] Ben and Jerry's, for example, set a cap where the top executive couldn't make more than seven times the average worker. So, what kind of salary ratio is really reasonable for a CEO to make over the average worker? Here in the U.S. it's around 400 times as much, but in other countries it's about 40 times, and their businesses do just as well. Increasing the minimum wage is another proposal that everyone is getting behind now. These are just a few examples of how we could make changes to our policies.
JACK SHONKOFF: I totally agree that these kinds of policy options could make a big difference, but I'm not optimistic that such dramatic changes could be achieved simply based on altruism. It's difficult to understand, for example, why there isn't a broad-based political backlash against the proposal to abolish the estate tax. One explanation that's been given is that a lot of people don't want to do away with some of these inequalities, because they believe that they themselves might benefit from them someday. I think that illustrates how deeply our culture supports the concept of working your way up the ladder. So, although I would personally welcome many of those policy changes and I certainly agree that they would make a difference, I think that a much more effective strategy would be to help people see how reducing many of these inequities is in everyone's interest, including their own, rather than pushing for this as simply the right thing to do.
MAKANI THEMBA-NIXON: I believe that most, if not all, of the people who are organizing to make these changes have worked really hard in the face of incredible opposition to articulate just why it would be a win-win for us to move toward a more equal structure. But one of the things that gets in the way obviously in this country – and in fact, is becoming a catalyst for reversal in countries that have had relatively equal structures like Denmark and the North Sea region – has been racism.
We have to work hard to advance the sense that we're all in this together, that it's okay for us to share, that everyone is deserving, and that the more stories that we tell to each other about why one group is more deserving or less deserving than the other, the more difficult it is to move on this agenda of equality.
In this country today, we have very low economic literacy. We have to help more people understand how the economy works, their role in it, and how the economy can be managed better so that more people win and everybody's in and hardly anybody's out. The more we can build on people's education, their literacy, and their understanding, including helping them understand that people of other "races" are not the enemy, the more we can help break down those barriers and create the space for the political will that we need to develop the kind of policy agenda that Meizhu so ably laid out.
MEIZHU LUI: To speak to Jack's point, it's not just that everyone is "deserving," but by not investing in people, particularly in communities of color, we're throwing away resources and talent which – in a global economy – is ultimately hurting us all in the end. How does spending so much money on incarcerating young men of color build our capacity to compete as a nation in the global marketplace? Already, the best education systems are no longer in the U.S.
3.1 The wealth inequality reader. Dollars & Sense and United for a Fair Economy (eds), Dollars & Sense, 2007.
3.2 Inequality matters: The growing economic divide in America and its poisonous consequences. James Lardner and David A. Smith (eds.), The New Press, 2005.
4. Is IQ related to health? In particular, are there chemically induced effects in the developing brain that later manifest in IQ?
JACK SHONKOFF: There is no question that brain function in general and intelligence in particular are very much affected by nutritional status and exposure to toxic substances early in life. It is absolutely true that there are environmental toxins that interfere with the development of brain circuitry and that these chemical exposures are unequally distributed across communities. The younger the brain, the more susceptible it is to these harmful effects, so a lot of these toxins are most dangerous during pregnancy, when they can damage a developing embryo or fetus. In fact, in many cases, levels of toxins that are safe for adults can be very harmful to children.(4.1)
There are very good data on toxins that we know a lot about, like lead and mercury, many of which have been shown to differ in measured exposure levels by income and social class. Most people know about the problem of lead in paint, which is more common in older housing, but there's also a lot of lead in the soil and in the dust in some areas. There are also differences in lead exposure related to whether people live close to chemical plants, or whether their water supply is affected. But beyond what has been studied for a selected number of known toxins, there's a bigger question about all the potentially toxic substances that have been introduced into the environment but haven't been tested at all. This gets to more general concerns about air quality and proximity to sources of pollution, which are also unequally distributed based on where people can afford to live.
All of that having been said, it's probably not very useful to talk simply about IQ. Most of us now understand that IQ tests are generally biased, based on cultural and language differences. So I wouldn't talk so much in terms of IQ anymore. Instead, I'd talk more in terms of overall brain function, which includes a wide range of capacities and skills including language, information processing, the ability to focus and sustain attention, and many other "executive functions" that have a lot to do with higher levels of performance.
So, to be very simple and straightforward about this issue, poor nutrition and exposure to toxins certainly are important threats to brain development, especially early in life.(4.2) And the prevalence of nutritional deficits and exposure to toxins is higher among people who are poorer, people who have less education, and people who live in geographic areas that are less protected.(4.3)
MAKANI THEMBA-NIXON: I just want to add that environmental protection has been probably one of the most active and engaged areas of work in the country. It's one of the few equity issues that's institutionalized at the federal government level, where there's an office that focuses specifically on environmental justice and another focused on child health and exposure to toxins. In fact, the staff from the Environmental Protection Agency screened the documentary recently to discuss how they could better incorporate some of this learning into their policy work, so I think it's going to be very exciting.
On the ground level, there have been a number of great groups active around improving water quality, and preventing children from being exposed to toxins and the kind of dumping that often happens in communities of color and poor communities. To name a few, there's the National Black Environmental Justice Network, Detroiters for Environmental Justice, the Newtown Forest Club in the south, and the Asian Pacific Environmental Network.
The work is really all over the country, and any of those organizations are linked to lots of local groups working on similar issues. By the way, the Office of Environmental Justice is run by Charles Lee, a former longtime environmental justice advocate, and the Web site has tools and resources for folks to engage in this work.
4.1 Early exposure to toxic substances damages brain architecture. Working Paper #4 by the National Scientific Council on the Developing Child, 2006.
4.2 Excessive stress disrupts the architecture of the developing brain. Working Paper #3 by the National Scientific Council on the Developing Child, 2005.
5. What role can religious organizations play in mobilizing a broader-based movement for racial equality and better health?
MAKANI THEMBA-NIXON: One particular denomination comes to mind that I think is a great model, which is the United Methodist Church, particularly the women's division. They've done incredible work at different levels, and the levels of their work are very instructive for other faith communities.
For example, they have one level of work, which is about building relationships between folks within congregations and across congregations to better understand how issues like health equity and other kinds of racial and gender equity issues affect people. So, it's about building individual relationships and understanding around people's experiences, but also identifying how institutions and structures shape race and class, and how people understand and navigate them. Then, at the next level, they have folks engaged in advocacy projects – some local, some national – to help make changes in those structures and systems and relationships. In fact, they bring together hundreds of women every year to train them for a week and have them engage in direct action work to address these issues. Then, at the third level, at the denominational level, they provide tools to congregations and to the national and international staff to think about how to move policy at the federal level, in addition to the local and state work that happens at the congregation and denominational level within those regional structures.
In many ways, this represents a very advanced way of organizing people to engage them in both creating better understanding, relationships and competency on the ground, but then also turning all of that into some real grassroots action with national impact.
6. How should health care professionals take social determinants into account when treating patients? Since I can't prescribe a change in their life circumstances, what do you suggest?
JACK SHONKOFF: This is a great question. For starters, people who provide healthcare on the ground need to understand – and many do, of course – how much the social and economic environment affects their patients' health. I'll talk just from the perspective of children, which is what I know best.
As a pediatrician, I don't accept the statement that we have to play the hand we're dealt. In fact, much of what pediatrics is about is trying to change the hand that some children are dealt. For example, if you're born poor, or if you're born with certain risk factors such as prematurity or low birth weight, then the job of the healthcare system is to shift the odds in your favor to produce a better outcome. Sometimes that requires the input of a medical subspecialist. So, if you're a primary care doctor, you have to know who to turn to when you need a cardiologist or a pulmonary specialist, among others.
In the same way, health care providers have to think about who they should be turning to when children are threatened by risk factors that are related to the communities in which they live. These could include elevated levels of pollution as well as exposure to violence in their families or neighborhoods.
So, this idea that the healthcare system is very limited in what it can do is only true if you think of health care in a very limited way. And that's the problem. We tend to think of the healthcare system only in terms of what goes on in a doctor's office or a hospital. Instead, we have to take a much broader view of health promotion and disease prevention. Then, healthcare professionals would not only have to take social determinants into account, but they would also have to figure out how to build collaborative relationships with people who can affect those broader social and economic factors that lead to either healthy or poor outcomes. This means that we have to build a public health approach into our personal healthcare delivery system.
So, clearly, I don't accept the premise that we can't prescribe a change in children's life circumstances. If children's environments are producing bad health, then the healthcare system has to figure out how to prescribe change in those environments. At the Boston Medical Center, for example, instead of just having pediatricians, nurse practitioners, nutritionists and social workers, they added lawyers to the staff. So if a child has a speech problem, you bring in the speech pathologist, and if the family doesn't have adequate heat in their apartment, you bring in the lawyer to do something about the landlord.
Stated simply, we provide excellent health care when children are sick, but what we really have to do is to figure out how to do a better job of promoting health and preventing disease. There's no reason why the healthcare system can't be designed to address these broader health issues. It's a serious mistake to think that life circumstances that produce bad health are inevitable.
MEIZHU LUI: I also want to add to that the whole issue of cultural competence because we have people from so many different places in our healthcare system now. There's a wonderful book by Anne Fadiman called The Spirit Catches You and You Fall Down about a Hmong girl with epilepsy, which shows how even the best of Western care can fail if it doesn't take into account different belief systems and values. Obviously it's complicated, but I think healthcare professionals and the healthcare system must remember to take into account the whole of patients' lives and needs, and not just look at treating diseases in a vacuum.
JACK SHONKOFF: Let me build on that. If you were to ask the average person what the biggest health challenges are for children in the United States, most would probably say it's a lack of health insurance for every child. And certainly that's the problem that gets the most attention. But when the day comes that every child in this country is covered by some form of health insurance, not all children will have access to healthcare. For some there will be language or cultural barriers, and for others there will be geographic isolation problems, particularly in some rural areas. Then, let's say, at some point in the future we solve the access problems and all children have what might be called a "medical home" – meaning they have a regular doctor to go to and the care will be paid for. The dilemma is that just when we think we've solved the problem, we'll have to confront the fact that the major threats to the health of children in this country are not going to get solved in doctor's offices or hospitals. And then we'll finally have to deal with these larger social and economic factors that undermine health.
This shortsightedness is not intrinsic to the healthcare system. It's a function of how much we default to an overwhelming focus on individual responsibility, and how narrowly we think about health promotion and disease prevention for children in the United States. It's also an indication of how we've got to think much more broadly. We spend more money per capita on healthcare than any country in the world, and we're not even ranked among the top 10 in most health indices. We're not getting as much back for our money as other countries are, because our dollars are largely focused on individual healthcare services, including expensive ones, and not focused on broader public health issues.
7. Should we focus on changing local conditions in our neighborhoods or national policies? What changes would make the biggest difference?
MAKANI THEMBA-NIXON: Well, it's really not an either-or question. We need to work in both places and wherever we can. There are some things that are the purview of local communities, like land use, for example. Certain kinds of issues are part of what a local community does, and it's different for each area, you know, so the level of local control is very important. At the national policy level, we have to address questions like how people get access to health insurance and the care they need, how healthcare providers are educated, issues like a living wage, job creation, the estate tax, and all these kinds of things that help to create more equality and more democracy in this country – which is really one of the most important factors in terms of how we create a healthier country.
All of these things work together. Obviously, policy with a national impact can make a huge difference, and you can create enormous resources at that level, but some things have to be handled on the local level. One is not better than the other. We need to have a policy agenda that allows us as community folks to have control over our environment at the local level, but we also have to make a commitment as a nation together that we really want this country, and everyone in it, to have the best possible quality of life that this nation can offer. We have the resources; we have the know-how to do it, and those things can happen up and down the sort of chain of policies, from the very local to the highest national level, to make that happen if we have the political will.
JACK SHONKOFF: I totally agree with Makani that it's not an either-or question. There are certain things that are more influenced by federal policy and some by state policy. But, in the end, a lot gets implemented at the state level, so that's a very important place to focus politically. Then, of course, there are all of the things that just happen at the community level. Therefore, it's really important to think not only in terms of government programs, but also in terms of things that communities can do either informally or through community organizations. So it's always both a top-down and a bottom-up approach.
In our policy work around early childhood development, we have taken more of a state-based approach rather than a federal one, for two main reasons. The first is that, recently, the federal political climate has been a very difficult arena in which to move a policy agenda for young children. Second, in the end, everything gets implemented at the local level. Because of the tremendous variability among the states in terms of how much they want to invest in children, the federal government traditionally has played a key role in attempting to establish an equitable baseline of services. But, in the end, the biggest role the federal government plays is how much money it sends down to the states.
Recently, we've found that significant policy movement can be achieved at the state level in many places. Five or ten years ago in many states, if you tried to begin a dialogue about public investment in young children, the conversation would immediately end with a conclusion that child-rearing is a private family matter and not the government's business. Now there's not a state left in the country that isn't trying to figure out what its early childhood agenda should be, and that's a sea change.
8. The welfare state made Americans soft, and now you're saying that we need MORE government handouts? Liberal tax-and-spend policies have failed before, and they'll fail again.
MEIZHU LUI: I assume that when the questioner says Americans are made "soft" by the welfare system, they mean that some people take up too much space and resources and contribute too little. That definition definitely fits the wealthy top one percent, who have benefitted enormously from past policies and have been allowed to amass more and more wealth and pay less and less taxes without even working. So we definitely don't need anymore of that kind of handout, and it's a common misconception in terms of who exactly is getting government handouts.
On the other hand, it's the obligation of a government to take care of its people, and ours always has. I don't know if people recognize that the free land given to their ancestors in the 1862 Homestead Act was a "handout" (one out of four white families can still trace some of their wealth to this program), as was the GI Bill that maybe allowed their father or their grandfather to get a free education and a low-interest mortgage after WWII, or if they call the low-interest small business loan that helped their relative re-start their business after the Depression "welfare." I mean, those were massive government handouts, but they were good ones in the sense that they helped build the middle class. Although, the problem, of course, is that they only went to whites. In fact, the skewing of government programs toward whites throughout history is the reason for current racial economic disparities.(8.1, 8.2)
The word handout implies you're throwing something to a beggar, but in terms of the GI Bill, for example, that was an investment, it wasn't a handout. Yes, it was a free college education, but it really did produce more money for the economy. For every dollar that was invested through the GI Bill, the economy got seven dollars back, because people started businesses, they had more skills, and they invented new things. So it's not so much a matter of spending more, but what are we spending on and for whom? We can choose to send young people to college or to send them to prison.
Most everybody works hard and/or is willing to work hard. We all know that we have to do that. But if you really have no assets at all, if you own no land or business and all you can do is sell your labor in an era of declining wages and increasing costs, you can tug away at those bootstraps but it's not going to get you anywhere. So it isn't so much the liberal tax-and-spend policies that have failed – because certainly those helped pull us out of the Depression – but it's some of the conservative tax-and-spend policies, where we're just giving money away to the wealthy and spending money on the war, as we're seeing right now, that are causing a real problem in our economy and affecting all of us.
JACK SHONKOFF: I would just add that it's important to level the playing field at the beginning of life to promote greater opportunity. Many of the adverse factors that we've been discussing increase the likelihood that people are not going to be very healthy, and many of these influences occur very early in life. These include lack of proper nutrition, exposure to toxins, exposure to recurrent violence, and living in very deprived and disorganized environments that are affected by deep poverty. These kinds of stresses literally get under the skin early in life and are incorporated into our children's bodies, leaving them more likely to have problems with learning, behavior, and both physical and mental health as they get older.
Removing those impediments to good health puts children in a better position to get off to a strong start. So, independent of any arguments people want to make about government programs to support vulnerable or dependent adults, policies and practices that level the playing field for children are both a matter of moral responsibility and a smart financial investment. This has nothing to do with creating soft people. It's just the opposite. It has to do with building a strong foundation so people are more likely to be healthy, to be better educated and skilled, and, ultimately, to be productive and responsible citizens. So, it's hard to imagine how one would see any government or private program that strengthens children's abilities to get off to a good start as making them "soft."
MAKANI THEMBA-NIXON: I know there are people who think about these investments as handouts. But I think the real question is, where do we want our tax dollars to go? This is our money. And part of the story that separates us is the idea that we shouldn't share and invest our money in our own communities, in our own folk, in our own country. I think people would be surprised how little of the money that they work hard for and pay into the pool for taxes actually goes into making lives better where we are. So as consumers of government – since this is our government – the money should be used to make our lives better, all of us. If we believe the story that we shouldn't share those resources to help everyone, then that makes it easier for some people to take that money and give it to things that have nothing to do with making our lives better. But if we stop and say, "Wait a minute, is this the right question, or what would we rather see happen with our money?" Then we can begin to ask, "Wouldn't we like our money to go into great schools? Wouldn't we like our money to go into great parks? Wouldn't we like our money to go into creating the kind of environment where people feel safe and folks won't feel like they have to rob one another? Wouldn't we like our money to help people engage, and feel like they have enough personal time and the kind of wages and the kind of work that allows them to be home with their families at a decent hour and eat together and share their lives?"
We know from the research and from reality that people whose lives allow them to have that kind of space to relate to other human beings – to just be human – are not only healthier, but also less likely to commit crimes, less likely to be bad neighbors. They're more likely to be full, productive citizens in every sense of how we understand that word. So I would say to this person, or to all the people who think of the public sector as just a waste: that's how a lot of things get done, us pooling our money together. And things like the water, the electricity, and all those things, those things used to be part of the public sector and they need to be again, because it's actually more efficient and cheaper when we pool our money and run things through the public sector. It's not that corporations automatically do things better. Actually, often the opposite is true.
MEIZHU LUI: Just to make one last point here. There's a hidden racial message in this question as well, implying that "welfare" is about giving to undeserving people of color who are lazy and who just want to get something for nothing. But the segment of the series that focused on Michigan showed that white working-class people who have worked really hard for a long time are going to need some government help to get themselves back in the game. People in communities of color – you know, last hired, first fired – have been kept on the outskirts of the economy by discriminatory policies and practices. Their poverty has nothing to do with being "soft" (I like to say that if hard work was the reason people get wealthy, than the descendants of slaves should be the wealthiest people in the U.S.). But white folks, too, need help today to get into the economy and to be able to contribute once again.
8.1 The color of wealth: The story behind the U.S. racial wealth divide. Meizhu Lui et al. The New Press, 2006.
8.2 HalfInTen.org – a new initiative proposed by Senator John Edwards, based on a report by the Center for American Progress, to cut poverty in half in ten years through government interventions. The report, with concrete recommendations, is available at the Center's Web site.
9. Is it better to improve the lot of parents, so they can provide a better foundation for their kids, or to focus on children, so they can grow up healthier despite the limitations of their parents?
JACK SHONKOFF: This is an easy one. You can't do anything for children, especially when they're very young, if you don't invest in their parents. So it's a false choice. Children don't live out of the context of their family and the environment of relationships around them. As a species, our young are helpless for the longest period of time compared to any other animals. If we're asking where in the life cycle we should intervene, from a biological point of view focusing on young children makes the most sense, because a lot of the physiological predisposition to illness and a shorter lifespan is built into our bodies very early in life, when exposure to excessive stress, nutritional deprivation, or toxins is most damaging. So it makes a lot of sense to focus very early in life and to build a strong foundation, rather than to try to fix things on a weaker foundation later.(9.1)
9.1 Young children develop in an environment of relationships. Working Paper #1 by the National Scientific Council on the Developing Child, 2004.
10. Are you suggesting that everyone should have the exact same health outcomes? How will we know when we've achieved "equity"?
MAKANI THEMBA-NIXON: I hear this a lot, particularly from the more conservative members of my family: Are we saying that everyone is the same, and should everyone end up exactly the same, and is that what we're trying to do? It's like picturing this big gray block where we're all melted together.
In many ways, what happens at the end is not so much the issue, but rather, have we done everything to make sure that everyone has a fair beginning? Have we done everything to make sure that the road that people must travel over the course of their lives allows them to go to school, have a job – you know, all these things – to be able to, as they choose, have families? Do we have any rules, structures, or policies that make it more difficult in an unfair way for people to do things because of the color of their skin, because of how poor they were born? Do we have barriers?
We have not only a moral obligation, but also a legal obligation, to ensure that democracy exists for all, that we have equal access to the resources, to support, to a fair beginning, and to a road to travel that allows us access to all of those things, no matter what happens at the end.
Before we can even begin to talk about what the end will be, can we say that we have equitable systems? Can we say that we don't have any unfair privilege? Can we say that we've fixed it so that just because you're born poor, you're not sentenced to a lifetime of poverty? Or are we saying that because you're born in a certain zip code that you absolutely have to go to a crap school? There shouldn't be any bad schools. And the reason there are bad schools has very little to do with the people who go there. So I think that the end result really is, do we have fair systems and a fair beginning and enough resources that allow people to make good choices? And once that happens, I think that over time we'll see a range of outcomes, but at least they won't be because our systems are unfair.
MEIZHU LUI: In terms of everyone having the exact same health outcomes, there's no group among us that would say, "I want my children to die at a higher rate than other people's children; I want to live less long." We all love life. Equity means that no group has poorer health due to reasons outside its control, but within society's control. In education and employment and other areas, they're saying, "Let's look at the results. Let's look at whether different groups of color, for example, are graduating at the same rates as whites." So if we have one group that's doing better, let's make sure we look at those outcomes, understand why, and reduce the disparity.
Knowing that genetics or biology is not the reason for poorer health, we should focus on using all our means to end the stress of racism, so Blacks do not have three times the infant mortality rate as whites; to improve employment, so immigrant populations don't experience poorer health the longer they live in the U.S.; and to ensure that indigenous populations are not exposed to toxic wastes. All of these things would provide groups the opportunity to be equally healthy.
JACK SHONKOFF: Generally speaking, health is normally distributed in a population, and is the product of an interaction between genetics and environment. Even in a totally equitable world, some people will die earlier and some will be healthier. In an inequitable world, people are more likely to be sick and to die earlier in a non-random way, related to their social class, and that's not fair. So the issue is not equality; there is no such thing as true health equality. The issue is whether people are unfairly burdened by threats to their health that are a related to racial discrimination, income, or social class. That's just unacceptable.
I was at a hospital-based medical conference several years ago where someone was talking about heart transplants for babies with congenital heart defects and how the numbers of needy recipients will always exceed the numbers of potential donors of healthy infant hearts. When the possibility of developing artificial, mechanical hearts was raised as the solution, a person in the audience asked, "Aren't you just postponing the inevitable?" The professor on the stage responded, "My dear man, everything we do in medicine is postponing the inevitable!" On some level, this was a very important point. The fact that people get sick and sometimes die is certainly not always avoidable. The important question is whether some people are unfairly disadvantaged because of adverse life circumstances that impinge on their lives because of their race, ethnicity, income, occupational status, or where they live.
11. Programs that promote "healthy communities" usually advocate more parks or safer streets or lead abatement programs. This strikes me as somehow inadequate. What else should we be doing?
DOLORES ACEVEDO-GARCIA: All of these interventions are valuable and can help enhance a given aspect of a neighborhood, which may have positive implications for the health of its residents. However, you are right that enhancing one aspect at a time seems inadequate. The extent of the disparities in neighborhood environment between white and minority kids is overwhelming. Poor Black and Latino kids are much more likely to live in poor neighborhoods than poor white kids. This means that for many minority kids, the disadvantage of living in a poor family is compounded by the disadvantage of also living in a poor neighborhood. This pattern of "double jeopardy" is very rarely experienced by white kids. What we really need are interventions that break this pattern of multiple disadvantages for minority kids.
There are non-poor neighborhoods in all metropolitan areas and white children, even poor white children, usually live in them. We need policies that allow minority families to move to non-poor neighborhoods. Housing policy experts agree that a range of policies can help us attain this goal. For example, at the local level, increasing the availability of rental housing, for instance by reducing housing restrictions to multifamily housing, can increase access for minority families.
Also, our main housing assistance program, the Section 8 housing voucher program, can be enhanced so that the assistance families receive allows them not only to afford their rent but also to find housing in low-poverty neighborhoods. We have a few programs in the country that enhance housing subsidies with housing counseling, so that families can find housing in better neighborhoods. These so-called "housing mobility programs" do work; i.e., they allow families to move to better neighborhoods. But we need to bring these programs to scale. For example, we can make counseling to promote moving to better neighborhoods a standard part of the Section 8 program.
From a public health perspective, housing mobility programs have great potential. There is evidence that moving to better neighborhoods can lead to improved mental health, i.e., less anxiety and depression. And this is only the effect of moving to a better neighborhood, since a health intervention has yet to be included in a housing mobility program. We can only imagine what a powerful program we could design if we supplemented a housing mobility program with a health intervention.
JACK SHONKOFF: There needs to be a match between the causes of increased vulnerability to disease and premature death and what we do about them. Parks, grocery stores, and lead abatement programs are absolutely critical, but at the same time, they don't do anything about people who are unemployed or underemployed in low-wage jobs and living with the stresses of poverty. They don't necessarily do anything about the problems of mental health – depression, substance abuse – or the problems of racism and other forms of discrimination, all of which can contribute to poor physical health. So it's not to take away from these things, but to say they're not enough, and to acknowledge that there are other causes of poor health that are not solved by the actions mentioned earlier. It's only when we understand the full range of causal mechanisms that we can design the full scope of appropriate interventions.
12. One obvious factor seems to be ignored: diet. What role does a changing diet play in eroding the better health of Latinos as well as African immigrants and affecting birth outcomes?
DOLORES ACEVEDO-GARCIA: You are right that a change in diet (or physical activity) may be one of the reasons why the health of immigrants deteriorates with time spent in the United States or with generations in the United States. We know that as immigrants spend more time in the United States, especially after they have lived here for five years or more, their weight profile is significantly worse (higher body mass index) than when they first arrived. This is a pattern that we see across all national origin groups, and for both men and women, so there is reason to think that there is something about the U.S. environment that makes people gain weight.
Qualitative research suggests that while food preparation and family meals are important for many immigrant groups initially, with time in the U.S. these become a commodity. People trade food preparation for the convenience of fast food so they can work more hours. This would not have to be this way if food prices did not steer immigrants toward unhealthy choices and if there were more food choices in ethnic neighborhoods. Also, obesity is rapidly increasing in developing countries where most immigrants to the U.S. come from, and U.S-based corporations play a role in the deteriorating food environment and increased obesity in those countries. So it is in our best interest to regulate the marketing of high-calorie, low-nutrient foods both here and abroad.
13. How much do violence and drug use contribute to poor health in our inner cities? Can you give examples where changing the local environment changed people's behaviors?
DOLORES ACEVEDO-GARCIA: Violence is an important contributor to poor health and to health disparities, both directly and indirectly. For example, violent death and injury rates are higher among minorities. Also, living in a violent environment may constrain our health choices. For example, someone living in a violent neighborhood may have less incentive or actual fear to engage in outdoors physical activity. From the Moving to Opportunity study conducted in the 1990s, we have learned that the major reason that people living in high-poverty neighborhoods want to move out of those neighborhoods is that they want to feel safe.(13.1) After moving to low-poverty neighborhoods, people report major improvements in their perceptions of safety and also in their mental health. More recent evidence from the Moving to Opportunity study suggests that women and girls are particularly adversely affected by a violent neighborhood environment and thus they stand to gain more from being able to move to safer neighborhoods.
MAKANI THEMBA-NIXON: There's some really important work that was done on this out of Boston. This group focused on zero youth homicides, and it's sad because they were doing something that was really working and making a difference, but then they ran out of resources and the political agenda shifted.
We know that there are a number of interventions that help to reduce drug use and people's likelihood to use drugs. Treatment is obviously very important, but we also know that relationships, the way neighborhoods are built, support for jobs and things for young people to do – all of these make a difference, and it's important to take a systems approach to the problem. In terms of the youth development piece, often in poor communities and communities of color, the focus becomes youth employment. While this is important to a certain extent, it's not like every minute that a child of color is not working, they're not being productive! We also need music and art and other kinds of programs that have been shown to make a huge difference. People need beauty and green space and those kinds of things too.
MEIZHU LUI: In terms of what happened in Boston, we also had a health commissioner, Deborah Prothrow-Stith – who was from the Black community – who reframed the violence and gang problem as a public health issue instead of a criminal justice issue. So the people of the city began to see our young people as engaged in unhealthy behaviors as opposed to being criminals. It humanized the problem and in the end, the kinds of programs created to reach out to young people with alternatives were very different from the model of knee-jerk punishment and incarceration.
JACK SHONKOFF: The most important lesson that we learned from the Boston experience was that you can't do just one thing; you have to deal with these kinds of complex challenges on multiple levels. The search for the magic bullet or the quick fix will always come up short.
But I do want to make one correction. If we're talking about the period in Boston when there was a significant drop in homicides, this was the result of a combination of the programs that Deborah Prothrow-Stith and others put forward, but it also was combined with a highly coordinated effort involving law enforcement and the faith-based community. The churches, for example, were extraordinarily active in the community, providing the kinds of positive supports that were missing, particularly for teenagers. But also the U.S. attorney's office, the district attorney's office, and the Boston police aggressively targeted the kids who were the major perpetrators of the violence and put a lot of them in jail.
So the key to this success was a multi-pronged approach that applied a good cop/bad cop strategy. The U.S. Attorney's Office and the Boston Police Department went up to these kids – because in the community everybody knows who they are – and said, "We're gonna tail you and as soon as you do something wrong, we're gonna grab you and put you in jail." Meanwhile, at the same time, the churches and other community programs said, "We're gonna offer you an alternative. Come on in." For those who gravitated to the positive programs, some wonderful things happened, and those who didn't were arrested and put in jail the first time they did something wrong The combination of the two literally cleaned the streets. Then, like a lot of pilot projects, the program ended and eventually the situation deteriorated again, although it never got as bad as it used to be.
MAKANI THEMBA-NIXON: It's true, the systems approach is really important. And having a father and grandfather who are Boston pastors and were very involved during that time, I think we have to recognize the importance of supportive community. For a lot of those young people who made the decision to embrace the alternative, you need that space to move away from your current negative lifestyle. So I think we all agree that a systems approach that engages the community in the solution can make a huge difference in terms of outcomes. We've seen that over and over again. The issue, though, is having the sustained resources and the political will to make this the norm, instead of just a demonstration or pilot.
13.1 Information on the Moving to Opportunity program and research findings available at www.nber.org/~kling/mto/.
DOLORES ACEVEDO-GARCIA: If you mean something we could change in a God-like fashion or by magic, I would eliminate racial and ethnic segregation in our society across neighborhoods and across schools. That would equalize resources across areas –for example, fiscal capacity – and teach us how to live with each other and work towards common goals. If I had to pick a policy, I would change the way we structure our public school funding and school choice system. Part of our property taxes would go to a state level school fund and then be distributed across schools with the principle of improving academic performance and achieving equity. Regardless of where you live in a given state, you could choose to send your kids to school anywhere, not only within your neighborhood.
MEIZHU LUI: I found this quote from MLK 40 years ago that says:
"We're called upon to help the discouraged beggars in life's marketplace. But one day we must come to see that an edifice that produces beggars needs restructuring."
I think we need to change our values from love of money to love, not money. The edifice of private gain from public resources, of individualism, of short-term profit, needs challenging. One simple way to start would be to reduce the number of hours that people are working outside the home, so that people have time for family, for rest, for community, and are not always chasing the next dollar. Past labor advances have already increased health: ending child labor, the 8-hour work day (where is it now?!), vacation time, and retirement benefits. As this series shows, building strong families and communities is essential to good health; people in healthier societies work less and relate to each other more.
MAKANI THEMBA-NIXON: If I could start with one thing, everyone would have enough resources, enough capital, and enough money to have a good quality of life. It's certainly not everything, but that could be a first step to removing some of the barriers and also allowing people to not have to deal with the basic survival stuff that gets in the way of them being fully engaged.
JACK SHONKOFF: Science tells us that if we have to pick one thing to start, we should invest first in the most disadvantaged children at the youngest possible age.(14.1) This would begin with making sure that they're provided with effective healthcare and early care and education in the context of a supportive environment for their families.
14.1 A science-based framework for early-childhood policy: Using evidence to improve outcomes in learning, behavior and health for vulnerable children. Report by the Center for the Developing Child at Harvard University, August 2007.
DOLORES ACEVEDO-GARCIA: Oppose measures that polarize our society even more, for example, tax advantages for the wealthiest groups. Support a change towards universal health insurance. Yes, health care is only one of many factors affecting health, but we have unacceptable levels of uninsurance.
MEIZHU LUI: I would just add that it's important to understand policy and get your voice in. It's your country and it's your tax dollars, and you should make sure they're going where you want them to go to make us all healthy. So three things would be to educate, to engage, and to be an advocate.
MAKANI THEMBA-NIXON: I would add to this great list to remember that everywhere, people are coming together to try to make this work happen. So just pick whatever issue most fires you up – whether it's wages or how children can have a better beginning. Whatever that is, take that thing and go in with the other three people who have decided to fire up, or ten people, and you may have found an issue where there are a thousand people who are engaged. Just commit to give three or four days a month as a start to make something happen. You will be surprised at how much your energy will make a difference and how much more work you'll get done, and how much closer you'll get to something concrete that can help bring about what seems like pie-in-the-sky stuff closer to real life and actual fact.