December 3rd, 2019
What are the most urgent needs when it comes to implementing programs that address community conditions? At the final roundtable event in the Drivers of Health project, a one-year research project led by the Harvard Global Health Institute and supported by the Robert Wood Johnson Foundation, health policy experts identified crucial research and policy needed to fill the gaps in community health and wellbeing.
Here are our key takeaways from the meeting:
Health and social needs vary considerably from community to community, but health data is not always detailed enough to capture these differences.
As CEO of the Asian & Pacific Islander American Health Forum Kathy Ko Chin explained, the uninsured rate of Asian-Americans as a whole is quite low. However, when you look at the rate of coverage for each specific nationality, there are significant disparities; Koreans, Bangladeshi, and Pakastani Americans have much higher rates of uninsurance, because they have a greater proportion of small business owners. Without this knowledge, policymakers may wrongly assume that Asian-Americans are covered, and that no more outreach needs to be done in these communities. In this way, the inability to disaggregate data perpetuates the “Model Minority” myth, said Chin.
The problem of demographic differences not captured in health data is not only an issue for national data collection. Alva Ferdinand, assistant professor of health policy and management at the Texas A&M School of Health and expert on rural health, pointed out that the community health needs assessments (CHNA) that hospitals are required to conduct often take a broad view at community health issues, but do not drill down into the needs of sub-populations in that community. These “umbrella CHNAs” often miss specific needs of rural communities such as food and housing security, and health literacy, missing opportunities for positive change in these areas. Further, using the same population health targets for rural and urban areas may not be realistic or achievable, said Ferdinand.
There is broad agreement among health care policymakers and researchers that community conditions greatly impact health. But we rarely examine the reasons why disparities in social factors exist in the first place, said Linda Goler Blount, CEO of Black Women’s Health Imperative. “Disparities exist because they’re rooted in historical systems of oppression,” said Blount. Identifying white supremacy as a cause of health disparities should be a prerequisite for health care institutions moving into the “social determinants space.”
The impact of racial discrimination on the health of Black women is profound. The stress caused by racism can raise cortisol levels and cause inflammatory responses, putting Black women at an increased risk of obesity and maternal mortality. Going upstream in addressing health issues for Black women means tackling racism.
Shola Olatoye, NYU visiting fellow and former CEO of the New York City Housing Authority, agreed: “We can’t have a conversation about the social determinants of health without talking about racism and white supremacy.” Implementing community health programs while ignoring systemic racism and oppression will only put a band-aid on the problem. However, the role of discriminatory policy in creating and perpetuating disparities is not always acknowledged.
For example, data gathered from the Drivers of Health interactive game found that most people attribute health care access to government policy (ie. Expanding insurance coverage), but far fewer attribute social factors such as education and income to historical government policies. Understanding how government policy created residential segregation and perpetuates income/wealth inequalities on racial lines is key to reversing health disparities.
Health policymakers and researchers value detailed quantitative health data– and rightly so. However, qualitative data can be just as important when researching community conditions, said Ferdinand. “When I was a graduate student, I heard from economists that ‘our job isn’t to talk to people.’ But through my work I realized just how important it is to do exactly that.”
Harold Pollack, professor at the University of Chicago School of Social Services, concurred. He recalled a needle exchange program that received pushback because they hadn’t elicited community feedback before implementing the program.
Knowing what to ask when eliciting stakeholder feedback is just as important. We shouldn’t be coming to community members with a program and asking them how to implement it, said Blount. Rather, “We should be asking community members, ‘What do you need?'”
Improvements in community conditions are desperately needed throughout the nation, but are hospitals and health plans the right entities to provide social services? Maybe not, panelists said, but health care is where the money is.
“The health care system is left holding the bag because our social services and policy levers aren’t doing the job,” said Pollack. “We don’t really have a choice. We have to learn how to do it through the health care system because no one else will do it.”
Health care systems moving into the social program space can create opportunities for positive change. Olatoye pointed out that working on social issues is an educational opportunity for young clinicians and trainees, who may not have considered the health impact of social factors before.
However, the panelists were also concerned about the “medicalization of social services.” What the health care sector might see as progress in provision of social services may lead to harm in practice. For example, hospitals would fight food insecurity by sending meals to people’s houses via drones, said Betsey Tilson, State Health Director and Chief Medical Officer of the North Carolina Department of Health and Human Services. But then you would lose the social interaction of Meals on Wheels, negating an important part of the program. “Health care likes the shiny objects but it’s really people to people that matters,” said Tilson.
Further, if the health care system is duplicating efforts of social programs, that is a poor use of resources. “If it’s all done by health care it’s bad, if it’s all community-based organizations it’s bad. There need to be partnerships” said Gary Sing, Director of Delivery System Investment and Social Services Integration at MassHealth.
The panelists discussed ways in which the power of health care institutions and government policy could be harnessed to improve community conditions. However, there are also numerous ways in which hospitals and clinics can transform themselves to reduce health disparities, such as being more welcoming to patients of all races and ethnicities, building trust with patients before screening for social needs, and putting less of a burden on patients to accessing and paying for health care.
As health care institutions are increasingly held accountable for improving community conditions, they should also be tasked with looking inward and making sure their discrimination policies and financial assistance policies are not actively harming patients.