Why ZIP Codes Matter: Advancing Health Equity in All Policies

Dec 1, 2014, 9:00 AM, Posted by Harry Heiman

Harry J. Heiman, MD, MPH, is an alumnus of the Robert Wood Johnson Foundation (RWJF) Health Policy Fellows program. He practiced clinical family medicine for more than 20 years and is currently director of health policy at the Satcher Health Leadership Institute, Morehouse School of Medicine. On December 5, Heiman will be a panelist when RWJF holds its first Scholars Forum: Disparities, Resilience, and Building a Culture of Health. Learn more.

The importance of place and geography and its impact on health is not a new concept in public health, but one that has been largely overlooked until recently. John Snow’s map of the London cholera outbreak in 1854, a precursor of today’s more sophisticated geo-spatial mapping, reminds us of the powerful impact public health has always had through assessment and intervention at the neighborhood level. Health care not only drains a disproportionate share of our resources, it also gets a disproportionate share of our attention. Access to affordable, quality health care is necessary, but not sufficient. While important and often life-saving to individuals, it is a relatively weak determinant of population health.[1]

A large body of research has demonstrated the importance of health behaviors, with almost half of all deaths attributable to tobacco, diet and sedentary lifestyle, alcohol and substance use, firearms, and sexual behavior. What has not been adequately understood or discussed is the influence of the social and economic environment on health behaviors. People in lower social classes are more likely to have unhealthy behaviors—something that is strongly associated with the lack of available healthy choices and the impact of increased psychosocial stress. The impact of stress is life-long, occurring not only in childhood, but prenatally, leading to what some experts refer to as inherited disadvantage.

Sandro Galea, MD, MPH, DrPH, and colleagues estimated the relative risk of death due to social factors—quantifying the impact of low education, racial segregation, low social support, poverty, and income inequality. These social factors accounted for more than a third of all deaths—more than smoking and obesity combined. Social determinants of health are compelling drivers of both health behaviors and health outcomes. A person’s ZIP code is a much more powerful predictor of health than their genetic code, especially in those communities and populations experiencing the greatest health disparities.

The U.S. Department of Health and Human Services has embraced this framework, defining health disparities as “health differences that are closely linked with social, economic, and/or environmental disadvantage.” Advancing health equity—assuring the conditions for everyone to reach the highest level of health—requires a "health in all policies" approach that addresses the structural and systemic conditions that create disadvantage. Broad population-based approaches alone, however, are inadequate to address the needs of those populations experiencing a disproportionate burden of risk or disease. Building equity into a "health in all policies" approach means targeting those communities experiencing the greatest disparities; it also means building health equity measures and metrics into policies and programs to ensure that we are having the intended impact on the population(s) of interest.

Achieving a Culture of Health and health equity will require a health and health equity-in-all-policies approach. This requires addressing factors across all sectors that frame the context in which people live to ensure that everyone has the opportunity to make healthy choices and reach the highest level of health.

1] McGinnis, MJ & Foege, WH. (1993). Actual Causes of Death in the United States. JAMA. 270(18):2207-2212 and Mokdad, A. et al. (2004). Actual Causes of Death in the United States 2000. JAMA. 291(10): 1238-1245. [return to text]

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.