Culture of Health Blog

My hometown of Eatonville, Florida, is known as “the town that Freedom built,” and for good reason: It was founded in 1887 by black freedmen on land they bought from a rare white landowner willing to sell large tracts to black people. Today, it’s the oldest historically black incorporated town in America. 

This place exists and has survived because of citizen leadership, vision, and persistence. Many people here, like me, have multigenerational ties to the town, and all of us take deep pride in Eatonville’s role in history. Many people who live or work here, or attend one of our many churches, have contributed to building a Culture of Health in town and winning recognition for our efforts from the state of Florida and the Robert Wood Johnson Foundation. But the spirit of collaboration that made that possible didn’t happen by accident. Eatonville has proactively empowered citizens to become leaders. We value the voices and contributions of all of our citizens.

This is how real systemic change happens.

Three years ago, it dawned on me that the concept of “well-being” might lead to a world of learning opportunities that could deepen and broaden the Robert Wood Johnson Foundation's (RWJF) work to build a Culture of Health. I was in Copenhagen, at the World Health Organization Regional Office for Europe, for a meeting about the United Nations Sustainable Development Goals and developing measures for well-being. As I listened, I realized that many of us in the United States who were working toward improved well-being were not considering what others around the globe were learning as they incorporated well-being into policy and practice.

We were missing out on insights, for example, from years of research and community engagement underpinning New Zealand’s well-being indicators and recently announced national well-being budget. Officially introduced in 2018, the country’s Living Standards Framework redefines the national government’s priorities and measures of progress. It expands beyond economics to also consider policy impacts on human and environmental well-being.

And just a week after the New Zealand budget made international news, the United Arab Emirates was in the headlines with its National Strategy for Wellbeing 2031, which aims to promote social cohesion and prosperity by improving quality of life.

There is growing evidence that safe and secure housing is a critical factor in achieving good health. Where we live can determine whether we’re connected to: safe places to play and be active; quality jobs and schools; and transportation to get us where we need to go. Yet millions of people in America live in substandard or overcrowded housing, temporary shelters, in cars, and on streets. Disadvantages also exist for the many living in residentially segregated neighborhoods isolated from opportunity. For them and others, the inability to access quality housing and neighborhoods deepens challenges and makes it much more difficult to be healthy and break out of poverty. 

Housing’s profound effect on health is often overlooked and misunderstood. This year, the Robert Wood Johnson Foundation (RWJF), led by President and CEO Richard Besser, MD, is shining a light on the link between housing and health. In his Annual Message, Besser discusses how safe and affordable housing supports positive outcomes across the lifespan—and how unsafe and insecure housing can deepen inequity and undermine a Culture of Health. 

He shares stories from housing initiatives across the country—from Boligee, Ala., to Chelsea, Mass., to San Antonio. These examples show that when we improve the quality and affordability of housing—health and lives also improve. Creating safe and affordable housing—as an essential part of comprehensive efforts to transform impoverished neighborhoods into places of opportunity—becomes a pathway to helping communities thrive.

Texas was the last of two states—Wyoming being the other—that treated truancy as a crime. Students and their parents faced court fines, and if penalties went unpaid, teen truants could be cuffed by constables and sent to jail.

None of this made any sense to me when 10 years ago, as San Antonio’s presiding municipal judge, I inadvertently began the process of changing the system across the state.

I had heard from a friend who handled attendance in one of the largest of San Antonio’s 16 school districts. This assistant principal was concerned because truancy cases filed in January could not be heard by justices of the peace until October. At the time, Bexar County, which includes the city of San Antonio, handled about 36,000 truancy cases a year.

I wondered why we weren’t figuring out why students were not going to school—as opposed to just jamming them into the school-to-prison pipeline. Troubled by that question and knowing there was nothing to preclude a municipal judge from hearing truancy cases, I stepped in to work through the backlog with another judge. We processed 1,200 cases over three weeks.

I could immediately tell the system was definitely broken.

This Sunday, families around the country will celebrate Father’s Day and pay tribute to the special caregivers in their lives. It’s a time when I find myself feeling especially grateful for all the positive ways my own father has influenced my life and the crucial role my husband plays in raising our daughters.

I also think about the many dads I have been lucky enough to meet throughout my life. These are the special dads who are determined to make sure that all kids--both their own and others--have every opportunity to grow up healthy and happy.

One such father who stands out for me is Steve Spencer. I learned of Steve a couple of years ago when he represented his home state of Oregon at Zero to Three’s Strolling Thunder event. The event brings together parents from across the country to meet their Members of Congress and share what babies and families need to thrive. As a single dad raising two boys, Steve is a knowledgeable and passionate advocate for the kind of supportive services parents rely on to give their kids the healthiest start.

Steve put it best when he outlined the day-to-day realities of parenting, "It's really hard to put focus in trying to figure out a way to keep the apartment and get food in these kids' bellies and so on and so forth on top of taking care of him [his four-month-old son] and not sleeping."

A veteran police officer in Cicero, Illinois, is quick with an answer when the therapist asks him: “What’s the worst thing you’ve witnessed on the job?”

Instantly, it’s 2010, an icy Valentine’s Day, and Officer Joseph Melone is staring in horror as flames engulf a three-story house. Melone is an arson specialist, and when the fire subsides, it’s his job to pick through the rubble. Seven people are missing. The oldest is 20; the youngest is that man’s newborn.

Melone finds the remains of the three-day-old baby.

“The 911 call from inside that place will haunt me until the day I die,” the 47-year-old Melone, now a sergeant, recalls. “You can hear the fire crackling around the caller and nobody could get in there.”

The story spills out from Melone as part of a training to give officers with the Cicero Police Department better tools for dealing with trauma in the lives of crime victims, as well as their own. The 8-hour course was built from scratch and tailored to the needs of the Cicero Police Department by local nonprofit staff from Youth Crossroads and the domestic violence agency Sarah’s Inn, as well as a psychologist from the local school district.

What does it take to build fair opportunities for health in rural communities? A passionate advocate shares firsthand insights, as well as a new funding opportunity aimed to help build on existing lessons.

Why States Matter

States have long been laboratories for innovations that influence the health and well-being of their residents. This role has only expanded with the greater flexibility being given to the states, especially as gridlock in Washington, D.C. inspires more local action. The bevvy of new governors and state legislators who took office early this year also widens the door to creativity.

Medicaid is perhaps the most familiar example of state leadership on health. With costs and decisions shared by state and federal governments, the program allows state policymakers to tailor strategies that meet the unique needs of their residents. Among other examples, efforts are underway in California to expand Medicaid access to undocumented adults, and in Montana to connect unemployed Medicaid beneficiaries to employment training and supports.

In Washington state and elsewhere, Medicaid dollars can now cover supportive housing services, while Michigan is among the states requiring Medicaid managed care organizations to submit detailed plans explaining how they address social determinants of health for their enrollees. All of this experimentation is happening as states struggle to control the growth of their health care spending—a balancing act of immense proportions.

Today, nearly 50 percent of children—over 35.5 million—are enrolled in Medicaid or the Children’s Health Insurance Program. These programs are essential to low-income children, and particularly children of color, who are more likely to lack access to other forms of health coverage. Both programs have been providing medical care to kids for about half a century.

However, the treatment of chronic illness, special needs, and adverse birth outcomes often receive higher priority attention than preventive interventions. This is because treatment for medically complex conditions drives costs in the health care system. So it is where state Medicaid agencies, and the managed care organizations (MCOs) that help them control cost, utilization and quality, invest their time and energy.

With most of the focus on treatment, it’s often difficult to make the case for community-based, family-centered prevention. But some states have started to implement prevention activities addressing childhood obesity and other areas of health promotion and disease prevention.

Change is not easy and it takes time. It can be especially challenging when we’re working to change policies and systems that have been in place for decades. But we know change is necessary because many people in America still face discrimination, live in poverty, and do not have the basics they need to be healthy.

We also know that some places are making progress to replace policies that are driving inequities with new policies that can help close health gaps. Places like Newark, N.J., where a unique collaboration led by the state’s largest health care system is accelerating a movement to transform the community’s food system.