Culture of Health Blog

In the Boston Edison neighborhood of Detroit, black children raised in low-income households have grown up to have an average household income of $28,000/year as adults, and under 1 percent of that population has been incarcerated as adults. In contiguous Dexter-Linwood, just one census tract to the north, the average earnings for the same group is $17,000/year, with adult incarceration rates hovering close to 8 percent.

If some neighborhoods lift children out of poverty, and others trap them there, the obvious next step is to figure out how these communities differ. Travel to Charlotte, N.C., which has one of the highest job growth rates in America. But data reveals (surprisingly) that availability of jobs and a strong regional economy do not translate to upward mobility in this region. Children who grew up in low-income families in Charlotte have one of the lowest economic mobility rates in the nation. What does help, according to the The Opportunity Atlas (the Atlas), is growing up with less discrimination, around people who have jobs and higher incomes—but only when those factors are found in their immediate neighborhood. If they are present a mile away, it doesn’t seem to matter much according to the data.

It’s only January and already, I’m counting down the days to spring when warm weather will arrive. The long, cold months of winter can be isolating—the snow and subzero temperatures make it difficult to get out and about. Winter is particularly tough for children who can’t go outside to play, and for newcomers from warmer climates who are not accustomed to the cold. For people who don’t have meaningful social connections, the cold weather season can exacerbate the isolation they face year-round.

Social isolation is a serious problem for many. It can lead to anxiety, depression, substance abuse, and even suicidal thoughts. Social isolation can impact our health in other ways too—by escalating unhealthy habits, stress, lack of sleep—and putting us at higher risk for coronary heart disease and stroke.

Fortunately, there are many creative ways in which communities across the United States are tackling social isolation and building a sense of community.

The small city of Hudson is nestled in Upstate New York and home to fewer than 7,000 people. The city was hit hard by deindustrialization in the late 20th century, facing economic decline as factories closed and industry jobs left. In recent years development has surged, with the opening of antique stores, restaurants and art galleries. The city has become a popular destination for tourists and second-home owners.

While our town is often celebrated as a story of revival, development has not benefited all of our community’s residents. For example, despite the presence of several high-end restaurants, there is still no grocery store. Rising costs have increased inequity, causing displacement for many families. Public funding is often directed toward maintaining Hudson as an attractive tourist destination versus addressing the needs of local youth and families.

Our organizations here in Hudson, Greater Hudson Promise Neighborhood and Kite’s Nest, have been working in partnership with many community organizations and individuals to improve conditions for youth and families.

There’s no bus service in his small town in rural North Carolina, so Dean* drives 10 miles to The Free Clinics ("Clinics") in Hendersonville every couple of weeks whenever he has money for gas.

Staff there helped him find affordable medications and treatments for cancer and for his shoulder, which he injured by falling 20 feet on a construction site. He’s unable to read due to learning disabilities, so they’ve also helped him find lawyers to file disability claims.

Dean is also one of the patients who attends the Clinics’ Bridges to Health ("Bridges") program, a drop-in group session where patients can discuss their social and emotional concerns as well as medical problems. He has battled depression since the age of five after enduring early childhood trauma. He credits the Bridges sessions, along with the Clinics’ holistic care, with easing his depression and improving his physical health, as well as “opening up avenues for me to get help.”

The amputation was scheduled for that day. John’s* uncontrolled diabetes had stopped blood flow to his lower leg. With the tissue starting to die, it seemed inevitable that his foot would have to be removed to save his life.

Thankfully, a team I work with had recently helped bring telehealth services to the rural Colorado hospital where John had been admitted. A cloud-based video system connected to electronic health records enabled his doctor to consult with an infectious disease specialist hundreds of miles away in Denver. The specialist suggested one last “cocktail” of antibiotics, to be administered by I.V. The protocol worked. John kept not only his foot, but also his livelihood as a rancher: his ability to graze cattle, grow wheat, and provide for his family.

When her regular job hours were cut, Lulu, who is in her 30s and lives in New York, couldn’t find a new full-time job. Instead she now has to contend with unsteady income and an erratic schedule juggling five jobs from different online apps to make ends meet. Cole, in his first week as an Uber driver in Atlanta, had to learn how to contend with intoxicated and belligerent passengers threatening his safety. Diana signed up to help with what had been described as a “moving job” on TaskRabbit. When she arrived, she had to decide whether it was safe for her to clean up what looked to her like medical waste.

Work is a powerful determinant of health. As these stories about taxi, care, and cleaning work from a new report show, it is a central organizing feature of our lives, our families, our neighborhoods, and our cities. And work—its schedules, demands, benefits, and pay—all formally and informally shape our opportunities to be healthy.

But the world of work is rapidly changing. Job instability and unpredictable earnings are a fact of life for millions. Regular schedules are disappearing. With “predictive scheduling,” a retail worker today is essentially on call, making everything from booking child care to getting a haircut impossible until the work schedule arrives. Health and other fringe benefits are less often tied to the job. Nearly six in ten low-wage workers today has no paid sick leave. Two-thirds lack access to employer-based health care benefits.

Medicaid is the largest health care program in the United States and impacts the lives of more than 76 million Americans, nearly one-quarter of the nation’s population. The program can play a powerful role in influencing the health and well-being of individuals and families.

State Medicaid programs can only be truly successful, however, if they are responsive to the needs and priorities of the clients they serve—not providers, but patients and their families. Medicaid officials understand this. However, in the resource- and time-constrained environments in which Medicaid staff operate, finding the right avenues for gathering meaningful consumer input can be a challenge.

The Robert Wood Johnson Foundation has been trying to address these challenges through its work to transform health and health care systems. As part of these efforts, the Foundation along with the Center for Health Care Strategies recently engaged experts, including representatives from across the patient advocacy world, around this issue. These experts include leaders from Altarum, American Cancer Society Cancer Action Network, Community Catalyst, Georgetown Center for Children and Families, Nonprofit Finance Fund, and the Patient Advocate Foundation.

Editor’s Note: Although foster care placement is sometimes necessary to ensure the safety and well-being of children, research indicates that keeping families together is generally better for children, parents, and the community. Working with the Corporation for Supportive Housing (CSH), the Robert Wood Johnson Foundation (RWJF) launched the Keeping Families Together (KFT) pilot in 2007 to explore whether supportive housing can help vulnerable families grow stronger, safer and healthier so that children—and their parents—may thrive. With the release of new findings from a federal demonstration project inspired by KFT, we are resurfacing this post.  

From too early an age, Irma faced a seemingly endless series of traumatic events that life threw at her as best she could—on her own.

But after a domestic crisis left her hospitalized, homeless, jobless, and in danger of losing her infant son, Irma finally received help from a supportive housing program that changed her life.

Keeping Families Together—the RWJF-supported model for the program that helped Irma turn her life around—has become my own personal touchstone for what building a Culture of Health should look like in the real world.

Irma’s story illustrates both the power of this model and the inner resilience that so many struggling families possess.

As the executive director of Philadelphia Physicians for Social Responsibility in the late 1990s, I worked closely with the local police department, the Women’s Law Project, and the district attorney. At the time, these forward-thinking professionals were frustrated. They were arresting the second and third generation of families involved in the criminal justice system. I knew some of these same individuals, and their histories as survivors of childhood trauma.

We were witnessing the downstream effects of unaddressed trauma in early childhood. Children who grew up traumatized landed in the juvenile justice system first and eventually within the criminal justice system as adults.

As a result, we knew we needed to find ways of building communities that would better support young children. Could we invest more upstream, in early childhood education, for example, and in doing so help prevent violence in our communities in the long-term?

Thanks to innovators like these and reams of new research on how early trauma and later violence affect individuals over a life course, we now understand that community conditions that impede children’s healthy development can impact everyone’s safety down the line.

When Dr. Rex Archer returned to his hometown of Kansas City, Missouri, to lead its health department in 1998, he was shocked by the city’s inequities. Life expectancy for white residents was 6.5 years longer than that of black residents. Gathering more data, he estimated that about half of the city’s annual deaths could be attributed to conditions in neighborhoods like segregation, poverty, violence, and a lack of education.

I also confronted stark disparities by neighborhood in my years as Philadelphia’s health commissioner, as does most every health commissioner/director across the country. It is truly unsettling to see how small differences in geography yield vast differences in health and longevity. In some places, access to healthy food, stable jobs, housing that is safe and affordable, quality education, and smoke-free environments are plentiful. In others, they are severely limited. Data can help us better understand the health disparities across our communities and provide a clearer picture of the biggest health challenges and opportunities we experience.