Culture of Health Blog

By harnessing trust, community health workers are becoming a powerful force for achieving health equity.

2020 was arguably one of the most difficult years in American history, challenging our resilience and surfacing enduring and systemic challenges to our collective health and well-being. As we continue to measure the pandemic’s impact on short- and long-term health, as well as other social and economic indicators, it is useful to note where we stood pre-pandemic. Understanding the conditions and trends that shaped our health before COVID-19 helps us assess whether the systems now being tested to respond to COVID-19 are robust. 

Last year, the Robert Wood Johnson Foundation (RWJF), along with the RAND Corporation, shared an update on the national set of measures that we have been using to track our journey toward a culture where every person has a fair and just opportunity to live the healthiest life possible. The goal of the Culture of Health measures is to offer signals of change with a focus on broader social and economic drivers of health, well-being, and equity, as well as the role all sectors play in influencing health outcomes. Developing a clearer picture of what is changing (or not) via the Culture of Health measures is useful for directing investments and identifying where, as a nation, we need to make progress. 

The RWJF Culture of Health Prize honors communities—urban, rural, tribal, large or small—that are beacons of hope and progress on creating places that enable health and well-being for all.

RWJF recognizes Culture of Health Prize winners for their broad definition of health and strong collaboration between community partners and residents, and across many sectors and levels of power. In a Culture of Health Prize community, those facing problems participate in shaping solutions. These communities commit to sustainable systems change and policy oriented long-term solutions. They create conditions that give everyone a fair and just opportunity to be as healthy as possible. They use data to measure and share progress and results.

Throughout 2020, winners used the strategies and networks they built to tackle the coronavirus and America’s reckoning with racial justice. We drew lessons and inspiration from these communities. In future posts we look forward to sharing how several Prize winners have put addressing systemic racism at the center of their work to promote health for all and how in other Prize communities, young people are forging networks, leading by example and finding new ways to advance health equity.

When acclaimed Barbadian author Karen Lord envisioned life on a small island during a pandemic in her story The Plague Doctors, she never imagined that within weeks of its publication, “history would become present, and fiction real life.” Lord’s short story in the Robert Wood Johnson Foundation’s (RWJF) first-ever book of fiction, Take Us to a Better Place, was written months before coronavirus emerged. With chilling prescience, it imagines a deadly infectious disease besetting the globe and follows Dr. Audra Lee as she fights to save her 6-year-old niece. The heroine confronts not just the disease but also a society that serves the wealthy at the expense of others.

This latter point was especially relevant here in the United States where COVID-19 hit communities of color dramatically harder than others. Centuries of structural racism have created numerous barriers to health including difficult living conditions; limited educational opportunity; high-risk jobs; lack of access to paid leave and disparities in care. Historical trauma has also driven deeply rooted mistrust of the medical establishment. All of these interconnected factors have magnified risk for both exposure to COVID-19 and the worst possible outcomes from the virus.

When Harris County voters approved a $2.5 billion bond to pay for more than 500 local flood-control projects, it seemed like a sound response to Hurricane Harvey. In 2017, the storm dropped 50 inches of rain in the Houston region, flooding some 166,000 homes. Based on a traditional return-on-investment analysis, it might also have appeared reasonable to spend that bond money in neighborhoods with the most expensive properties.

But county officials understood what that would mean—little protection for communities living with the most inadequate social, physical, and economic resources—many of whom are communities of color. And so, they chose a different policy approach. They gave preference to projects that ranked higher on the Centers for Disease Control and Prevention’s Social Vulnerability Index, which uses socioeconomic status, racial and ethnic status, household composition, housing, access to transportation, and other metrics to uncover potential vulnerability. The result: funds for flood control prioritized towards low-income communities and communities of color, those least able to recover from disasters.

Since we originally published this post in July 2019, more cities and countries are exploring ways of centering decision-making on human and planetary well-being—from Iceland, which revealed a new well-being framework, to Canada, which is exploring budget indicators that encompass happiness and well-being. 

Meanwhile, the COVID-19 pandemic is a reminder of how interconnected we are and always have been across lives, livelihoods, and well-being of communities and societies everywhere. In the United States, its spread has sharply illuminated inequitable conditions and ongoing systemic racism. Rates of infection and complications from the virus are significantly higher in communities of color, Native communities and tribes, immigrant communities, and other groups that live with higher rates of air pollution, spotty health insurance coverage, persistent health inequities, and lack of paid leave or a financial safety net to follow “stay home” public health orders. As we recover, prepare for potential future outbreaks and rebuild, we must prioritize equitable well-being as the ultimate goal. We might take a lesson from New Zealand, which adopted a well-being budget last year, has made significant investments in vital services like mental health and education as well as environmental protections, and has had an exceptionally low mortality rate and relatively rapid recovery from COVID-19.

Fifteen years ago the Robert Wood Johnson Foundation (RWJF) confronted a puzzling question that still resonates today: Why can some communities rebound after disasters, while others are unable to recover? We first studied this in the aftermath of Hurricane Katrina. Some parts of the Gulf Coast were irreparably damaged, while others were able to recover. Researchers at the RAND Corporation, with RWJF support, sought to identify the qualities that resilient communities shared after a natural disaster, such as the strength of collaborations among government and non-governmental organizations pre-disaster and robust plans to support those most affected. The same team later built on that research by examining community well-being after other types of disasters, including economic downturns and community violence. The researchers partnered with local governments and—time and again—found that prioritizing equity and building collaborative networks bolstered communities under extreme stress.

Editor's Note: The health impacts of our rapidly changing work environment are often overlooked. Since 2018, when this post was first published, we reported on the health equity implications of unstable incomes, unpredictable schedules, and lack of access to paid sick leave. In the wake of COVID-19, these questions about health equity are more important than ever. See what we’ve learned, and apply for funding to explore what the next five to 15 years may hold for workers.

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 a rideshare 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 an app that links workers with gigs. 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 2018 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 have no paid sick leave. Two-thirds lack access to employer-based health care benefits.

One of the most troubling aspects of the COVID-19 pandemic is how it is exacerbating long-standing and deeply rooted inequities in communities of color. Health disparities stemming from structural racism have contributed to COVID-19’s devastating toll on blacks and Latinos in America. Often overlooked is how heightened stress from this heavy burden is impacting mental health.

Yolo Akili Robinson, a recipient of the RWJF Award for Health Equity, is swiftly responding to this new reality the pandemic has created. As the executive director and founder of Black Emotional and Mental Health Collective (BEAM), he leads his colleagues in training health care providers and community activists, as well as non-mental health professionals (family members, peers, etc.) to address mental health needs in communities of color. Robinson is witnessing firsthand how lack of access to testing and fear of profiling while wearing face masks, among other issues are increasing toxic stress and straining mental health.

In the following Q&A, Robinson shares insights about the impact and implications of COVID-19 on mental health within communities of color.

In the Robert Wood Johnson Foundation's (RWJF) first-ever book of fiction, Take Us to a Better Place, published earlier this year, Dr. Karen Lord and nine other writers use the power of fiction to help us imagine paths that may lead to a healthier, better place for all--and those that may lead us astray.  

In her short story The Plague Doctors, Dr. Lord envisioned what life on a small island during a pandemic might look like. Now, she reflects on foreseeing some of today’s challenges and solutions in her latest blog post.

Note: The following post originally appeared on the William Temple Foundation Blog and has been republished with permission. 

Last year, I was asked to write a story about the future of health. Speculating about the future is my job, but for something this specific and important, I asked Dr. Adrian Charles to be my advisor for all things medical. We chose that perennial favourite of history and fiction—a pandemic—never guessing that within weeks of the story’s publication, history would become present, and fiction real life.