Health Equity: NewPublicHealth Q&A with Brian Smedley

Jun 30, 2011, 4:42 PM, Posted by NewPublicHealth

Improving health inequity was a key focus of many of the sessions at the recent American Public Health Association Midyear Meeting.

NewPublicHealth spoke with Brian Smedley, Ph.D., director of the Health Policy Institute at the Joint Center for Political and Economic Studies in Washington, D.C. Dr. Smedley spoke about health equity during the meeting.

NPH: What issues do you work on primarily?

Brian Smedley: The issue that I work on is persistent racial health inequities that literally span from the cradle to the grave in the form of things like higher rates of infant mortality among many population groups relative to more advantaged groups. So African Americans, American Indians, Pacific Islanders, and others, have two to three times higher rates of infant mortality as whites. We see a higher rate of chronic disease and disability among many populations of color relative to the majority population, and premature mortality.

NPH: At the American Public Health Association Midyear Meeting, you spoke about public health moving beyond just educating people about health issues. What specifically?

Brian Smedley: The work that so many folks do in public health has been important—educating people about risks, ensuring that folks who are at risk for certain diseases are screened and have appropriate access to needed services, and that we also ensure that risks to the population’s health are reduced. But we also need to do more, to work upstream and address those fundamental causes in the case of racial and ethnic health inequities.

NPH: What do you identify as the fundamental causes?

Brian Smedley: The root cause, as a lot of research shows, is residential segregation. And that’s surprising to a lot of people because we tend to think that we have made a lot of progress in this country in desegregating communities. We no longer have Jim Crow laws on the books, and that’s good. But the reality is that we remain a very segregated country. So my discussion at the APHA Midyear Meeting was about the depth of that segregation and the implications of segregation for health inequities. On average, highly segregated communities have a higher concentration of poverty. These are communities in many instances that expose people to more environmental health risks. They tend to lack access to healthy foods, and in many cases, these communities don’t have safe places to exercise. So, the very things that we are teaching people to do in terms of eating right, exercising, ensuring that people are more conscious of their health, are harder to do in much highly segregated, high poverty, communities.

NPH: And how do you think this should be addressed?

Brian Smedley: I argue that public health, in the face of all these challenges and in the face of budget cuts, needs to do a better job of working across sectors and engaging with others. Within government, we can work better across agencies. It’s not just public health that should be tackling these problems. Public health can partner with housing agencies, transportation agencies, to ensure that we support policies for mixed income housing, better housing mobility strategies so that people can move out of distressed communities, and housing mobility we think ought to be a public health intervention, one of many strategies we used to address segregation and poverty concentration. We can do place-based investments, trying to ensure that there are appropriate incentives for grocery stores or farmers markets to locate in food deserts, in communities that don’t have fruits and vegetables for sale.

In contrast what they do have is a lot of things that are bad for you--fast food, carry out restaurants, tobacco, liquor vendors--so we need to work with planning agencies, land use departments, so that we do a better job at reducing the concentration of these kinds of health risks in distressed communities. For example, not offering permits for fast food restaurants that already exist in abundance in some of these distressed communities; ensuring that when we plan parks and recreational facilities and transportation, that they’re exercise and pedestrian-friendly; and ensuring that we address disproportionate environmental contamination. So, it’s important that health departments at local, state, and federal levels work with a variety of other governmental agencies, but also the private sector. It is critically important that we work with business leaders, faith leaders, educators, community based organizations, and others, so that we are working toward health equity--even for those folks who are not in the health sector, per se, who do not see their work as related to health, but clearly their work has health consequences.

NPH: Is there a concern that you will improve neighborhoods, only to find that wealthier people move in and displace poorer people who then move to a different distressed neighborhood?

Brian Smedley: That’s a very important question because we can always invest in communities and make them attractive to live in, but then typically what happens is that people who have lived there for years or generations are then forced out, and gentrification happens. We see that happening in city after city. The important thing is to recognize that we can be smart about planning and growth. Investments in communities are great, it’s great to see new people coming into communities to revitalize them, but we shouldn’t displace people in a wholesale way. So we argue that we need to have both place-based investments and people-based investments. When those two forces come together, we reduce the risk that people can be either shut out of neighborhoods that are emerging in terms of new businesses and new amenities that make them attractive, and we also don’t leave behind people in distressed communities and allow a lucky few to get out of disadvantaged neighborhoods and into neighborhoods that are healthier.

NPH: Do you have examples of places where any of this is happening?

Brian Smedley: Yes, the Joint Center operates an initiative called Place Matters, where we’re focusing on building a capacity of leaders in 24 communities around the country to identify and address social, economic, and environmental conditions in communities that shape health, and that are the major drivers of health inequities. So there are some very important examples from our work where we think that Place Matters teams have made an important difference in advocating for equity across a range of policies.

For example, in King County, Washington, the county just passed Equity and Social Justice Ordinance, which requires that all laws, policies, and programs of the county be analyzed with an equity lens before they’re implemented. This is to ensure that vulnerable populations aren’t left behind as these new programs are implemented. So for example, if you’re doing a new housing development, the Equity and Social Justice Ordinance suggests that you might look at mixed income housing strategies, or you might try to figure out how to bring businesses in to work with low income housing.

There are other communities that are doing fabulous work. In Boston, the Boston Public Health Commission along with the Boston Place Matters team initiated a program called “What’s your health code?” This was an effort to raise awareness among people in the city that where you live is so important to your health. Again, because of patterns of residential segregation, there are some pockets, and this is true in almost every urban community, there are some pockets where you have high levels of segregation and high poverty. And businesses don’t want to invest there, there are few jobs, the quality of the schools tends to be poor, the retail food environment is poor. These are the kinds of issues that the “What’s your health code?” initiative attempted to shine a bright spotlight on and raise awareness among city residents.

So, we are doing a variety of things to raise public awareness and build public will for policy action to address equity and to address differences in health conditions in different communities. There is also engaging elected officials, collecting data to actually document the health status of these communities and to look at their relationship to neighborhood conditions that shape health. We think all of these kinds of things are important to build a national movement for health equity. And the action really is local, and the action is facilitated where we see strong public and private partnerships.

This commentary originally appeared on the RWJF New Public Health blog.