The following comments were submitted by Richard Besser, MD, Robert Wood Johnson Foundation (RWJF) President and CEO, in response to The Centers for Disease Control and Prevention (CDC) in the Department of Health and Human Services (HHS) invitation to submit comments in regard to the Surgeon General’s Call to Action: “Community Health and Prosperity.”
RWJF is the nation’s largest philanthropy dedicated to improving the health and well-being of all in America. Since 1972, we have worked with public and private-sector partners to advance the science of disease prevention and health promotion; train the next generation of health leaders; and support the development and implementation of policies and programs to foster better health. We are working alongside others to build a national Culture of Health that provides everyone in America a fair and just opportunity for health and well-being.
We know that health is inextricably tied to where we live, learn, work and play. But for too many of us, the prospects for good health are limited by things such as how much money we make, or discrimination we face.1 We recognize the Centers for Disease Control and Prevention’s definition of community health as “a multi-sector and multi-disciplinary collaborative enterprise that uses public health science, evidence-based strategies, and other approaches to engage and work with communities, in a culturally appropriate manner, to optimize the health and quality of life of all persons who live, work, or are otherwise active in a defined community or communities."2 Our work and research continue to show improving community health has the potential to prevent disease and injury and improve individual and community prosperity. We also recognize that the pursuit of community health requires a range of strategies including efforts to change community conditions in order to ensure everyone has the opportunity for better health and well-being. This means access to good jobs with fair pay, high performing schools, affordable and stable housing, safe neighborhoods, and quality medical care. We all benefit when everyone has the opportunity to live in a place where the conditions promote health and well-being. This is health equity—when we all have the opportunity to be as healthy as possible.
That is why, now, more than ever, we are convinced that this vision must be championed not solely by those in the health sector, but also by sectors such as retail corporations, the criminal justice system, real estate development, financial institutions and the technology sector, as well as organizations focused on civic engagement, equity, and economic prosperity. Community efforts to improve resident and employee health needs to be coupled with strategies to change the community conditions and policies that contribute to better health and prosperity—and there are important roles for private and public sector actors in each approach.
Communities that provide the conditions for health and opportunity are associated with not only better physical and mental health for residents, but also lower rates of obesity and smoking and higher levels of education.3 All of these factors contribute to a healthier, more productive workforce that misses fewer days of work and drives lower health care expenditures.4
We applaud the Office of the Surgeon General, in collaboration with the Centers for Disease Control and Prevention, for exploring this issue of how to work together to build up the health of all our communities so that everyone thrives. We are pleased to provide the following information which demonstrates how investments in community health have the potential to improve the health and prosperity of communities.
Section 1: Evidence that suggests that healthier communities help private sector businesses to be more efficient, profitable, successful, or competitive:
Research points to a link between a lack of health-promoting policies in communities (one component of conditions for community health), and an unhealthy workforce.5 Improved community conditions for health, such as clean air laws, access to an abundance of healthy food options, clean and safe neighborhoods, and opportunities for exercise and physical activity, can help positively influence health behaviors and lead to a more productive workforce.
But what is the business case for improving policies and conditions in communities to better support health? To help answer this question, RWJF has supported eight research teams examining the dynamic relationship between the innovation and drive of American businesses and entrepreneurs and the needs and health of the residents in communities that support them.6 Topics range from how poor health outcomes negatively influence businesses to how labeling and incentives can be used to change consumers’ healthy food purchasing behavior. Other studies provide evidence on the value of employers’ investments in the health and well-being of workers and their communities and inform strategies and best practices for engaging businesses to contribute to building a Culture of Health. For example, one of these RWJF funded research teams7, found that employees living in counties with poor community health outcomes had considerably higher rates of absenteeism and tardiness (ABT). In one company, the annual value of lost wages due to ABT was more than $1.3 million per year. Employees reported that poor social and community health outcomes (e.g., poverty, caregiving burdens, family dysfunction, drug use) resulted in “mental stress” leading to distraction, poor job performance, and more rarely, lapses in safety.4 As new evidence from these research studies emerge, we hope to share results with you and your team.
Section 2. Types of investments the private sector and local policy makers can consider to improve health and wellness of employees and families, and community well-being and prosperity.
While the unemployment rate is lower than it has been for many years, many families still struggle to earn steady and adequate income to meet their needs, achieve stable employment, and stable housing. Instability can also create a negative feedback loop, where stress and scarcity limit a person's executive functioning capabilities and affect their ability to achieve their goals.8
There is a need to develop strong public policies and programs to ensure stability and promote upward mobility and equity, using an approach that is driven and designed by the community. Policies that the private sector and local policymakers can work on together, and have a strong evidence base to improve the health and wellness of families and employees, include:
Paid Sick Leave: Employment that does not offer paid sick leave is plausibly linked to worse health outcomes including a higher risk of mortality through reducing one’s earnings and job productivity. If one continues to work while sick, a phenomenon known as “sickness presenteeism,"9 the duration and severity of illness may be lengthened, by not allowing for adequate medical attention and rest. In addition, paid sick leave may result in other positive effects, such as reducing the chances of spread of infectious diseases such as influenza to coworkers, and enabling care for sick children and elderly family members.10 Empirical studies have linked sickness presenteeism to a higher risk of serious coronary events.11 Furthermore, lack of paid sick leave has been shown to be a barrier to cancer screening and medical-care seeking in the United States.12
Paid Parental Leave: The beneficial effects of leave-taking for both parents and children are well-documented: paid parental leave policies have been associated with increased breastfeeding, decreased infant mortality, decreased postpartum depression, and increased immunizations.13 Researchers also found that providing family supportive programs like paid leave promotes the retention and recruitment of employees and increases worker productivity.14 Nearly 90 percent of businesses surveyed about the effects of California’s paid leave law said that the policy had either a positive effect on productivity or no noticeable effect.15 Despite these benefits, parents in the United States face incomplete job protection laws and a patchwork of state and local policies that provide partial pay for only some parents. As a result, only about 13 percent of private-sector workers in the United States have any paid leave through their jobs.16
Fair and Stable Scheduling: Employment instability is an increasingly important social problem in the United States that threatens the well-being of families and communities and poses considerable challenges to our safety net. Many workers experience unpredictable, variable, and nonstandard hours, temporary or contingent employment, and involuntary part-time positions. Precarious employment has also increased in the past 30 years, due to macroeconomic changes and the use of workplace policies that pass risk from the market onto workers. Research indicates that employment instability leads to economic insecurity for workers, their families, and their communities.17 Research has also shown that flexible scheduling improves employee health,18 work-life-balance19 and stress.20