Solving health problems requires more than health care, CRSP speaker says
“Health doesn’t happen just in hospitals and doctors’ offices,” said social scientist Jason Q. Purnell during his March 13 presentation at the Center for Race and Social Problems. The basic conditions of life in our poorest communities must be improved to create healthier behaviors and increase life expectancy there, he said —and that won’t happen “without changing the context in which that behavior happens.”
Health care, Purnell added, thus may not be the primary remedy for America’s health problems.
A psychologist teaching public health in the Brown School of Social Work at Washington University at St. Louis, Purnell outlined his research project, dubbed For the Sake of All (FSA), as he spoke on the topic “Translating Evidence Into Action for Community Health.”
FSA, begun in 2013 and still producing results, looks at social disparities and the social determinants of health: the conditions in which people are born, live, work and play. Our culture and political decisions also affect the health of communities, he pointed out.
Purnell displayed an FSA-created map of life expectancy at birth by ZIP code in St. Louis County, which contains the city of St. Louis and 89 other municipalities. The county includes Ferguson, Missouri, site of the 2014 police shooting of Michael Brown, which began a series of nationwide protests that centered on racial inequalities. Purnell compared the residents of ZIP code 63106 in the northern part of the county with residents of 63105, near Washington University. The two places are separated by less than 10 miles, but residents of the area surrounding the university have 18 more years of life expectancy than the poorer area to its north.
He calls this “the geography of inequality.” ZIP code 63106 is 95 percent African American and they have one-sixth the median income of the 63105 residents. “These might as well be different worlds,” Purnell said. “And just more and better health care is not going to fix these gaps.
“Conscious decisions, both historically and in the present day, created this reality,” he noted, citing practices promulgated by real estate dealers and mortgage lenders at banks as only the latest manifestation of racial separation in the U.S. Today the St. Louis metropolitan area is among the top 10 most segregated regions in the U.S. Cardiovascular disease death rates and cancer mortality rates follow this same segregation map, with higher rates in places where more poor African Americans live.
In fact, Purnell said, another study of American life expectancy 2001-14 found that the richest people live longer than the poorest. While this might be expected, the study also found that life expectancy continues to rise as income increases, all the way from the bottom to the top of the scale.
The study also showed that, among people in the lowest quartile of income, there was a great degree of variation in longevity depending on such health factors as obesity and smoking — but also simply on where people lived.
A gap also can be seen between those of different education levels, with college graduates gaining one and a half years of life expectancy.
“Education is one of the strongest … predictors of health outcomes that we have,” he noted. “But education is not enough.” Nationally, an African-American woman with a college education — even through graduate school — is still more likely to deliver a low birth-weight baby than a white woman with only a high school education.
In St. Louis County, he said, that translates into an infant mortality rate that is three times higher among African Americans.
Using FSA data, he said, 500 of the 3,000 deaths in St. Louis County in 2011 can be attributed to social determinants of health among African Americans 25 years and older who had higher rates of poverty and less than a high school education.
Researchers and academics knew about such social determinants of health prior to the FSA study, Purnell said. But they haven’t been able to communicate such facts to the public in ways that spark action.
He believes there is thus a need for civic education to influence policymakers and aid social service organizations in directing their missions toward the right solutions on the ground. The FSA project therefore has not only focused on determining what and where health disparities are found, he said, but on devising better ways to communicate these findings.
“Academics aren’t always the best at this kind of strategic communication,” he admitted — but policymakers aren’t reading academic papers.
Instead, FSA has focused its outreach to engage with people in its local communities — both those affected by the disparities and those who may not think they are involved at all.
“Treating community members as co-equals in the design, development and dissemination of public health projects” is vitally important, he added: “We’re not going to solve complex public health problems with a single organization.”
Don’t just catalog the latest health disparities, he recommended: “Actually getting into communities and implementing strategies or solutions that help move the needle” also is crucial.
Policymakers are most easily swayed by a narrative that stresses concrete community improvements that might come if health disparities are addressed, Purnell said. “It’s important not just to tell a moral story, but to tell an economic story. If the moral story would have held sway, we would have solved the problem by now.”
Thus, in reported FSA results he emphasizes a $4 billion impact that would come to the local economy if more African Americans graduated from high school and spent more money on everything from groceries to housing. “The business and policy people, their ears begin to perk up,” he said. FSA reports also emphasize a $65 million savings in health care, including mental health care, that would come from local black communities fostering better lives.
Among the FSA’s recommendations are: improving the quality of early childhood development programs; bringing health intervention programs to schools, along with programs to improve students’ mental health, nutrition and physical activities; investing in quality neighborhood services such as grocery stores, banks, parks and affordable and safe housing; and expanding chronic disease prevention and management.
The 2014 Michael Brown shooting in Ferguson brought the FSA’s conclusions much greater attention than Purnell had expected: “Suddenly this work takes on broader promise. People are looking to our data to find out what happened and why it happened.”
Still, he said: “Did any of this matter, is the question. Will messages reach intended audiences? Can community members be engaged, mobilized to respond to this information?” And will practices and policies change?
Thus, marketing has become Purnell’s emphasis since the FSA issued its first policy papers. FSA representatives have met with more than 200 St. Louis groups as well as local officials. They have produced a website and videos to promote their results and recommendations, and are active on social media. They’ve used the FSA recommendations to form different local discussion groups, as well as “action tool kits” for community groups to use, and now are creating groups to strategize implementation of FSA recommendations.
A balance of black and white people, reflecting St. Louis County demographics, has been involved in such efforts, he said. Even the local commission charged with reporting on the Ferguson shooting said the FSA was valuable in helping reach its conclusions, Purnell noted.
Although it is still too early to measure results from the FSA, he concluded, “we believe we’re reaching the intended audience.”
Updated March 30, 2017 at 9:56 am