We expect differences in life expectancy between countries. But how do you explain a 28 year difference in life expectancy within a single city? A city with a universal health care system? Sir Michael Marmot posed this question in his keynote address to the American Public Health Association’s annual meeting while describing the difference in life expectancy between the most and least fortunate residents of Glasgow, Scotland.
The answer lies in the social and economic conditions that prevail in the different city neighborhoods. Inequities in access to good jobs, good education and adequate housing; experiences of discrimination and neighborhood conditions are powerful determinants of health.
In a response to the inequities that exist within the United States, public health departments across the country are attempting to reformat their programs to address the root causes of disparities. Alameda County, home of San Francisco, has set the standard for these programs. The Alameda County Public Health Department (ACPHD) social and health equity program has three components: community capacity building, local policy agenda and internal capacity building. These components work together to promote equity and social justice throughout the community, forming a solid foundation for improving community health.
Community Capacity Building
ACHPD has created a geographically focused program, called the City County Neighborhood Initiative, to address inequity in two of the worst-off areas of Oakland. The Initiative has conducted neighborhood surveys, created a community-administered mini-grant program, and offers a diverse set of training to community members covering everything from undoing racism, to emergency preparedness, to civic engagement. The public engagement processes will work in combination with its internal capacity building (see below) to develop a strategic plan to address inequities. This program stands out from past efforts of public health departments because of its brazen willingness to address power imbalance as a root cause of disease.
Local Policy Agenda
Like many public health departments, ACPHD had a history of working on state and federal public health issues, but had not invested in infrastructure to address local policy needs. To address this disconnect, they created a system of needs assessment, combined with internal and external stakeholder engagement. Their efforts led to successful advocacy against a public transit bus fare increase (PDF) for youth and disabled customers. They are now struggling to find ways to institutionalize this process. Traditionally, health departments have not used their evaluation and advocacy capacities to evaluate the equity of policies, nor has there been a systematic approach to reviewing local decisions outside the direct realm of health and human services. By extending their expertise to proposals that will indirectly impact community health, they offer a helpful check and balance for local policy making.
Internal Capacity Building
Neither community engagement nor policy work will achieve success without strong leaders within the health department. Indeed, Gayle Christopher, VP of the Kellogg Foundation (a funder of the ACPHD program), says that what we need most to bring about equity are “people who can imagine the world as it should be.” At the ACPHD, new employees receive training in social justice, current leaders are provided with management development opportunities, and all staff are eligible to self-select and become leadership fellows. As part of the program, leadership fellows took part in additional social justice dialogue sessions where they explored issues of race, class and gender-based discrimination, and joined senior managers and community partners in strategic planning sessions. The genius of this program lies in training internal staff to put the best practices that health departments regularly use with community organizations outside the department to use inside the health department.
What’s truly worldchanging about this project is that it changes the traditional focus of the health department: rather than defining its actions by problems, the ACPHD instead works to create a vision for the future. The breadth of ACPHD’s social and health equity program is its greatest strength. Achieving health equity is going to require institutional change, community change and policy change, and ACPHD is tackling each of these components head-on.
But those aspects alone probably won’t be enough to create an equitable society. In another session at APHA, Dr. Robert Ross, President & CEO of the California Endowment noted that in public health the biggest challenge is not finding interventions that work, but in "scaling up an innovation once we’ve found one that works.” What great about this program is that it builds the community, advocacy and leadership systems that would be needed to scale up a program and provides a way to begin to ask the question: What kinds of resources are needed to achieve equity across every neighborhood in a county? In a state? In a region? In a country?
Lori Williams is a community organizer for active living and sustainability in the Seattle area. She holds an MPH and PhD in Epidemiology and can usually be found riding her bike.
Photo credit: flickr/Metro Library Archive, Creative Commons license.
