Re­defin­ing pub­lic health

Our view: In Bal­ti­more, re­duc­ing dis­par­i­ties in life ex­pectancy is not just about disease, it’s about eq­uity and jus­tice as well

Baltimore Sun - - FROM PAGE ONE -

It’s well known that the most im­por­tant health in­di­ca­tors of com­mu­ni­ties are of­ten closely re­lated to their de­mo­graph­ics. Peo­ple liv­ing in wealthy com­mu­ni­ties gen­er­ally tend to live longer, be more ac­tive and have fewer se­ri­ous chronic dis­eases than peo­ple liv­ing in poor com­mu­ni­ties. From a pub­lic health stand­point, that means some com­mu­ni­ties are health­ier on av­er­age than others, and the dif­fer­ences can be stark. In Bal­ti­more, for ex­am­ple, res­i­dents of the city’s wealth­i­est neigh­bor­hoods can ex­pect to live up to 20 years longer than their less af­flu­ent peers, even though their homes may be only a few miles apart.

The huge dis­par­i­ties that ex­ist along racial and class lines in Bal­ti­more rep­re­sent the big­gest chal­lenge fac­ing pub­lic health of­fi­cials. But clos­ing the gap in health out­comes be­tween the city’s most priv­i­leged and most dis­ad­van­taged res­i­dents isn’t just a mat­ter of visits to the doc­tor’s of­fice or emer­gency room ad­mis­sions. In­stead, it’s re­lated to a com­plex in­ter­ac­tion of so­cial, eco­nomic and en­vi­ron­men­tal fac­tors that to­gether help de­ter­mine peo­ple’s over­all phys­i­cal and men­tal well be­ing. And as a re­sult it’s not a prob­lem that can be “treated” without also ad­dress­ing the bar­ri­ers that keep peo­ple trapped in un­healthy sit­u­a­tions.

Bal­ti­more City Health Com­mis­sioner Dr. Leana Wen rec­og­nizes that pub­lic health work­ers aren’t so­cial en­gi­neers. They can’t wave a magic wand that will sud­denly make the re­sults of decades-old dis­crim­i­na­tion and struc­tural in­equal­i­ties dis­ap­pear. But she also rec­og­nizes that im­prov­ing pub­lic health in­volves more than just bet­ter med­i­cal care (though that cer­tainly is also needed). To be ef­fec­tive, pub­lic health must also ad­dress the is­sues of eq­uity and so­cial jus­tice that the dis­par­i­ties in health out­comes re­flect. It’s sim­ply not re­al­is­tic to ex­pect peo­ple to be able to lift them­selves out of poverty if they’re so ill they can’t work, or so trau­ma­tized by their ex­pe­ri­ences that they can’t be good par­ents.

That is why the long-term plan Dr. Wen re­leased last week is not so much a pro­gram­matic blue­print as a com­pre­hen­sive strat­egy state­ment for tack­ling the so­cial de­ter­mi­nants of Bal­ti­more’s health dis­par­i­ties. The plan, dubbed Healthy Bal­ti­more 2020, frankly ac­knowl­edges the role that race and class have played in cre­at­ing those dis­par­i­ties and pro­poses to cut them in half over the next decade by fo­cus­ing on four ar­eas: be­hav­ioral health, vi­o­lence preven­tion, chronic disease and “life course,” in­clud­ing the gap in life ex­pectancy be­tween the city’s wealth­i­est and poor­est neigh­bor­hoods. (Though the goals run for a decade, the health de­part­ment plans to eval­u­ate progress much sooner, hence Healthy Bal­ti­more 2020 rather than 2026.)

The plan is de­signed to iden­tify the ar­eas where the health de­part­ment can make the big­gest dif­fer­ence for res­i­dents, but it also rec­og­nizes the com­plex­ity of the task be­cause of how closely each of the el­e­ments over­laps with all the others. Be­hav­ioral City Health Com­mis­sioner Dr. Leana Wen un­veiled a strat­egy to ad­dress so­cial and eco­nomic de­ter­mi­nants of health. health, for ex­am­ple, fo­cuses on ad­dic­tion and sub­stance abuse, but it’s also tied to is­sues of vi­o­lence, poverty, men­tal ill­ness and the crim­i­nal jus­tice sys­tem. Sim­i­larly, life ex­pectancy is a func­tion not just of in­come but of chronic ill­nesses like heart disease and di­a­betes as well as drug over­doses and vi­o­lent crime.

Dr. Wen con­sid­ers all those fac­tors pub­lic health is­sues. A pre­ven­tive strat­egy to re­duce youth vi­o­lence, for ex­am­ple, might mean in­vest­ing more in early child­hood ed­u­ca­tion, pro­vid­ing eye­glasses to ev­ery child who needs them (as the city is now do­ing) or in­ter­ven­ing to keep chron­i­cally tru­ant stu­dents in school. Re­duc­ing car­dio-vas­cu­lar ill­ness, still the city’s num­ber one killer, might in­volve weight-loss or smok­ing-ces­sa­tion pro­grams, while clos­ing the gap in life-course dis­par­i­ties could in­volve ini­tia­tives to pro­tect young chil­dren from lead-paint poi­son­ing or more ef­fec­tive re­sponses to in­fec­tions like Zika and HIV.

Ob­vi­ously, the health de­part­ment can’t do all this on its own. The strat­egy be­hind Dr. Wen’s plan is to set city­wide goals on which all the area’s hos­pi­tals, clin­ics, so­cial ser­vice agen­cies and non­prof­its can col­lab­o­rate. Mod­ern medicine can per­form mir­a­cles when it comes to sav­ing the lives of ac­ci­dent vic­tims or crit­i­cally ill pa­tients. But that doesn’t al­ways trans­late into health­ier com­mu­ni­ties. Most of what keeps peo­ple alive doesn’t hap­pen in a doc­tor’s of­fice or a hospi­tal op­er­at­ing room. Bal­ti­more’s plan rec­og­nizes that re­duc­ing the dis­par­i­ties in long-term health out­comes along racial and class lines re­quires a com­mit­ment to eq­uity and jus­tice as well as to med­i­cal sci­ence, and the health de­part­ment should be com­mended for tak­ing on the huge chal­lenge of ad­dress­ing them both.


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