I'm Dr. Camara Phyllis Jones, past president of the American Public Health
Association. You may have heard the saying an ounce of prevention is worth a
pound of cure. When it comes to health and well-being, preserving health is
always best, but there's more to the story.
Imagine that someone is walking along and–whoops!–
they have just fallen off the cliff of good health. And if that were you, you'd
be relieved to find an ambulance at the bottom to speed you on to health care.
But what else can we do to protect you? How about a net to catch people?
But nets have holes, so some people may still fall through and the net is likely to rip
over time. What else can we do?
Clearly we need to build a fence at the top of the cliff to keep people from
falling in the first place. But if a lot of people are near the edge of the cliff,
even a really strong fence will not be enough. To keep everyone safe, we need to
move all the people away from the edge of the cliff. We do that by addressing
the drivers of poor health that go beyond our genes and beyond our personal
behaviors. Things like low wages, and under-resourced schools, and unsafe
housing. The environments in which we live, work, and play shape our health.
These are the social determinants of health. These things can either propel
people toward the cliff's edge or keep them at a safe distance from it.
But this cliff analogy is incomplete. We need to also realize that the cliff is
really three-dimensional, and then to notice that resources and people are not
evenly distributed along this cliff. At some parts of the cliff the ambulance at
the bottom may have a flat tire, or maybe there's no ambulance there at all.
Maybe there's no net, nor fence, and usually at those parts of the cliff the
people are being pushed closer to the edge. These are the differences that lead
to health disparities in a population. Differences in the speed and quality of
the ambulances represent differences in quality of care. Differences in the
presence of ambulances, nets, or fences, these represent differences in access to
care. And differences in the distance to the edge of the cliff represent
differences in the opportunities, and exposures, and stressors that make some
people and communities sicker than others. We need to ask a lot of questions:
Why is the cliff three-dimensional? Why do some parts of the cliff lack
ambulances or nets or fences? And why are some people being pushed closer to the
edge? It's because our economic system fails to provide an even playing field.
It's because racism, which is foundational to our nation's history, is
still with us and continues to cause profound harm to us all. And because
discrimination against people of color, women, immigrants, the LGBTQ community,
poor people, and others holds back our nation's health and well-being.
Everyone should have the opportunity to achieve good health. If we try to address
the social determinants of health without tackling these bigger systems of
structured inequity, like racism and sexism, we risk moving some people away
from the cliff's edge but not others. We risk making health disparities worse.
Experts at the Urban Institute are exploring how local, state, and national
policies have gotten us to this point, and what policy solutions inside and
outside the healthcare system can drive fundamental improvements in health and
well-being for everyone. We can all play a role. We can support our kid's teachers.
We can participate in neighborhood cleanups. We can volunteer with community
organizations. And let's recognize and dismantle racism, sexism, and the other
big systems that assign value and structure opportunity in ways that
undermine some groups more than others, but hurt us all.
Doing so will radically improve health and well-being for everyone by creating
the conditions all of us need to have the best health possible.