In high school, I frustrated my history teacher with my repeated question: Why? Her approach of reciting what happened in the distant past was not nearly as interesting to me as understanding the mores and motives and tracing the consequences of what happened. Today, Google makes this information easy to find on my own.
For example, while driving through Orlando as a new resident in 2013, I saw children playing in a yard near the busy Interstate 4 (I-4) and State Route 408 interchange. I was horrified. There they were, enveloped in the particulates discharged from the hundreds of thousands of vehicles that used those busy highways daily. I thought they must have asthma! Why are their families living amid such pollution? Quick research answered the question: Construction of I-4 through Orlando in the early 1970s isolated Black residents of the Parramore neighborhood into an unhealthful environment.
Orlando is not the only American city where this has happened. Last fall, the US Department of Transportation announced grants to remove these transportation divides, reuniting some cities. However, it is not just a question of why we put major roadways where we put them. A comparison of old redlined city maps to today's maps illustrates how development affects health determinants such as clean air, neighborhood safety, walkability, and access to green spaces, to name just a few. Those patterns of built segregation, along with socioeconomic inequality and practices that prohibit access to opportunity, become manifest today as health outcomes that have more to do with zip code than genetics.
Health services researchers have long examined how health outcomes become a function of where people live. They continue to find intermingled and mutually reinforcing factors that influence health, including social and economic conditions, physical environment, and access to and quality of healthcare. These social and economic factors include community safety, air quality, housing, transit, education, income, employment, family, and social support.
COVID-19 morbidity and mortality statistics make the disparity especially glaring. One study found that people living in Chicago's Black-majority neighborhoods were twice as likely to test positive for COVID-19 than residents in the city's White-majority neighborhoods (Tung et al. 2021). These statistics also reflect historical policies and practices that have left some neighborhoods disinvested, or without the social capital and wherewithal to protest harmful industrial or city development. There clearly is a long history of health outcomes that relate to place, race, and income.
To shift my line of questioning: Who is in a position to change this reality? Integrating health services and systems allows healthcare organizations to leverage their economic power and resources and encourage integrated social services in underserved communities. With the move from fee-for-service to value-based reimbursement, there is an urgent need for healthcare leaders to prioritize impact factors beyond care delivery. The Affordable Care Act's requirement for a community health needs assessment and implementation plans reinforces this responsibility. The challenge is that even with the best efforts, success will not come overnight. Lasting success requires commitment from senior leadership, robust community partnerships, and medium- to long-term investments.
Some may argue that embracing the responsibility for socioeconomic conditions or tackling racism as a public health emergency is mission creep, and that it is a Sisyphean task. However, considering a patient's home address may determine their health outcomes, limiting care only to treatment of the presenting disease is myopic. There is also a moral imperative to address these health determinants—absent state or federal investment in comprehensive public health infrastructure and beyond emergency response. For healthcare organizations, whether the mission statement is either succinct or several paragraphs long, improving the health and well-being of the populations served is their raison d'etre.
Overwhelming evidence suggests that we in healthcare have been treating symptoms and are yet to tackle the root causes, a point that The Joint Commission has underscored with its new requirements for health disparities that go into effect in January 2023.
In This Issue
Frontiers of Health Services Management continues its three-part series on ESG (environmental, social, and governance) with an exploration of social criteria (the fall issue focused on environmental strategies; the spring issue will focus on governance). We showcase the initiatives that progressive healthcare organizations are taking to undo entrenched health inequities and deliver whole-person care.
Boston Medical Center (BMC) Health System CEO Kate Walsh describes BMC's Health Equity Accelerator, a concerted plan to bridge efforts both beyond and within their walls to root out race-based health inequity. BMC has given food prescriptions since 2001 and has arranged with community partners to find housing for patients with complex conditions since 2016—among many other accelerants to the cause. In her article, Walsh describes the work that led to BMC's recognition as a Lown Institute socially responsible hospital.
Emily Kryzer and Christopher M. Nolan, FACHE, leaders of BJC HealthCare's Community Health Improvement Team in St Louis, Missouri, share their practical strategies for transforming community socio economic conditions and addressing the root causes of health inequity along with their lessons learned. Recognizing that this work is a long journey, they share advice for other leaders and suggest ways to measure both processes and outcomes to record the wins necessary to keep up the momentum. Their advice for what not to do is a clear endorsement of partnership: “Don't go at this alone.”
Denise Brooks-Williams, FACHE, senior vice president and CEO of market operations at Henry Ford Health System (HFH), shares the bold actions HFH is taking to tackle social and racial injustices. Her article describes programs to achieve health equity, diversify the healthcare professional pipeline, advocate for social justice, and empower the Detroit community.
Randy Oostra, DM, FACHE, recently retired president and CEO of ProMedica, recounts his organization's work as a community anchor in Toledo, Ohio. He describes strategies to revitalize Toledo's UpTown, a neighborhood long starved of development. ProMedica's initiatives include job training, housing, and financial coaching programs to meet the nonmedical needs of the population served. Recognizing that employees also may have unmet social needs, Oostra explains how employee assessments can inform wellness and benefit offerings and improve engagement.
Janice G. Murphy, FACHE, president and CEO of Sisters of Charity Health System in Cleveland, Ohio, guides us through their innovative reverse ride-along program for medical residents. By venturing into inner-city areas, the young doctors get proximity to the communities they serve and a greater understanding of the unique needs of the patient populations. In reverse ride-alongs, participants cross bridges over perceived barriers to care and cocreate solutions to improve health outcomes for the community. In so doing, the next generation of physicians comes to fully appreciate culturally responsive care delivered beyond hospital walls.
The case study by Christina Campos, FACHE, presents multifaceted responses to the expansive challenges that rural hospitals face. At the 10-bed Guadalupe County Hospital in Santa Rosa, New Mexico, Campos illustrates how the social determinants of health become magnified in rural areas. Her piece highlights the special inflection points for social health determinants that require urgent attention in this context.
Innovative, collaborative, and inspiring strategies like those described in this issue are urgently needed to realize optimal health outcomes. When future scholars scrutinize the current era, they should be able to understand what we in healthcare did to help and why we did it. Today's actions will result in tangible and intangible consequences reflected in the world we leave to them.
Until then, let's continue the conversation at [email protected].
Tung E. L., Peek M. E., Rivas M. A., Yang J. P., Volerman A.. 2021. “Association of Neighborhood Disadvantage with Racial Disparities in COVID-19 Positivity in Chicago: Study Examines the Association of Neighborhood Disadvantage with Racial Disparities in COVID-19 Positivity in Chicago.” Health Affairs 40 (11): 1784–91. https://doi.org/10.1377/hlthaff.2021.00695