In his 1994 essay “Health Is Membership,” Wendell Berry wrote, “The community in the fullest sense is the smallest unit of health ... to speak of the health of an isolated individual is a contradiction in terms.” Nestled within his statement is a bold challenge to America's dominant narrative about what creates health.
The Kentucky poet/farmer discovered, long before public health researchers did with the aid of Big Data and well-funded research, that health is mostly about living conditions and relationships. Individual habits and choices matter, but our health is largely determined by our community and our social circumstances.
Despite Berry's insight and the recent data that support it, this perspective is still not yet widely accepted or honored. The World Bank reports that the United States devotes more of its total gross domestic product to health care expenditures than any other major developed nation. The US Central Intelligence Agency's World Factbook shows us how little we get in return—we are 43rd in life expectancy and 58th in infant mortality.
The problem is not that we are not investing enough money on health; rather, it is how we are investing that money. Unlike countries with better health outcomes, we spend relatively little on keeping people healthy and devote massive amounts to treat people after they are sick.
Why do we stick with such a flawed strategy? Part of the answer lies in our country's dominant narrative about what creates health, a narrative that emanates from the cultural ideal of the independent, rugged individual. That narrative posits that staying healthy is the responsibility of individuals, and sick people are the responsibility of the health care system. This individual-centered perspective allows little room for community or social influences. Widespread use of this narrow frame explains the chronic underfunding of public health and social services in the United States, as well as the underresourcing of other sectors that influence health.
Not only does this individual-focused approach yield a poor return on investment but it also contributes to other negative outcomes including disparities in health status between racial and ethnic groups. My own state of Minnesota ranks high on many lists of healthy states; still, we have some of biggest health disparities in the country negatively affecting populations of color and American Indians. Health disparities not only affect the health of people and neighborhoods on the bottom of the health and socioeconomic ladder but also limit the potential of everyone in our society to achieve full health. We should be motivated not only by social justice but also by simple self-interest in addressing these disparities.
How can we in public health possibly take on the social and economic factors (the social determinants of health) responsible for these health disparities? How can we reduce and eliminate disparities that have been plaguing communities for decades or even centuries? How can we advance health equity so that everyone has the opportunity to achieve optimal health?
The answer lies in transforming the work of public health. It will require a more inclusive, community-oriented narrative about what creates health; sharing the responsibility of creating health with partners outside of the health care and public health sectors; and engaging communities to foster change in the conditions where people live and work. We can do this by embracing the Triple Aim of Health Equity (see Figure). Like the well-known Triple Aim of Health Care, this model highlights 3 major practices that are critical to the overall goal. The Triple Aim of Health Equity highlights the powerful influence of narrative, partnerships, and community.
The Triple Aim of Health Equity includes 3 core practices, or “aims:”
- Expand our understanding of what creates health.
- Implement a Health in All Policies approach with health equity as the goal.
- Strengthen the capacity of communities to create their own healthy future.
When I issued the 2016 ASTHO President's Challenge, I encouraged ASTHO members to join me in using the Triple Aim of Health Equity as a way to frame our public health work. Specifically, I urged all members to select at least 1 health equity–focused policy, program, or activity that could be initiated or implemented in the next year. Read more about the challenge on the ASTHO Web site at www.astho.org/health-equity/2016-challenge.
The Triple Aim of Health Equity recognizes that we must change the dominant narrative about what creates health. That is why the main focus of the 2016 ASTHO President's Challenge is on state health officials. With a “bully pulpit” that no one else possesses, each state health official has the opportunity to shape the narrative about health in his or her state.
Health care and public health are crucial to creating healthy communities, but the Triple Aim of Health Equity recognizes that many other partners are needed to advance health equity in our communities. Achieving health equity and optimal health for all requires inviting federal, state, and local government officials from “nonhealth” agencies and nonprofits and community groups focused on such issues as transportation, education, law enforcement, housing, agriculture, criminal justice, and economic development to partner with us in this work.
Most of all, to build healthy communities for generations to come, the community—not the health care system or even the public health community—must be in charge of health. This may be the biggest challenge for those of us in government because it will require a culture change in how we do our work. We can start the discussion, but we cannot fully steer it. We must listen to and learn from community voices, even as we ask them to expand their own perspectives. This collaboration and sharing of ideas may be the most challenging of all the elements in the Triple Aim of Health Equity, but it will be the most important factor as we work to advance health equity and help all people in our country achieve their full health potential.