V. Combating Structural Inequalities
From a structural perspective, housing, education, employment, transportation, and other systems interact to produce racialized outcomes; which, in turn, produce persistent health inequities. One of the most pressing fundamental causes of these disparities is residential segregation. Racial and ethnic minorities are more likely to live in segregated and high-poverty communities.
The research is clear--place matters. Where children and families live, learn, work and play affects their health. People thrive when they earn living wages and live in communities with safe affordable housing. They thrive when they have easy access to parks, playgrounds, and grocery stores that sell nutritious food.People cannot thrive in unhealthy environments and are therefore suffering from the many diseases and injuries, including stress, diabetes, cancer, high blood pressure, asthma, traffic injuries, and violence.
This suggests that policy interventions focused on social domains outside of the health care system are essential. These should include efforts to improve housing and community living conditions, food resources, nutrition options, conditions for exercise and recreation, and ultimately, to reduce economic and educational gaps. Almost all aspects of federal, state and local policy in education, transportation, housing, commerce, and criminal justice influence the health of residents; these aspects can have a disproportionate impact on marginalized communities. Governments that consider the health impacts of policy decisions are inherently engaging in health equity work.
The Obama administration is taking a number of promising steps to address the structural causes of health inequities. For instance, the federal government is developing and coordinating interagency plans that address health disparities in arenas outside the health care system. On June 10, 2010, President Obama signed an Executive Order creating a National Prevention Council. An important component of the ACA, the National Prevention Council brings together seventeen federal departments and agencies to plan and coordinate prevention efforts across the government and the nation through the development of a national prevention strategy. Significantly, promoting health equity for communities of color is one of the core principles guiding the strategy.
In a bold and clear language, the federal government recognizes the causal effects that structural factors have on minority health: “Health disparities are often linked to social, economic, or environmental disadvantages (e.g., less access to good jobs, unsafe neighborhoods, and lack of affordable transportation This federal recognition is welcome news for health equity advocates; and it is more than symbolic. The National Prevention Strategy commits the federal government to take action in a number of arenas including: supporting and expanding cross-agency activities to enhance access to high quality education, jobs, economic opportunity, and opportunities for healthy living; developing community-based interventions to reduce health disparities and health outcomes; identifying medically underserved areas that experience health disparities and aligning existing resources to meet these needs; and, supporting policies to reduce exposure to environmental and occupational hazards, among others.
Many of the federal agency initiatives have already started. For example, the U. S. Department of Agriculture's (USDA) Healthy Food Financing Initiative, aims to increase full-service grocery stores and other healthy food retailers in underserved urban and rural communities across America. Many of these neighborhoods and communities contain “food deserts”--a term that denotes limited access to affordable and nutritious foods. For decades, community activists have organized around the lack of access to healthy foods as an economic, health equity, and social justice issue. Empirical research has demonstrated that limited access to healthy food choices can lead to poor diets, higher levels of obesity, and other diet-related diseases. Predominantly African-American neighborhoods contain a disproportionate number of food deserts.
In concert with the USDA program, the ACA and several other Obama Administration initiatives takes additional important steps. HHS recently announced the availability of over $100 million in funding for grants created by the ACA to help communities address health disparities, including eliminating food deserts. These grants will allow communities to build on existing programs or create new initiatives. Empirical evidence confirms that community-based interventions have a potential for success, as measured by reported improvements in fruit and vegetable sales, consumer psychosocial behaviors, healthy food purchasing patterns, and consumer diet.
The Administration has committed to eliminating America's many food deserts in seven years, as part of the First Lady's Let's Move! campaign. The First Lady recently announced nationwide commitments from major food retailers to open or expand stores to help provide healthy and affordable food to millions of people living in underserved areas. Participating national retailers include: Wal-Mart, Walgreens, Supervalu, and regional supermarkets such as Brown's Super Stores in Philadelphia, and Calhoun Foods in Alabama and Tennessee. Together, they promised to open more than 500 stores that will employ tens of thousands of people. Additionally, the California Endowment has secured $200 million to finance healthy food projects in California. According to the organizations involved, all together, these commitments will serve 9.5 million individuals and create tens of thousands of jobs.
Several federal agencies are leading in other areas, including building and promoting healthy and safe community environments. For instance, the Environmental Protection Agency and Departments of Housing and Urban Development and Transportation are coordinating investments and aligning policies to give Americans more housing choices, make transportation systems more efficient and reliable, and support vibrant and healthy neighborhoods that attract businesses. This action marked a fundamental shift in the way the federal government structures its transportation, housing, and environmental spending, policies, and programs.
Currently, the three agencies have pilot programs in place in five communities where there is a convergence of structural factors that adverse affect health--multiple brownfield sites, economic distress, public transit needs, and the need for affordable housing. They are helping these communities clean up and reuse contaminated and vacant properties, which will provide new sustainable housing and transportation choices, create jobs, and expand economic opportunity. Since 2009, the agencies have dedicated more than $2.5 billion in assistance to more than 200 communities in 48 states to help meet housing and transportation goals; simultaneously, they have been reducing emissions, improving environmental quality, promoting equitable development, and improving health.
Advancing environment justice is a final concrete example of coordinated federal effort to address a structural problem that causes health inequity. Environmental contamination leads to costly health risks and discourages investments and development in affected communities. Racial and ethnic minority communities are disproportionately hurt by the presence of toxic waste dumps, industrial and occupational hazards. Recently, heads of 17 federal agencies signed a Memorandum of Understanding on Environmental Justice. The signatories agreed that environmental justice means that all communities facing pollution--particularly minority, low income and tribal communities--deserve the same degree of protection from environmental and health hazards, equal access to the federal decision-making process, and a healthy environment in which to live, learn, and work. The Memorandum requires each agency to identify and address any disproportionately high and adverse human health or environmental effects of its program's policies and activities on minority and low-income populations.
Separately, EPA Administrator Lisa Jackson has made environmental justice a priority and is in the process of integrating that policy into the agency's rulemaking and actions. The federal commitment is a welcome change from the policies of the previous administration, which allowed environmental justice to falter and become all but became invisible at the EPA.
In summary, federal efforts should continue to look to a broad range of social and economic policies, when crafting strategies to improve and equalize health status for all. Future efforts should focus more on community-level interventions to promote healthy behaviors and environments. State and federal agencies can exert legal and regulatory authority to reduce community-level health risks factors such as violence, public advertisement of tobacco products, the greater availability of alcohol, and the lack of access to health resources. Such interventions are vital for low-income communities and communities of color, which have fewer community resources for exercise (e.g., safe public parks and recreation centers), effective nutrition, and reduction of individual health risks.
