Communities in Action
Pathways to Health Equity
Committee on Community-Based Solutions to Promote
Health Equity in the United States
James N. Weinstein, Amy Geller, Yamrot Negussie,
and Alina Baciu, Editors
Board on Population Health and Public Health Practice
Health and Medicine Division
A Report of
THE NATIONAL ACADEMIES PRESS
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This activity was supported by the Robert Wood Johnson Foundation under contract number 72444. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
Library of Congress Cataloging-in-Publication Data
Names: Weinstein, James N., editor. | Geller, Amy (Amy B.), editor. | Negussie, Yamrot, editor. | Baciu, Alina, editor. | National Academies of Sciences, Engineering, and Medicine (U.S.). Committee on Community-Based Solutions to Promote Health Equity in the United States, issuing body.
Title: Communities in action : pathways to health equity / James N. Weinstein, Amy Geller, Yamrot Negussie, and Alina Baciu, editors.
Description: Washington, DC : National Academies Press, 2017. | Includes bibliographical references.
Identifiers: LCCN 2017005055| ISBN 9780309452960 (paperback) | ISBN 0309452961 (paperback) | ISBN 9780309452977 (pdf)
Subjects: | MESH: Health Equity | Healthcare Disparities | Community Health Planning | Health Promotion | Socioeconomic Factors | United States
Classification: LCC RA418 | NLM W 76 AA1 | DDC 362.1—dc23 LC record available at https://lccn.loc.gov/2017005055
Digital Object Identifier: 10.17226/24624
Additional copies of this publication are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu.
Copyright 2017 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2017. Communities in action: Pathways to health equity. Washington, DC: The National Academies Press. doi: 10.17226/24624.
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COMMITTEE ON COMMUNITY-BASED SOLUTIONS TO PROMOTE HEALTH EQUITY IN THE UNITED STATES
JAMES N. WEINSTEIN (Chair), Dartmouth-Hitchcock Health System
HORTENSIA DE LOS ANGELES AMARO, University of Southern California School of Social Work and Keck School of Medicine
ELIZABETH BACA, California Governor’s Office of Planning and Research
B. NED CALONGE, University of Colorado and The Colorado Trust
BECHARA CHOUCAIR, Kaiser Permanente (formerly Trinity Health until November 2016)
ALISON EVANS CUELLAR, George Mason University
ROBERT H. DUGGER, ReadyNation and Hanover Provident Capital, LLC
CHANDRA FORD, University of California, Los Angeles, Fielding School of Public Health
ROBERT GARCÍA, The City Project and Charles Drew University of Medicine and Science
HELENE D. GAYLE, McKinsey Social Initiative
ANDREW GRANT-THOMAS, EmbraceRace
SISTER CAROL KEEHAN, Catholic Health Association of the United States
CHRISTOPHER J. LYONS, University of New Mexico
KENT McGUIRE, Southern Education Foundation
JULIE MORITA, Chicago Department of Public Health
TIA POWELL, Montefiore Health System
LISBETH SCHORR, Center for the Study of Social Policy
NICK TILSEN, Thunder Valley Community Development Corporation
WILLIAM W. WYMAN, Wyman Consulting Associates, Inc.
AMY GELLER, Study Director
YAMROT NEGUSSIE, Research Associate
SOPHIE YANG, Research Assistant (from June 2016)
ANNA MARTIN, Senior Program Assistant
ALINA BACIU, Senior Program Officer (from October 2016)
MICAELA HALL, Intern (from June 2016 to August 2016)
HOPE HARE, Administrative Assistant
ROSE MARIE MARTINEZ, Senior Board Director
DORIS ROMERO, Financial Associate
National Academy of Medicine/American Academy of Nursing/American Nurses Association/American Nurses Foundation Distinguished Nurse Scholar-in-Residence
SUZANNE BAKKEN, Columbia University School of Nursing
James C. Puffer, M.D./American Board of Family Medicine Fellowship
KENDALL M. CAMPBELL, East Carolina University, Brody School of Medicine
ARIEL COLLINS, The City Project
DEBORAH KIMBELL, The Dartmouth Institute for Health Policy and Clinical Practice
NANCY NEGRETE, The City Project
RON SUSKIND, Harvard Law School
MAKANI THEMBA, Higher Ground Change Strategies
CESAR DE LA VEGA, The City Project
SUNMOO YOON, Columbia University
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
DOLORES ACEVEDO-GARCIA, Brandeis University
MARION DANIS, National Institutes of Health Clinical Center
JOSÉ J. ESCARCE, University of California, Los Angeles
RAUL GUPTA, West Virginia Bureau for Public Health
MEGAN HABERLE, Poverty and Race Research Action Council (PRRAC)
ROBERT A. HAHN, U.S. Centers for Disease Control and Prevention, Community Guide Branch
VALARIE BLUE BIRD JERNIGAN, University of Oklahoma Health Sciences Center
HOWARD KOH, Harvard T.H. Chan School of Public Health
MARGARET LEVI, Stanford University
MAHASIN S. MUJAHID, University of California, Berkeley
ADEWALE TROUTMAN, University of South Florida
WILLIAM A. VEGA, University of Southern California School of Social Work
CHRISTOPHER WILDEMAN, Cornell University
EARNESTINE WILLIS, Medical College of Wisconsin
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by JACK EBELER and SARA ROSENBAUM, the George Washington University Milken Institute School of Public Health. They were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
Our nation’s founders wrote that all people are created equal with the right to “life, liberty, and the pursuit of happiness.” Therefore, the principles of equality and equal opportunity are deeply rooted in our national values, and in the notion that everyone has a fair shot to succeed with hard work. However, our nation’s social and economic well-being depends in part on the well-being of its communities, and many are facing great and evolving challenges. Across the country there are communities with insufficient access to jobs, adequate transit, safe and affordable housing, parks and open space, healthy food options, or quality education—the necessary conditions and opportunities to fully thrive. This lack of opportunity is particularly evident in the disparities that exist in health status and health outcomes between different zip codes or census tracts.
Other wealthy developed countries outperform the United States in health status, despite our high level of spending on health care. For example, not only does the nation’s life expectancy when compared to peer nations lag behind,1 but life expectancy in the United States also varies dramatically—by roughly 15 years for men and 10 years for women—depending on income level, education, and where a person lives. In the poorest parts of the country, rates of obesity, heart disease, cancer, diabetes, stroke, and kidney disease are substantially higher than in more affluent regions. Tragically, infant mortality—the number of deaths under
1 National Research Council and Institute of Medicine. 2013. U.S. health in international perspective: Shorter lives, poorer health. Washington, DC: The National Academies Press.
1 year of age per 1,000 live births—is much higher in certain populations. In 2013, among non-Hispanic whites, 5.06 infants of every 1,000 live births died before their first birthday; among African Americans, that rate was double, at 11.1 per 1,000.2 Rates were also higher for Native American (7.61 per 1,000) and Puerto Rican (5.93 per 1,000) infants, as well as for low-income white infants in the Appalachian region, where in 2012, 7.6 infants died for every 1,000 live births.3 Research has shown that access to health care is important, but it is not sufficient to improve health outcomes (see, for example, Hood et al., 20164). To change the current state will require addressing the underlying social, economic, and environmental factors that contribute to health inequities. This report has examined the evidence on the current status of health disparities as well as the research examining the underlying conditions that lead to poor health and health inequities.
It will take local, state, and national leadership in the public and private sectors to improve the underlying conditions of inequity, and that will take time. However, there is great promise in communities that are taking action against health inequities across the United States. Moreover, advancements in the use of large disparate, population-based data with sophisticated analytic tools allow us to be more focused on possible solutions that tackle the multiple factors that shape health in communities. New partners in education, transportation, housing, planning, public health, business, and beyond are joining forces with community members to promote health equity. In this report the committee examines and shares examples of solutions implemented in several communities in the hope that other communities might adapt relevant elements and lessons learned to foster community-based approaches in their own unique environments. The report presents thorough evidence that health equity adds an important perspective in trying to improve community well-being, economic vitality, and social vibrancy.
During the committee’s time together, while reviewing the large body of scientific evidence and hearing from expert researchers on the social, economic, and environmental factors that affect health, several public health crises surfaced, including lead-contaminated water poisoning of children and other residents in Flint, Michigan, and the worsening opioid
2 Mathews, T. J., M. F. MacDorman, and M. E. Thoma. 2015. Infant mortality statistics from the 2013 period linked birth/infant death data set. Hyattsville, MD: National Center for Health Statistics.
3 Children’s Defense Fund. 2016. Ohio’s Appalachian children at a crossroads: A roadmap for action. Columbus, OH: Children’s Defense Fund-Ohio.
4 Hood, C. M., K. P. Gennuso, G. R. Swain, and B. B. Catlin. 2016. County health rankings: Relationships between determinant factors and health outcomes. American Journal of Preventive Medicine 50(2):129–135.
drug epidemic primarily affecting low-income people in rural communities across the country. These events are not the first of their kind, but they underscore the potential to galvanize public attention on health inequity at the community level.
In preparing this report, the committee took seriously its charge to review the state of health disparities and explore the underlying conditions and root causes that contribute to health inequity in order to inform much-needed efforts to reverse such inequities. The committee urges looking at disparities through the lens of health equity, as well as from other perspectives, to inform the changes necessary to improve the wellbeing of communities and our nation. The committee’s recommendations are offered with a focus on health equity as an essential component of health and well-being, but also with an awareness of the work at many levels necessary to address the myriad of challenges facing those most in need.
Health inequities are a problem for us all: the burden of disparities in health adversely affects our nation’s children, our business efficiency and competitiveness, our economic strength, national security, our standing in the world, and our national character and commitment to justice and fairness of opportunity.
This committee is grateful to the Robert Wood Johnson Foundation for the opportunity to delve deeply into the nature and causes of health inequity, to understand the critical need for solutions, and to examine the inspirational work that is being done in many communities to improve their well-being for themselves and for generations to come. It is the committee’s hope that this report will inform, educate, and ultimately inspire others to join in efforts across the nation so that members of all communities can enjoy life, liberty, and the pursuit of happiness undeterred by poor health.
James N. Weinstein, Chair
Committee on Community-Based Solutions to Promote Health Equity in the United States
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The committee wishes to acknowledge and thank the many individuals and organizations that contributed to the study process and the development of Communities in Action: Pathways to Health Equity. Their contributions significantly enriched the committee’s information gathering and enhanced the quality of this report.
To begin, the committee would like to thank the sponsor of this study. Support for the committee’s work was provided by the Robert Wood Johnson Foundation.
The committee found the perspectives of multiple individuals and groups immensely helpful in informing its deliberations through presentations and discussions that took place at the committee’s public meetings. The speakers whose presentations informed the committee’s work include, in order of appearance, Steven H. Woolf, Camara Jones, Rachel Davis, Richard Hofrichter, Edward Ehlinger, Martha Halko, Gregory Brown, Anna Ricklin, Sam Zimbabwe, Robert Bullard, Marianne Engelman Lado, Thomas LaVeist, David Zuckerman, Michelle Chuk Zamperetti, Katie Loovis, Doran Schrantz, Nina Wallerstein, Manal Aboelata, Beatriz Solís, and David Erickson. The public meeting agendas are provided in Appendix C.
The committee also greatly appreciated the input of the Association of State and Territorial Health Officials, National Association of County and City Health Officials, Mildred Thompson at PolicyLink, Prevention Institute, Liz Welch at Thunder Valley Community Development Corporation, and Richard Wood at the University of New Mexico.
The committee extends its utmost gratitude to the individuals who served as consultants to the committee by sharing their time and expertise during the writing of this report. They were instrumental to the study process as the committee explored the complex issues of health inequity and the role of community-based solutions in advancing equity. These individuals include Ariel Collins, Deborah Kimbell, Nancy Negrete, Ron Suskind, Makani Themba, Julie Troccio, Cesar De La Vega, William Weeks, and Sunmoo Yoon.
The committee is especially grateful to the nine inspiring communities highlighted in this report for generously sharing their experiences, challenges, and achievements. Specifically, the committee would like to thank Sasha Cotton and Gretchen Musicant (Minneapolis Blueprint for Action to Prevent Youth Violence); John Fairman and Neuaviska Stidhum (Delta Health Center); Juan Leyton, Andrew Seeder, and Harry Smith (Dudley Street Neighborhood Initiative); Mary Ellen Burns, Henrietta Muñoz, Sebastian Schreiner, and Jeniffer Richardson (Eastside Promise Neighborhood); Shoshanna Spector (Indianapolis Congregation Action Network); Patricia Bowie, Ron Brown, and Lila Guirguis (Magnolia Community Initiative); Trisha Chakrabarti and Dana Harvey (Mandela MarketPlace); Clarke Gocker, Ahmad Nieves, and Julia White (People United for Sustainable Housing, Buffalo); and Peggy Shepard (WE ACT for Environmental Justice).
The committee thanks the National Academies of Sciences, Engineering, and Medicine staff who contributed to the production of this report, including study staff Amy Geller, Yamrot Negussie, Sophie Yang, Anna Martin, Alina Baciu, Micaela Hall, Hope Hare, and Rose Marie Martinez. The committee thanks the National Academies communications and report production staff, including Greta Gorman, Nicole Joy, Sarah Kelley, and Tina Ritter. Thanks also to other staff of the Board on Population Health and Public Health Practice who provided occasional support. The committee was also fortunate to have support from Suzanne Bakken and Kendall Campbell, who contributed their time and expertise throughout the report development. This project received valuable assistance from Daniel Bearss and Ellen Kimmel (National Academies Research Center); Dana Korsen and Jennifer Walsh (Office of News and Public Information); Doris Romero (Office of Financial Administration); and Clyde Behney, Chelsea Frakes, Lauren Shern, and colleagues (Health and Medicine Division Executive Office and Office of Review and Communications).
Finally, the National Academies staff offers additional thanks to the executive assistants of committee members, without whom scheduling the multiple committee meetings and conference calls would have been nearly impossible: Sandra Aponte, Tiffany Eckert, Robbie Fox-Dunigan, Maria Gallegos, Chandra Halstead, Faith Johnston, Ruth Ann Keister, Lorena Maldonado, Cheryl Mance, Justin Nguyen, and Lauren Pell.
1 THE NEED TO PROMOTE HEALTH EQUITY
Disparities in Health Outcomes
Impacts of Health Inequity in the United States
Changing Social and Environmental Context
Momentum for Achieving Health Equity
2 THE STATE OF HEALTH DISPARITIES IN THE UNITED STATES
Addressing Health Inequity in Unique Populations
3 THE ROOT CAUSES OF HEALTH INEQUITY
How Structural Inequities, Social Determinants of Health, and Health Equity Connect
4 THE ROLE OF COMMUNITIES IN PROMOTING HEALTH EQUITY
Community Action: Vitally Necessary
The Evidence on Community-Based Efforts
Elements of Successful Community Efforts
Building Evidence to Support Community Action
5 EXAMPLES OF COMMUNITIES TACKLING HEALTH INEQUITY
Summary of Key Elements, Levers, Policies, and Stakeholders
Selection Process for Community Examples
6 POLICIES TO SUPPORT COMMUNITY SOLUTIONS
Taxation and Income Inequality
Housing and Urban Planning Policies
7 PARTNERS IN PROMOTING HEALTH EQUITY IN COMMUNITIES
Other Community-Based Partners
Cross-Sector Collaboration—Health in All Policies
8 COMMUNITY TOOLS TO PROMOTE HEALTH EQUITY
Crosscutting Tools and Processes
Making Health Equity a Shared Vision and Value
Increasing Community Capacity to Shape Health Outcomes
Fostering Multi-Sector Collaboration
A Native American Health: Historical and Legal Context
B Community-Level Indicators and Interactive Tools for Health Equity
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Acronyms and Abbreviations
associate of arts
Patient Protection and Affordable Care Act
American Civil Liberties Union
American Community Survey
American Hospital Association
Agency for Healthcare Research and Quality
acquired immune deficiency syndrome
American Planning Association
American Public Health Association
academic performance index
Association of Schools and Programs of Public Health
community benefits agreement
Congressional Budget Office
community-based participatory research
Columbia Center for Children’s Environmental Health
Community College Pathways
Community–Campus Partnerships for Health
child development associate
U.S. Centers for Disease Control and Prevention
community development corporation
common data element
Center for Environmental Health in Northern Manhattan
community health needs assessment
Community Information Now
community land trust
Centers for Medicare & Medicaid Services
community-oriented primary care
Council of Representative
Community Planning and Economic Development
Chicanos Por La Causa, Inc.
Clinical and Translational Science Award
New York City Department of Environmental Protection
Delta Health Center, Inc.
U.S. Department of Transportation
Dudley Street Neighborhood Initiative
East Bay Asian Local Development Corporation
U.S. Department of Education
Environmental Health and Justice Leadership Training
earned income tax credit
Environmental Justice Institute
U.S. Environmental Protection Agency
Eastside Promise Neighborhood
Every Student Succeeds Act
Federal Interagency Health Equity Team
federally qualified health center
gross domestic product
General Education Development
Government Performance Results Act
health enterprise zone
U.S. Department of Health and Human Services
Health In All Policies
human immunodeficiency virus
Health Resources and Services Administration
U.S. Department of Housing and Urban Development
Institute for Healthcare Improvement
Indian Health Service
Indianapolis Congregation Action Network
Institute of Medicine
Integrated Voter Engagement
Kansas City Health Department
Los Angeles County Department of Public Health
Leadership in Energy and Environmental Design
lesbian, gay, bisexual, and transgender
Low Income Housing Tax Credit
local organizing committee
Magnolia Community Initiative
military sexual trauma
Metropolitan Transit Authority
marine transfer station
National Association for the Advancement of Colored People
National Association of County and City Health Officials
National Alliance on Mental Illness
National Academies of Sciences, Engineering, and Medicine
National Center for Health Statistics
National Institute of Environmental Health Sciences
National Institutes of Health
National Partnership for Action to End Health Disparities
National People’s Action
National Park Service
National Research Council
Natural Resources Defense Council
National Survey on Drug Use and Health
National Task Force on Anchor Institutions
National Vital Statistics Survey
New York Public Interest Research Group
New York State Department of Health
New York State Transportation Equity Alliance
Office of Economic Opportunity
Program of All-inclusive Care for the Elderly
Promise and Choice Together
Partnership of Academicians and Communities for Translation
Parks after Dark
People Improving Communities through Organizing
Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences
posttraumatic stress disorder
People United for Sustainable Housing
Quitman County Development Organization
regional health equity council
Robert Wood Johnson Foundation
San Antonio Independent School District
Substance Abuse and Mental Health Services Administration
Seattle & King County Health Department
Supplemental Nutrition Assistance Program
Strong, Prosperous, and Resilient Communities Challenge
Standards for Quality Improvement Reporting Excellence
Supplemental Security Income
sexually transmitted disease
science, technology, engineering, and mathematics
tris(2-carboxyethyl)phosphine hydrochloride [flame retardant]
Transforming Communities Initiative
Transit Riders Action Committee
Uniform Data System
U.S. Department of Agriculture
University of Wisconsin Population Health Institute
U.S. Department of Veterans Affairs
Veterans Health Administration
Veterans Sustainable Agriculture Training Program
World Health Organization
Young Men’s Christian Association
|community||Any configuration of individuals, families, and groups whose values, characteristics, interests, geography, and/or social relations unite them in some way.|
|community-based solution||An action, policy, program, or law driven by the community that impacts community-level factors and promotes health equity.|
|health||A state of complete physical, mental, and social well-being and not merely the absence of disease.|
|health disparities||Differences that exist among specific population groups in the United States in the attainment of full health potential that can be measured by differences in incidence, prevalence, mortality, burden of disease, and other adverse health conditions.|
|health equity||The state in which everyone has the opportunity to attain full health potential and no one is disadvantaged from achieving this potential because of social position or any other socially defined circumstance.|
|public policy||A law, regulation, procedure, administrative action, incentive, or voluntary practice of governments and other institutions that affects a whole population.|
|social determinants of health||The conditions in the environments in which people live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. For the purposes of this report, the social determinants of health are education; employment; health systems and services; housing; income and wealth; the physical environment; public safety; the social environment; and transportation.|