Role Models

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I recently discovered that if you 'like' your role models on Facebook — say Michelle Obama or Amanda Palmer — they will leave messages on your wall just like you're actually friends. So you can imagine my excitement when I signed in this morning to see that Saul Alinsky — the esteemed community organizer himself — had left me a message. He's been dead for over 30 years! Inspired, I grabbed my yellowed copy of Reveille for Radicals on the way out the door, and, after wedging into a seat on the bus, opened to a random page and began reading:

“The fundamental issue that will resolve the fate of democracy is whether or not we really believe in democracy. Democracy as a way of life has been intellectually accepted but emotionally rejected. The democratic way of life is predicated upon faith [in] mankind, yet few leaders of democracy really possess faith in the people. If anything, our democratic way of life is permeated by man’s fear of man."

Those familiar with Saul Alinksy know he catalyzed the formation of numerous People’s Organizations that called for social justice at a time when racial tension in American cities was high. His book made me recall toying with the idea of a blog on segregation — but deciding against it. After all, who wants to hear about segregation from a girl who grew up in white, suburban America? Well, my hometown may have been an integration fail, but I like to believe we had good values, and since Saul would approve, I’m writing this blog anyway.

On Racism, Segregation and Health

Let’s be real here: It’s impossible to talk about the issue of segregation without first acknowledging that racism is as real today as it was in the 1950s. Since I am no expert on the topic, I thought I would share a useful framework developed by social scientist Camara Jones. According to Jones, there are three levels of racism: Institutionalized racism refers to unequal access to power and resources resulting from societal structures. Examples include unjust public policies or being denied a promotion regardless of merit. Personally mediated racism takes the form of prejudice and discrimination, such as being treated with undue suspicion. Finally, internalized racism occurs when people begin to believe the false and devaluing messages directed at them. For instance, a teen believing she is not “good enough” to go to college. Racism has hindered mobility across neighborhoods — in spite of civil rights legislation and housing policy reforms that People’s Organizations fought for.

Racial segregation affects community health through multiple pathways, such as the physical environment and resource availability. Consider that hazardous fixtures such as dumps and freeways are disproportionately located in low-income black and Hispanic communities. Racial minorities living in segregated neighborhoods also tend to have limited educational opportunities. This has an indirect effect on health by denying youth the resources and means of attaining an optimal standard of living in the future.

There is still relatively little known about the direct impact of racism on physical and mental health. This is in part because of the challenge social scientists face in measuring experiences of racial discrimination. No standardized methodology exists for how to go about asking people to report their experiences with racism. Further, self-reported measures rely on subjective evidence, meaning the respondent must “perceive” discrimination — something that may prove difficult given the degree to which racism is internalized.

Segregation Declines, but Disparities Remain

Segregation is viewed by some as a driving force behind many of the racial inequalities that persist today. So it was the talk of the nation when a recent study from the Manhattan Institute described a decline in segregation since its peak in 1970, a trend the authors attribute to federal housing policy reform and changes in racial attitudes.

According to the authors, the decline in segregation is primarily due to African-Americans leaving segregated cities in the north and moving to less segregated cities and suburbs in the Sun Belt — as opposed to gentrification or an influx of immigrants into black neighborhoods. “[For] every prominent example of a black neighborhood undergoing gentrification — in Harlem, Roxbury or Columbia Heights — there are countless more neighborhoods witnessing no such trend," they wrote. "Instead, the dominant trend in predominantly black neighborhoods nationwide has been population loss.” In other words, these neighborhoods are still segregated, but there are fewer people living in them.

The authors measured a decrease from 80 percent (1970) to 55 percent (2010) on the index of dissimilarity, which they used to measure the evenness with which black and white residents were distributed across neighborhoods in the United States. The measure represents the percent of either group who would have to change neighborhoods in order to achieve a balance. What puzzled the authors was that when they measured dissimilarity for individual metropolitan areas, decreases were relatively small — so why the national decline?

This is where the power of maps comes in. It turns out the measures for each metropolitan area failed to capture the effect of residents relocating to other regions. In 1970, only two Sun Belt cities appeared in the top ten list of metropolitan areas with the largest black populations. In 2010, half of the cities on this list were in the Sun Belt. The authors concluded that integration has occurred “partly through the process of neighborhood change but largely by the establishment of new neighborhoods with an inherently integrated character.”

The takeaway here is that racial inequalities persist despite a decline in black/white residential segregation — and if the authors are going to define segregation narrowly in terms of where people live, don't you wonder about the experiences of other minority groups?

I'd like to delve deeper into this subject, but dinner awaits. So instead, I'll leave you with another random quote before putting Alinsky back on the shelf: “Even the best outside organizer, one who has democratic convictions and practices them, who has complete faith in the people and their leadership, cannot build a People’s Organization to a complete structure. He can serve as a stimulus, a catalytic agent, and render invaluable service in the initial stages of organization. He can lead in the laying down of the foundations — but only the people and their own leaders can build a People’s Organization.”

Reveille for Radicals!

The Map is Mightier than the Word

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My first encounter with maps was in sixth grade social studies class. Our assignment was to shade every country in Europe a different color – a class exercise that went awry when the U.S.S.R. was dissolved and we’d erased our maps so many times that Europe was either missing or took on the glow of a Mark Rothko painting.

This was right around the time that the first global positioning system became operational and the census bureau implemented TIGER. This bastion to data nerds assigned a unique position to every road, street address, boundary and waterway in our country – creating a mix-master-map that we all can access. TIGER laid the groundwork for Yahoo, Mapquest, Google Earth, Bing and other web mapping services that were hard to imagine back when maps were drawn on paper and “gaming” meant shooting four-pixel deer on Oregon Trail.

My (80s) generation witnessed an entire geospatial revolution from beginning to end, all while burning mixed tapes and coveting Molly Ringwald's job at the record store, and boy does that make me feel dated. So if the words “geographic information system” make you uncomfortable, then this blog is for you. It turns out geospatial maps are free and easy to create, and with a little practice, even those of us who are old enough to remember when Nirvana topped the Billboard charts can use them to tell compelling stories about public health.

Putting Community Health on the Map

Over the past few years President Obama has promoted an open government initiative that encourages policymakers to be more transparent and collaborative. The initiative has supported public-private partnerships in building applications that will make government health data more publicly available. This is important because for years, mapping health data has been too expensive and laborious for the average Joe. Thanks to these partnerships, we are seeing more online maps that can be customized with the click of a button – maps rich with information ranging from disease rates (John Snow, maybe the Charles River is a concern) to whether your neighbors are eating their veggies (love my Boston Organics).

An oldie-but-goodie is Bing Health Maps, created in 2010 as part of the U.S. Health and Human Services Community Health Data Initiative. The application essentially mashes up HHS health data with Bing maps, allowing us to display dozens of community health indicators by state and county. Using the map is easy: Select a state and health indicator from the drop-downs. Once the map is populated with data and counties are shaded, you can click on any county to view a list of health indicators.

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Since 2010, HHS has launched health challenges encouraging government and the public sector to work together to improve the health of Americans. The newest challenges include a mobile health application to help consumers visualize health care quality and a web application to enable community use of data on cancer prevention and control. I give a virtual fist bump to President and First Lady Obama for putting community health on the map!

Maps as Centerpieces for Public Health Dialogue

The proliferation of free, user-friendly technology for geocoding and mapping data is enabling us to tell stories about community health using pictures and animations that are (literally) worth a thousand words. The following maps, for example, generated much dialogue and deliberation among community members and public health providers in Baltimore, MD:

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The red shading on the upper map highlights the ideal service area of a Baltimore-area clinic based on the location of medically underserved areas. The orange shading on the lower map, in turn, highlights the actual service area. The juxtaposition of these maps ignited a debate over whether the clinic was meeting the needs of underserved areas – as well as explanations for the previously unrecognized service area range. As the investigators wrote, the maps led stakeholders to "strategize around unrecognized patterns of clinical use, including unexpected use by remote populations."

Participatory interpretation of the mapped data was described as essential to understanding why some communities were accessing health services and others were not. "Interaction between administrators, clinicians, and community members allowed the unique knowledge and expertise of each – whether in data, neighborhood geographies, [or] community history – to capture the real power of mapped data."

The following is another example of maps serving as centerpieces for community health dialogue. In this case maps were used to identify areas within a transitioning community in Charlotte, NC, with significant health needs. Maps were again created and interpreted using a participatory approach: The investigators developed a research network that "brought together health providers, community members, and researchers with the shared goal of improving community health by increasing access to primary care."

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To create this map, the research network's community advisory board met to decide which community attributes to take into account when assessing an area's need for primary care. Ultimately the network chose five attributes: socioeconomic status, population density, insurance status, patterns of emergency department use, and primary care safety net. A separate map was created for each attribute, with each census tract shaded according to score. A composite map was then compiled from the separate map layers to show census tracts with the greatest health need. "We were able to provide detailed geographic information indicating where services were required and where their location would probably have the greatest impact," the authors wrote.

On Digital Maps and Mixed Tapes

These examples underscore the importance of a community perspective on health and the power of geographic communication to bring health data alive and make it more accessible.

This may be a good point at which to turn the conversation over to you. What are your thoughts on President Obama's "open data" initiative and the potential to make health information more publicly available? In what other ways are folks using geographic information systems? Please join the conversation – and be sure to share your favorite songs from any mixed tapes you made in the 1990s.

Map Example Sources:

Bazemore A, Phillips RL, Miyoshi T. Harnessing geographic information systems to enable community-oriented primary care. Journal of the American Board of Family Medicine 2010; 23(1): 22-31.

Dulin MF et al. Geographic information systems demonstrating primary care needs for a transitioning hispanic community. Journal of the American Board of Family Medicine 2010; 23(1): 109-120.

Maps were reproduced with written permission from the corresponding authors and journal.

Taking a Stand for Community Health

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Welcome to The People’s Health — a blog where I'll be sharing my curiosity as an aspiring epidemiologist, devoted yogini and cowgirl-at-heart. The philosophy is no different than Real Health Policy; this is about people, not politics.

I recently read a testimonial by a yogi who said “when it feels like your world is turned upside down, the best thing to do is stand on your head so you can see things clearly.” A community perspective on health may sound simplistic, but perhaps it isn’t until we are forced to look at familiar issues in a new way that we can fully appreciate what it takes to build healthier communities.

Health is a very personal experience shaped our cells at the most micro level, the planet we live on at the most global level, and millions of layers in between. Within those layers is our community — where we spend our time and the people (and animals) we spend our time with. On the one hand, our community reflects who we are. But on the other hand, our community influences who we are. You may find this idea of community influence to be radical at best. After all, we're free agents. Communities are not living things (although as former tropical ecology student, I would argue that they are). And communities don't get sick — people do.

Dear Boston: You're Breaking my Heart

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If you are one of those free agents who call the idea of a living community radical at best, I challenge you to a head-stand or a reading from Geoffrey Rose's Strategy of Preventive Medicine. Both present their own challenges, but you may look at things a little differently.

Rose showed that what accounts for variations in health within a community often differs from what accounts for variations in health between communities. Studying why similar people may have very different health outcomes, depending upon where they live and who they socialize with, reveals important clues about staying healthy. Take heart disease for example. For those of us in North America, smoking is the factor that most influences our chances of heart disease. Yet people living in Japan have lower rates of heart disease — despite smoking more Marlboros than we cowgirls out West. What's surprising is that when people from Japan move to North America, their risk of heart disease gradually increases to match that of other North Americans. It goes to show that health is not only influenced by our personal attributes, but also by the societies that shape who we are.

You might also consider epidemiologist Michael Marmot's insightful exploration of the influence of income on health. We know that health of individuals in the United States varies by income and that people from wealthier neighborhoods live longer than people from poorer neighborhoods. What really matters, then? My income or that of my neighbors?

If you’d asked me five years ago, I would have said that only my own income matters, because you can't assume my wallet is as thick as my neighbor's. But as Sir Marmot points out, I would have only been partly right. While individual income does matter most, neighborhood income has a modest effect on life expectancy that is independent from individual income. For better or for worse, where we live and who we spend time with influences our thoughts and behaviors — and in turn our health.

Health, Wealth and the Neighborhood Paradox

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So why don't we all just pack our bags, move to nicer neighborhoods and call it a day? As critical reflections on housing mobility programs infer, building healthier communities around us may be equally as beneficial. To quote Charles Bukowski, "If you think I’ve gone crazy, try picking a flower from the garden of your neighbor." It's hard to feel socially included when your new neighbors are outside building fences.

Consider what I'll call the neighborhood paradox: Why is it that one study could show that low-income families living in poor neighborhoods have higher rates of mortality than low-income families living in wealthier neighborhoods — and another could show the opposite? What this paradox seems to illustrate is that living in a wealthy community is no guarantee that you'll derive the same benefits as your neighbors; just because resources and social opportunities are available does not mean everyone has equal access to them.

Individuals from the first study undoubtedly experienced the benefits of living in a wealthy community, be they supermarkets where you can buy healthy food at an affordable price (better nutrition); fewer environmental toxins (lower cancer risk); safe living and working spaces (lower levels of stress); adequate housing (lower rates of asthma); job opportunities and good public schools (means to provide for yourself). However, individuals from the second study may have faced exclusion from the same benefits that supported the health of their neighbors. "In a society where both participation and receipt of services depend heavily on individual income, its lack is serious," Sir Marmot wrote.

So there you have it: a case for thinking not only about "an apple a day," but also about the health of our communities. Our individual attributes and the attributes of our community each have a distinct impact on our health. And while people in wealthier neighborhoods are generally healthier than people in poorer neighborhoods, focusing resources on the former may do more to destroy communities than to promote health. This makes the task of building healthier communities that we all have equal opportunity to participate in an important goal.

On a Sentimental Note...

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While living in Austin, Texas, I took a class at a curious place known as Casa de Luz, where residents were challenged to rethink the concepts of health and wellness and consider our personal responsibilities in building more integral communities.

During the last class we were each asked to stand up and complete the sentence “I stand for _________.” Just believe me when I say it’s awkward.

My first attempt was a crash and burn: I avoided the exercise entirely by stretching partially out of my chair and beginning with a passive “well I guess.” The consequence was having to stand at the front of the room and repeat the sentence twice, in my loudest voice, without the “well I guess” part. For someone like me, who hates being the center of attention, belting this out was at once mortifying and empowering: “I stand for creative means of bringing a voice to marginalized communities."

With that said, I expect this blog to provide a space for personal exploration of the concepts of health and wellness and a sounding board for those who share the goal of eliminating health disparities. Do you know of any upcoming Boston events that would be of interest to readers? If so, please contact me with your idea, so we can get our boots back on the pavement!

Economy Getting You Down?

We here at Real Health Policy have been overwhelmed not only by the great conversations you have started, but also by the voracious demand for pug photos. We can only attribute this to the need of you, our readers, for more laughter and mini-doses of joy at this time of economic uncertainty. So to make the topic more uplifting, we are pleased to illustrate the first of three blogs on health reform with...well, you guessed it.

This entry was spurred by an e-mail from activist Fred Lennox of San Diego, CA. Truth be told, we enjoy serving as a sounding board for community health issues. We have even stooped so low as to post puppy videos. But our wonk-free guarantee prevents us from responding directly to the question: "If the public option is too expensive for a government with a massive budget, how can we expect people living hand to mouth to pay for private insurance, as required by Obama's health reform plan?"

Policymakers may not agree upon how to make America healthier, but what they have come to a consensus on is that the health care "system" is broken. The Obama Plan is a means of addressing the symptoms of this ailing system, most notably skyrocketing health care costs. But as Fred suggests, we don't have to tread far into wonky waters to recognize that as policymakers weigh the economic feasibility of a public health insurance option, many of us are worried about our ability to afford coverage if it is eventually mandated.

Putting 'Delivery' Back into Health Reform

Given that the mission of Real Health Policy is to put communities at the heart of public health dialogue, I want to dedicate the next two blogs to the issue of improving health care delivery. And I would love to hear from readers about whether you also feel this important issue has been overshadowed by current debates over health insurance reform.

This week a friend of mine drew a comparison between health care and cars, suggesting that like car insurance, health coverage should be mandated. My response was that if the auto industry were anything like health care, we'd be looking at $5,000 tune-ups and $350 gas bills (what I paid out-of-pocket for my last PCP visit, which lasted 5 minutes). The bottom line is that health insurance does not just cover us in the event of an accident. It has become synonymous with health care access, since even basic preventive care is so expensive.

Surely change agents should go beyond their current focus on coverage to ask whether health care is being delivered in an optimal way. Today we see physicians ordering unnecessary tests and referring us to specialist after specialist — and our medical bills growing — because this is the surest path toward maximizing profits (and avoiding a lawsuit). Yet it is easy for one to imagine a delivery system that is instead centered around the goal of maximizing health outcomes. We here at Real Health Policy submit that creating a health care delivery system that is more efficient, equitable and responsive to community needs is absolutely essential to driving down costs — and making health care accessible to all.

I begin here by outlining some of the basic issues to be addressed in improving health care accessibility. Next week I will provide a brief history of market competition in medicine to show how today's system is neither a perfect monopoly nor perfectly competitive — something that says a lot about the context in which Democrat and Republican proposals are operating.

The ABZs of Health Care Access

If you are like me and have had the joy of enrolling in a high-deductible insurance plan, then read no further. You understand what there is to know about issues with health care access. These issues are in my opinion driven by three primary factors: a) rising costs; b) insufficient insurance coverage; and z) a failing delivery system characterized by provider shortages, barriers relating to geography, race and ethnicity, socioeconomic status, and a focus on "sick care" as opposed to health.

Issue A: Rising Costs

Health care cost inflation is contributing both to the growing number of uninsured and to the rising prices that consumers face. Since 2000, the annual increase in insurance costs has been four times that of the accompanying growth in wages. As insurance becomes increasingly expensive, employers are cutting health coverage from their benefits packages and leaving workers to seek plans in the private market.

Unlike health plans purchased through employers, coverage purchased by individuals in the private market is not tax deductible. The result is that a growing number of Americans are choosing to remain uninsured or are purchasing catastrophic plans, which are cheaper than those that afford comprehensive coverage.

In either case, high out-of-pocket costs deter Americans from utilizing health care until they are very sick — and the benefit of a doctor’s visit is considered to be worth the high co-payment. For the uninsured, emergency rooms have become a primary point of access to the health care system, since the Emergency Medical Treatment and Active Labor Act requires emergency room staff to provide care to patients regardless of ability to pay.

Issue B: The Uninsured and Underinsured

More than 15 percent of Americans are currently uninsured. Millions more are underinsured, meaning they carry high-deductible plans that do not provide access to primary care for disease prevention or management of chronic conditions such as diabetes and asthma. In a country where preventive care and chronic disease management are not universally provided as a public good, coverage matters: People without continuous health coverage suffer poor health outcomes when compared to those who are insured.

Issue Z: An Inadequate Health Care Delivery System

While delivery models vary by state, with some like Massachusetts placing a greater emphasis on primary care, the majority of Americans have a delivery system that focuses on disease rather than wellness. People with high-deductible policies are choosing to forego preventive care, and those without insurance are relying upon emergency care, creating long wait times for everyone utilizing these services.

While there is conflicting evidence as to whether greater focus on preventive care will result in a net reduction of health care spending, there is general consensus that treating most illnesses before they reach an advanced stage is more cost-effective than providing labor- and technology-intensive urgent care. The current system is therefore inefficient in that it neither minimizes cost nor maximizes health outcomes.

One result of this inefficiency is that more and more physicians are seeking lucrative and prestigious careers in the medical specialties. Resulting shortages of primary care physicians and nurses has made access to primary care even more difficult, particularly in rural areas and impoverished communities where few providers choose to practice. Inadequacy of the public health delivery system is even more obvious when one considers that even when controlling for insurance status, geography and income level, racial and ethnic minorities are less likely than Caucasians to be able to access medical services.

Enough Already!

All right, all right...that is about as wonky as it is going to get. In keeping with our focus on health care delivery, I hope to feature a few examples (sent in by readers) of public and private organizations that have devised innovative and effective ways of delivering health care. Do you know of any good examples? Please send a suggestion or two to me via the contact page so that I can begin compiling your ideas!

Peeps: It's What's for Breakfast

Thank you to everyone who posted comments on the discussion board. You’ve brought up some good points about the challenges of improving access to healthy foods. As someone who has been known to regard “one row of marshmallow peeps” as a nutritious breakfast, I am not sure I am the best person to moderate this discussion, but I will give it a go.

A Brief History of Epi-What?

The history of epidemiology (not to be confused with the study of human skin, which is what a kid in one of my biology classes thought he had signed up for) lends insight into why so few doctors go beyond treating disease to ask why certain patients get sick in the first place.

In many ways, medicine and public health have gone their separate ways. People today tend to focus on the link between exposure and disease in individuals (“I ate peeps for breakfast for two months and now I have a vitamin deficiency”) rather than the factors that influence exposure in populations (“everyone around here eats peeps because one row is cheap and filling”).

But this wasn't always the case: The early 1800s was a time when the medical community put great effort into understanding the social and environmental causes of illness — like crowding 30 people into a brownstone with no plumbing. By the end of that century, their attention turned to "germ theory," or the role that bacteria and viruses play in making us sick. Since World War II, the focus has been on chronic conditions such as diabetes, which today impact far more people in the industrialized world than infectious disease.

In my opinion, the progressive de-emphasis on social and environmental context has been harmful, given the known correlation between health and factors such as income and neighborhood environment. That is why Bostonians like Dr. Nancy Krieger have been outspoken about the need for citizens, elected officials and health care providers alike to ask “who and what is responsible for population patterns of health, disease, and well-being, as manifested [in] social inequalities in health."

The Cost of Healthy Choices

Let's face it: Everyone knows that poor diet and lack of exercise are bad, bad things. Nevertheless, two-thirds of all people in our country are overweight, and of them, more than half are clinically obese. It's pretty obvious that knowledge hasn't curbed our addiction to fast food, so in the words of Bruno: What's up?

While it's hard to deny that what we eat is largely a function of individual determinism, for many people in cities and rural areas, it is also a function of neighborhood environment. A recent study, for example, found that the presence of supermarkets where fresh produce can be bought at fair market prices is correlated with a person's likelihood of eating well. Put simply, living in neighborhoods where the only choices are convenience stores and high-priced specialty markets makes purchasing produce cost-prohibitive.

My neighbors are primarily working-class people who don't own cars, meaning they rely on public transportation to get to the supermarket. It's no wonder that at the end of a long work day, many settle for the affordable fast-food alternative. Is price the only reason fruits and veggies get the boot? Probably not, for the same reason I continue to eat peeps even after viewing these experiments. The bottom line is that if there is a lack of affordable healthy food choices in a community, a person's decision to eat better is less likely to come to fruition. So where do we go from here?

Putting "Real Food" Back on the Table

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Last week I paid a visit to the Bowdoin Street Health Center in Dorchester, whose providers play an active role in promoting community health by partnering with local businesses and even employing community organizers. What I saw when I pulled into the parking lot was this sign, which I think speaks to Steve's question about whether farmers' markets are catering to middle- and high-income people.

What I found out is that there is a growing movement to promote availability of whole foods that don't cost a "whole paycheck." As Katie commented, both grassroots campaigns and government initiatives are helping Americans to put "real food" back on the table.

In Boston, farmers' markets are being set up in even the most unlikely locations — from inner-city clinics to highway rest stops. And because farm stands are accepting EBT cards and WIC, the produce is accessible to people at all income levels. What makes these efforts unusual is that they are addressing social determinants of illness — as opposed to promoting healthy living without accounting for the extent to which people can control their exposure to risks.

At the federal level, the quest to make healthy food options available in school cafeterias is on the front burner with the Child Nutrition Act now up for reauthorization. As part of a National Day of Action, hundreds of communities are organizing "eat-ins" to support increased federal funding for school lunch programs. In Boston, the Food Project and Boston Localvores are organizing a Labor Day Eat-In in the Common that will take place from Noon to 2:30 pm tomorrow at the gazebo in Boston Common.

A Shout Out to Community Organizers

Yesterday I was at the Norwich Farmer's Market, where I picked up a magazine article by community organizers Angela and Richard Berkfield, who described their successes and failures in promoting access to locally-grown foods in Brattleboro, VT. Their lesson learned was that projects cultivated and led by community members saw the greatest levels of participation. "We need to support projects that come out of communities," they concluded, "instead of doing what we think is needed or wanted."

While only time will tell whether the movement to bring farmers and consumers together has a significant impact on health, the Berkfields' findings say something about the likelihood of success if citizens are not properly engaged.

Have you participated in or helped organize food security projects in your neighborhood? If so, what aspects of these projects have been the most successful? What parts didn't go so well, and why? If you have the chance to post a comment, we here at Real Health Policy would love to hear some of your insights. In the meantime, I am off to Skunk Hollow to enjoy a relaxing Labor Day weekend, Vermont-style...

Health Reform: Keeping It Real

Thank you for surfing into Real Health Policy, a blog cultivated by the health-writing, wonk-fearing Somerville resident Melissa King and her pug, who transitioned from her work in science journalism a few years ago to pursue a career in public health policy.

You are probably wondering what real health policy is all about. The answer came to me on September 15, 2008, when I was sitting in a hallway at St. David’s Episcopal Church in Austin, Texas. I had met homeless advocate Renee Hopper during a planning meeting for a citywide forum on homelessness, where she was doing what she does best: stirring things up.

When the group brought up the ten-year plan for ending homelessness, Renee had asked why we weren’t thinking more along the lines of a one-year plan. Her comment was dismissed as politically infeasible; clearly this brash older woman needed a reality check. Renee was visibly livid. A few minutes later the meeting was adjourned.

As we walked out of the meeting, I put my hand on Renee’s shoulder and asked if she could help me with some research on affordable housing. During my time at the LBJ School, Renee was the person I could count on to keep me updated on new housing-related legislation. I wouldn’t know until weeks later that she had been living, ironically, in the back seat of a car.

I bought us each a cup of coffee, and the conversation went something like this:

How do you think public housing legislation could be made better?

“People who go through a terrible divorce like I did, who have a health event that bankrupts them…They are pushed out of housing and forced into this cycle. The number-one fear of every senior or person with disabilities is the fear of being kicked out of their homes.”

Renee explained that there is little accountability to public housing residents at the local level. “The city is not required by law to improve a property unless you request it,” she said, adding that they have people come in now and then “to throw a few flowers around the place.” She wondered why they didn’t give these jobs to the residents. “Unless citizens come together and make suggestions, there are not going to be any changes.”

Aren’t these the type of issues that you can bring up at Resident Council meetings?

“People are afraid to go to the [resident council] meetings,” explained Renee, who had served for two years as president of her Resident Council. “They have become accustomed [to] nothing being done. And if you go to the meetings, there is a fear factor. The fear of losing your apartment or housing.”

So everyone has the philosophy that they had better keep their mouth shut.

“That’s right,” she said. “Public housing is the mire of the universe. That is why I went back to the streets, and why so many people go back to the streets."

For Renee, influencing public policy had become an exercise in pounding the pavement and having the gumption to believe that even the most marginalized citizens have ideas worth listening to. Her philosophy is that through democratic organizing, we can work together to build healthier communities now — not at some point in the future. These actions in turn send a powerful message to elected officials about community values. (Examples of democratic organizing might include facilitating a forum on homelessness or starting a neighborhood clinic that engages community members in all stages of program evaluation.)

Our country has a long tradition of promoting social change through democratic organizing. Clearly, however, there is some sort of disconnect between the process of democratic organizing and the outcome of influencing policy. The idea that democratic organizing is sufficient for promoting social change causes, shall we say, cognitive dissidence with what what you learn in policy school. Namely, that citizens typically must also:

  1. Effectively communicate their interests to “policymakers” (Renee once incorporated the use of paper airplanes in the Driskill Hotel lobby for this one);
  2. Hope that studies supporting their ideas are published in academic journals;
  3. Elect a leader who is sensitive to the issue; and finally
  4. Wait for a figurative galactic alignment that fosters immediate need for change.

We've got studies supporting the need for a better health system, a president that has gotten the health reform ball rolling, and according to my cousin Bobby, an actual galactic alignment. Yet there remains a need for more democratic organizing and, in turn, a means for citizens to communicate their interests to elected officials (like at Austin's Community Forum on Homelessness, right, where my friend and teacher Oliver Markley led a Future Search). Which brings us to the purpose of this Web site.

Let's begin with what this site is not. If you are looking for a wonk room, this is not the place to be. I am not a politician, although I did once stand on Nancy Pelosi's balcony and "Hi5" the Ambassador of Togo in Haitian Creole. This is a certified Wonk-Free Zone: I won't advocate a particular party line, try to sell you anything, or obsessively watch and comment on floor debates. I find regular people — and what they have to say — much more interesting.

Real Health Policy is a blog and community action resource with a simple philosophy: that the most successful health policies are developed in direct dialogue with community members. It is we who know when safe housing is the real cure for asthma, job security is the real antidote to stress and heart disease, and wage is the real determiner of where we live and what we eat.

This blog supports “real health policy” discussion that is rooted in an appreciation of community needs. Word on the Street serves as a digest of events promoting public dialogue on issues ranging from housing rights to health care access. The latter is designed to support community organizing efforts and provide a centralized list of opportunities for engaging in dialogue with elected officials — thereby creating a bridge between process (organizing) and outcome (influencing policy).

The job hunt beckons, so this is all she wrote for today. In the next entry, I will talk about the current movement to view public health issues through a social epidemiology lens — which emphasizes the influence of the physical and social environment on health.

In the meantime, take a moment this week to ask a friend or family member what (s)he thinks has the greatest influence on health in your community. Chances are health care access is a big issue, but I think you'd be surprised by how many people name factors that are social, economic or political in nature: job stress, for instance, or the ratio of supermarkets to package stores in their neighborhoods. It makes you question whether chronic illnesses such as heart disease and diabetes are at root an issue of health care or healthy communities.

Feel free to share your thoughts in response to this posting!