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!