Health and health care in the United States are in trouble. There’s a great deal of focus on access to care and the medical system, and rightly so. But up to 40 percent of health outcomes are driven by inequitable social and economic factors*, a broad systemic problem that’s arguably even more challenging. For too many Americans, the conditions and choices that make for a long, healthy life simply aren’t available.
Why, despite our best efforts, have we been unable to make progress? How do we shift the dynamics that have produced and continue to perpetuate these entrenched health inequities?
Reos Partners proposes that we begin by stepping back to have new and better conversations: the kinds of inclusive, challenging conversations that create a widely shared understanding of the systemic nature of these inequities. In our experience globally, such understanding breaks down artificial boundaries between people and sectors, allowing them to collaborate in unprecedented ways. That in turn allows real progress, finally, on even the toughest problems.
To that end, we’ve produced “A Conversation Guide for Health Equity”, one of several upcoming tools associated with the Robert Wood Johnson Foundation’s Open Box Initiative. Informed by dialogue interviews we conducted with multiple thought leaders serving in diverse capacities, it’s a tool anyone can use to launch an inquiry into the interconnected realities of health and well-being where they live and work. And further, to explore how they might work together to effect change.
“The way this guide is constructed is very helpful in having higher-quality conversations that open us up to our own mental models,” says Dr. Victor Garcia, a professor of surgery and paediatrics at the University of Cincinnati School of Medicine who participated in our interviews. “Quality conversations — versus debating or downloading — are provocative yet are not going to shut down the necessary dialogue.”
Systemic Inequities Call for System Leaders
The health inequities that the Conversation Guide is designed to illuminate are vast. Because of differences in access to care, education, employment, housing, income, safety, and environment, there can be as much as a 20-year difference in life expectancy between Americans who live just a few miles apart.
We see neighborhoods with disproportionately high concentrations of obesity, diabetes, and heart disease — and limited access to affordable, nutritious food. High rates of asthma in people living near contaminated industrial land. Family and intimate partner violence linked to economic decline. These inequities often stem from the historical legacies of slavery, racism, and colonialism.
As the interconnections become clear, so does the fact that health equity is beyond the power of any individual institution, sector, government, or region to achieve. The aim of the Robert Wood Johnson Foundation (RWJF) and this project, then, is to build a community of committed system leaders who cross and connect these.
“I think we have a lot of learning to do,” says Catherine Malone, programme officer at RWJF. “The sectors are very diverse and need to do things within their own systems. But collaboration both within and across sectors is critical if we’re really going to advance health equity in communities and across the country.”
Who is a health equity system leader? Anyone in a formal or informal position of leadership, influence, or power who sees what needs to be done and is willing to do it. A teacher, a neighborhood leader, a CEO … Many of the people whose leadership is needed don’t think of health as part of their sphere of influence. The Conversation Guide is designed to reveal that they do have a role to play in transforming the health of their community.
What insights and novel approaches might emerge from conversations between people engaged in medicine, business, nonprofit work, education, government, finance, entertainment, technology, faith-based initiatives, and media?
In addition to being open to new ideas, we need to be prepared to see the mistakes we’ve been making. As one leader we interviewed said, “Your programme can be at odds with what it takes to actually solve the problem.”
Mistakes are often the result of working with an incomplete picture. Fundamental to collaboration, always, is the inclusion of all stakeholders. “Those most affected by the inequities have to be directly engaged in the conversation and in co-creating solutions,” says Malone. “That’s not only the right thing to do, but also the smart thing if we want real, sustainable solutions.”
The good news is that, while the differences between zip codes can be shocking, they also suggest that intervening at the neighborhood level can have a significant impact. And indeed, neighborhoods that have experienced the most positive changes have been successful, in part, because of informal networks, community-building initiatives, and peer groups.
Using the Conversation Guide to Connect the Dots
During our Dialogue Interviews, certain interrelated themes and factors that affect health equity came up again and again. The Conversation Guide is built around these already identified issues, providing both structure and a head start.
The guide’s first section, a conversation “launch pad,” outlines four themes that point to ways in which we need to think and act differently if we’re going to address health inequities successfully: adopting a systemic view, leveraging an equity-based approach, changing our narratives, and convening the full spectrum of stakeholders.
On adopting a systemic view, Garcia offers the personal example of using the guide to connect climate change, socioeconomic status, and health: “Our climate is warmer, and it turns out that the poor are the ones who are dying because of these extremes of heat.” We also saw socioeconomic inequity at play, he notes, in the disproportionate impact of hurricanes Sandy and Katrina on minorities and poor people living on the coastline.
Regarding narratives, other interviewees pointed to a growing story of vilification of the “have-nots” in America. Poverty is personalized, leading to a sense of shame that creates real and damaging barriers to health equity.
The second section points to and guides discussion of eight factors that create or thwart health equity, and the relationships between them:
- Power, leading to unilateral responses
- Historical legacy /enslavement of both Africans and Native Americans
- Policy leadership
- Impact of funding
- Connecting with others
- Connecting with self
Just one example of the striking “connection circles” that emerged among these factors during our interviews is that of policy leadership, neighborhood, and historical legacy. Historical legacies have produced systemic racism, which in turn has produced a wide range of policies that tend to concentrate inequities in certain neighborhoods. When policy makers work at uncovering their blind spots, they can see the full impact of their decisions, past and present. This process presents opportunities to both heal old inequities and avoid new unintended consequences.
Connection Is Health
Overwhelmed by the immediacy and urgency of the challenges, in health equity and other arenas, we often think the answer is more information, more research, more evaluation. As necessary as those are, health and health care in the United States have run up against their limits, hard.
The truth is that we also need to focus on relationships, which is perhaps less comfortable, but more rewarding. Only relationships can enable the level of creative collaboration needed to effect change in such a complex system. And they start with conversation.
It’s worth noting that communities where people are more connected with each other tend to be healthier than ones where they aren’t. So in the case of health equity, conversation might do more than enable change. It may, itself, be literally healing.
Download the Conversation Guide here. We invite you to post your responses and reflections at the hashtags listed in the guide.
* “Communities in Action: Pathways to Health Equity,” National Academy of Sciences.