Health Affairs, 24, no. 2 (2005): 339-342 doi: 10.1377/hlthaff.24.2.339 © 2005 by Project HOPE	New Online   Obama's Success & Next Steps   3 Health Policy Options for President Obama   A Hybrid Proposal   Bipartisan Compromise

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Origins Of Disparities

PERSPECTIVE

Communities And Health Policy: A Pathway For Change

Abstract

 
Improving the health system can reduce the effects of health disparities, but it can do little to eliminate them. An upsurge in new research is documenting the impact of physical, social, and economic environmental factors: air quality, housing conditions, racism, relationship to community institutions, and neighborhood economic conditions, all of which affect health status over time. A combined focus on community and the policies that affect communities’ environments presents opportunities for altering and ameliorating the underlying forces at the heart of the determinants of health. This Perspective presents examples of successful community involvement and policy change.

The experience of health disparities means that low-income communities and communities of color must cope with higher rates of disease, hospitalization, and death and more absenteeism from work and school, which result in limited opportunities for income and educational advancement and reduced expectations for a long, healthy, and productive life. Improving the health system can reduce the effects of disparities, but it can do little to eliminate them. Adding a focus on community and prevention holds much promise for improving health status and reducing the additional ramifications of health disparities.

David Williams and Pamela Braboy Jackson point out that addressing health disparities calls for "a reconceptualization of what constitutes health policy" to include and affect "policies in societal domains far removed from traditional health policy."³ As they suggest, a focus on these policies "can have decisive consequences for individual and population health." A focus on policies that affect communities’ physical, social, and economic environment presents just this type of opportunity.

Policy, place, and community matter. The physical, social, and economic environments—air and water quality, housing conditions, connectedness or isolation from community institutions, and neighborhood economic conditions—all affect health status over time. Attention to these determinants of health offers the potential for closing some of the gaps associated with health disparities. Affecting these determinants requires deliberate attention on policy and community.

Combined, policy and community can alter or ameliorate the underlying forces that lie at the heart of the determinants of health. Policy determines the rules by which opportunities are framed—what is allowed, encouraged, discouraged, and prohibited. Policy also determines the shape, size, and character of communities: Are industrial facilities near residential neighborhoods? How must industrial facilities treat their neighbors? How dense will neighborhoods be? What materials can be used to build houses? Who will live in a neighborhood? Can businesses locate in the neighborhood, and if so, what kind? Are there tax or other incentives available for locating in a neighborhood?

Example: Asthma.

Top Example: Asthma. Example: Obesity. NOTES

 
The implications of policy and community on health determinants and disparities can be illustrated by discussing disparities in the prevalence of asthma, a chronic disease that has higher incidence, prevalence, and impact in low-income communities and communities of color.

Rates of asthma have been rising, most rapidly among preschool-age children.⁴ Asthma affects low-income people and people of color disproportionately. The national prevalence rate of childhood and adult asthma is 7 percent, but some African American communities report one in four children suffering from this serious disease.⁵ Puerto Rican children have the highest prevalence of active asthma of any U.S. ethnic or racial group, and in California, Latino children are hospitalized for asthma at a rate that is 10 percent greater than that of white children.⁶

In addition to the considerable health care treatment costs associated with asthma—$9 billion—there are sizable additional costs.⁷ For example, between 1990 and 1996, children lost fourteen million school days to asthma each year, while workers lost fifteen million workdays because of their or a family member’s asthma.⁸

How do policy and community affect asthma? Studies have found strong relationships between outdoor air pollutants and asthma. Sources such as power plants produce environmental triggers for asthma.⁹ Emissions from chemical plants and oil refineries produce toxic and organic gases that react to sunlight to cause ozone, another asthma trigger. Particulates from diesel emissions are known triggers, and some pesticides can also be problematic.¹⁰ Children who live near freeways suffer higher asthma rates.

Public policies determine air pollution tolerances and how much pollution specific sources may "contribute" to poor air quality. Active and organized communities can influence decisions regarding these levels.¹¹ In fact, a window of opportunity for policy change opens when there is a favorable confluence of problems, possible solutions, political circumstances, and public/community engagement.¹²

For example, California organizations have worked together on an initiative designed to reduce asthma triggers through a focus on community involvement and policy change. Twelve coalitions, comprising parents, community and health-oriented organizations, and health care providers, examined asthma and environmental triggers to identify local circumstances that contribute to asthma disparities and potential public policies to address those circumstances. A diverse array of priorities emerged based on each community’s unique characteristics.

For groups in California’s Central Valley, where air pollution is the worst in the country, the state’s Clean Air Act became the target for local and statewide policies to eliminate the act’s agricultural exemption. With asthma advocates as active and vocal participants, the focus expanded to include environmental and health concerns. Advocates worked locally to educate and inform the public and policy-makers about asthma, its effects, and the connection between air quality and the incidence and severity of asthma. As the measure moved successfully through the legislature, a key state senator commented that he now understood the measure as being about more than just the environment and that he needed to consult with local asthma groups to better understand the impact of the bill and amendments that were being proposed.¹³ The passage of this legislation will reduce emissions in the Central Valley, a positive impact for asthma and for residents’ overall health.

Policy and community can interact in other ways that dramatically affect health. Dust is an indoor environmental trigger for asthma. Many schools across the country have poor indoor air quality; some portable classrooms have high concentrations of formaldehyde and volatile organic compounds.¹⁴ There are both short- and long-term steps to reduce or eliminate these problems. The U.S. Environmental Protection Agency (EPA) has developed Tools for Schools—specific steps that schools can take to improve indoor air. One step is regular cleaning and replacement of air filters. But school administrators don’t necessarily connect their policies about ventilation system maintenance and replacement as affecting health and revenues (schools do not receive per diem funds when students are absent). Parents and local coalitions are pushing individual schools and school districts to change their policies to improve classroom air and student performance.¹⁵

Example: Obesity.

Top Example: Asthma. Example: Obesity. NOTES

 
An examination of obesity highlights additional reasons why a focus on policy and community holds the promise of improving the determinants of health. Rates of obesity have skyrocketed, with 31 percent of the population now considered obese compared with a rate less than half that size twenty years ago.¹⁶ Low-income people and people of color have been particularly affected; they now suffer from disproportionately high rates of obesity, overweight, diabetes, and heart disease. Experts believe that a variety of factors related to diet and exercise are to blame. Changing neighborhood environments can produce multiple new opportunities for healthy eating and physical activity, as well as additional community benefits such as increased economic activity, access to jobs, and a more attractive and welcoming physical environment.

One area of interest is increasing residents’ ability to make healthy eating choices by increasing access to fresh fruits and vegetables. Studies suggest that this approach could work. Research has demonstrated that poor and segregated neighborhoods have fewer supermarkets than other neighborhoods.¹⁷ When there are more commercial options, people make different choices. African Americans’ intake of fruits and vegetables increased 32 percent for each additional supermarket, a recent study by researchers at the University of North Carolina concluded. Also, more residents in an African American neighborhood limited their intake of fat when they had access to a supermarket compared with residents in a neighborhood without any markets.¹⁸

Public policies can provide incentives, including economic ones, for stores to locate in underserved areas, and can help establish farmers’ markets in low-income neighborhoods.¹⁹ The efforts of organized communities are key to the establishment and the successful implementation of these programs, as experiences in San Diego, Harlem, Detroit, and other areas of the country show.

Moreover, communities are working with existing stores to improve available options. One program provided assessments and incentives for initial offerings of fresh fruits and vegetables to allow small grocers to experiment with expanding the stores’ offerings. Stores were able to make a profit and chose to regularly offer fresh fruits and vegetables.²⁰

These examples are just a few out of many. Other efforts focus on food choices in schools, eliminating the availability of sodas and requiring healthy school food menus as well as ensuring that requirements for physical education are implemented. In addition, there are myriad activities across the country designed to increase access to parks and to improve the safety and amenities in existing parks. All of these policy changes and community efforts represent promising new avenues for effecting the determinants of health and improving health status. With concerted long-term attention and support, they can reduce the severity and incidence of the diseases associated with health disparities—charting a new and much-needed pathway for change.

Editor's Notes

 
Judith Bell (jbell{at}policylink.org) is president of PolicyLink in Oakland, California. Marion Standish is disparities in health program director of the California Endowment in San Francisco.

NOTES

Top Example: Asthma. Example: Obesity. NOTES

 

1. J.M. McGinnis and W.H. Foege, "Actual Causes of Death in the United States," Journal of the American Medication Association 270, no. 18 (1993): 2207–2212, citing CDC data.
2. For a listing, see PolicyLink, The Influence of Community Factors on Health: An Annotated Bibliography, A PolicyLink Report, Fall 2004, www.policylink.org/CHB/Publication.html (4 January 2005).
3. D.R. Williams and P.B. Jackson, "Social Sources of Racial Disparities in Health," Health Affairs 24, no. 2 (2005): 325–334.[Abstract/Free Full Text]
4. D.M. Mannino et al., "Surveillance for Asthma—United States, 1980–1999," Morbidity and Mortality Weekly Report 51, no. SS01 (2002): 1–13; Joint Center for Political and Economic Studies, Health Policy Institute, and PolicyLink, Breathing Easier: Community-Based Strategies to Prevent Asthma (Washington: Joint Center, 2004), 3, citing American Lung Association, Action on Asthma: Position Statements: Fact Sheet, Sec. 1 (Washington: ALA, November 2000), 1; and U.S. Department of Health and Human Services, Healthy People 2010, 2d ed. (Washington: DHHS, November 2000), 24–25, Part B: Focus Areas 15–28.
5. PolicyLink, Reducing Health Disparities through a Focus on Communities (Oakland, Calif.: PolicyLink, November 2002), 27.
6. G. Flores et al., "The Health of Latino Children: Urgent Priorities, Unanswered Questions, and a Research Agenda," Journal of the American Medical Association 288, no. 1 (2002): 82–90[Abstract/Free Full Text]; and Policy-Link, Fighting Childhood Asthma: How Communities Can Win (Oakland, Calif.: PolicyLink, 2002), 6.
7. ALA, Asthma in Adults Fact Sheet, June 2004, www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=22596 (4 January 2005).
8. U.S. Centers for Disease Control and Prevention, "Healthy Youth!, Asthma, Fact Sheet: Addressing Asthma in Schools," 16 November 2004, www.cdc.gov/healthyyouth/asthma/facts.htm (4 January 2005).
9. Community Action to Fight Asthma, "Asthma and Outdoor Air Quality in Schools," fact sheet in Asthma: Reducing the Risk for California’s Children, briefing packet (Oakland, Calif.: CAFA, 2004).
10. Ibid.
11. A.G. Blackwell, M. Minkler, and M. Thompson, "Community Organizing to Influence Policy," in Community Organizing and Community Building for Health, ed. M. Minkler (New Brunswick, N.J.: Rutgers University Press, 2005), 406.
12. Ibid., 407, citing B. Longest, Health Policymaking in the United States, 2d ed. (Chicago: Health Administration Press, 1998).
13. From hearings on California Senate Bill 700, by Senator Dean Florez, Passed 22 September 2003, Chapter 479, Statutes of 2003 (Took effect 1 January 2004).
14. See, for example, California Air Resources Board, "California Portable Classroom Study," May 2003, www.arb.ca.gov/research/indoor/pcs/pcs.htm (4 January 2005); D.G. Shendell, "Assessment of Organic Compound Exposures, Thermal Comfort Parameters, and HVAC System Driven Air Exchange Rates in Public School Portable Classrooms in California" (D.Env. dissertation, School of Public Health, Environmental Sciences and Engineering Program, University of California, Los Angeles, 2003); and D.G. Shendell et al., "Final Methodology for a Field Study of Indoor Environmental Quality and Energy Efficiency in New Relocatable Classrooms in Northern California" (Berkeley, Calif.: E.O. Lawrence Berkeley National Laboratory, August 2002).
15. G. Smedje and D. Norback, "New Ventilation Systems at Select Schools in Sweden—Effects on Asthma and Exposure," Archives of Environmental Health 55, no. 1 (2000): 18–25.[Medline]
16. K.M. Flegal et al., "Prevalence and Trends in Obesity among U.S. Adults, 1999–2000," Journal of the American Medical Association 288, no. 14 (2002): 1723–1727.[Abstract/Free Full Text]
17. K. Morland, S. Wing, and A. Diez Roux, "The Contextual Effect of the Local Food Environment on Residents’ Diets: The Atherosclerosis Risk in Communities Study," American Journal of Public Health 92, no. 11 (2002): 1761–1767.[Abstract/Free Full Text]
18. K. Morland et al., "Neighborhood Characteristics Associated with the Location of Food Stores and Food Service Places," American Journal of Preventive Medicine 22, no. 1 (2002): 23–29.[CrossRef][ISI][Medline]
19. Pennsylvania is beginning an innovative program offering special financing incentives to stores that locate in low-income areas. Pennsylvania Senate Bill 1026 to amend Section 1. Title 64 of the Pennsylvania Consolidated Statutes was approved by the governor, 1 April 2004 (Act no. 22).
20. Literacy for Environmental Justice, "The Good Neighbor Policy Incentives to Create Healthy Food Access on Bayview’s Third Street Corridor" (San Francisco: LEJ, 2004).

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