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Reframing the health conversation: Look to inequality and its effects

A new discussion about health is taking place across the country. Individuals, organizations and communities are asking different — and tough — questions. Questions such as:

• Why do U.S. residents have one of the lowest life expectancies and the worst disease outcomes of any industrialized nation, despite spending more than any other country on medical care? 

• Why, in a nation committed to equal opportunity and fairness for all, are there so many health inequities, with income, neighborhood, education, social class and race predicting health and life expectancy?

Evidence increasingly shows that the circumstances in which a person is born, lives and works have as much impact on health as genetic makeup, lifestyle choices and medical care. And yet, according to the Centers for Disease Control and Prevention, the U.S. spends 90 percent of its health budget on “downstream” individual medical care and only 8 percent on community and societal conditions that affect health.

Better health lies ‘upstream’

In Minnesota, we take pride in the fact that we are widely regarded as one of the healthiest states in the nation overall. However, a closer examination of health data by race, ethnicity, income and education reveal an alarming pattern of health disparities. In our state, as in other states, the root causes of health disparities tend to lie “upstream.”

So, what are the solutions?
The new PBS documentary series “Unnatural Causes: Is Inequality Making Us Sick?” dramatically and powerfully illustrates the extent and cost of health inequities. It provides a new framework for looking at health — a shift from the conventional, biomedical model of improving health to a cross-sectoral, socio-ecological approach to achieving better health. The new frame shifts from holding individuals solely responsible for their own health to recognizing that the policies that affect health are too large for individuals to tackle on their own. The four-part series offers hope and shows that as a society, we can make different policy choices that lead to better health for all members of our communities.

Through a combination of stories of real people, interviews with experts and research data, the opening program of the series reveals how differences in social class and income level create up to a 10-year gap in life expectancy between rich, middle- and working-class neighborhoods in Louisville, Ky. Another segment explores the protective health factors of close family and community ties for recent Mexican immigrants in California — and the lessons that can benefit others. A third episode features a new approach to neighborhood redevelopment in Seattle, where federal funds were used to build a mixed-income community with health as the focus.

Social policy is health policy
“Unnatural Causes” demonstrates the importance of a social-determinants approach to health. Public health systems in Canada, Australia and northern Europe are adopting upstream approaches by addressing social, economic and environmental influences on health, and they’re working.

The Blue Cross and Blue Shield of Minnesota Foundation is one of just a handful of foundations in the United States with this focus. Our board and staff have committed to a 10-year, multimillion-dollar investment that combines grantmaking, public awareness and policy support, and leadership development and recognition. Building on earlier findings by the Minnesota Department of Health, we are now working in partnership in four key areas for creating healthier communities:

• Early childhood development — critical to school readiness as well as strong social and emotional skills, it’s also an important part of efforts to increase high school graduation rates, improve earning potential later in life, reduce the likelihood of criminal activity and experience better overall health.

• Affordable and safe housing — especially important in protecting children against asthma, lead poisoning and mold exposure.

• Social connectedness — especially important to the mental health and healthy adjustment of immigrants and refugees.

• Environment — particularly as it relates to the short-and long-term effects of environmental contaminants, which cost Minnesotans up to $1.5 billion in health care costs each year.

While we must continue to improve health care access and outcomes for all through health systems changes and lifestyle interventions, focusing more attention upstream can yield significant health improvements.

We encourage people to watch all four programs in the “Unnatural Causes” series broadcast on public TV this spring. (The first installment is scheduled on TPT for 9 p.m.  Thursday, March 27, on Channel 17.) We applaud California Newsreel and its partners for creating this bold documentary. Our nation’s current life expectancy ranking of 29th internationally can improve, and we can get more health for the money we’re already spending. In the words of executive producer Larry Adelman, “We hope that ‘Unnatural Causes’ will bring into view how economic justice, racial equality and caring communities may be the best medicines of all.”

Joan Cleary is the vice president of the Blue Cross and Blue Shield of Minnesota Foundation. The foundation’s work extends beyond the traditional reach of the health care system to improve community health long-term and close the health gap that affects many Minnesotans. It has become the state’s largest grantmaking foundation to exclusively dedicate its assets to improving health in Minnesota.

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Comments (2)

  1. Submitted by myles spicer on 03/25/2008 - 12:07 pm.

    Ms. Cleary’s remarks are cogent, and important. However, having said that,I wonder if the “conversations” will involve the salaries of top Blue Cross executives that are also part of the problem!

    In Massachssetts, William Van Faasen recently reitred from BC with a $16.4 million payout. In NC, the ten top execs at BC earned $10 million. In PA, a recent merger brought a discussion of the two BC entities merging because one CEO was earning $3.2 million, where the other had only $1.6 million compensation. And in MI, the top BC exec earned $1.5 million.

    That’s OUR premiums folks; and BCBS is a NOT FOR PROFIT organization.

    Yes, any discussion of improving our health care system requires a visit to compensation at all the health insurance companies.

  2. Submitted by Dan Hoxworth on 03/25/2008 - 04:14 pm.

    The Blue Cross/Blue Shield Foundation of Minnesota is a model for corporate foundations. Their expansive focus on public health is a method for addressing the roots causes of disparities in the health of our communities and people. David Durenberger has pointed out the small investment our nation makes in public health and preventative health care. BC/BS is paving the way for a much broader debate about the health of our people that is much broader than health care. Their annual forum is one of the most provocative discussions of innovation and research in public health in the nation and reaches one of the most diverse audiences to attend any conference. They walk the talk!

    We will know that we are arriving at a new level of understanding when the following happens. First, our presidential candidates will not simply debate access to health care but discuss their plans for creating healthy communities with much more comprehensive solutions. Second, when we as a society decide that poverty for children and families is too high of a cost to our nation and that we will work to eliminate poverty and thereby augment both the health of our children and thereby provide them with the opportunity to reach their full potential. And finally, that the millions of dollars of gifts to private hospital foundations be invested not in their organizations but in their local communities to ensure that every individual has access to exercise facilities and preventative treatment. Their goal should be to reduce the need ultimately for their intervention services. If all of this comes to fruition, then we will know that the health of our communities and families are first and foremost in our hearts and minds and not empty rhetoric.

    I commend the Blue Cross/Blue Shield Foundation for so forcefully pushing this agenda forward. Our state is blessed by their commitment.

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