Tuesday, September 5, 2017

Health Equity and Social Cohesion

(The September/October issue of MetroDoctors (the journal of the Twin Cities Medical Society) is dedicated to “Striving for Health Equity.” The articles in this issue are accessible at: Twin Cities Medical Society: 2017 September/October Striving for Health Equity. A modified version of the article I contributed to the journal is included below. EE)

“The greatest epidemic today is not TB, HIV, or leprosy – it is being unwanted. … Being unwanted, unloved, uncared for, forgotten by everybody is a much greater hunger, a much greater poverty than (having) nothing to eat.” – Mother Teresa

The standard approaches of contemporary healthcare and public health have been insufficient to reduce the persistent and seemingly intractable health disparities in our society. This should challenge us in public health to rethink how we do our work. Given our current understanding of what determines health, we must expand our focus beyond clinical care and disparities to include the inequities in opportunities in our political, economic, educational, healthcare, and social systems that are at the core of health disparities and then work to change them.

We also must recognize that creating health and health equity is not just about the health of individuals but the health of communities. As poet/farmer Wendell Berry said, “…the community in the fullest sense is the smallest unit of health…to speak of the health of an isolated individual is a contradiction in terms.” Unfortunately, that’s not the common perspective. Most people focus on health as an individual issue which minimizes the importance of the community and social cohesion to health. Therefore, it is critical that we understand how the lack of community and social cohesion (a lack of belonging or “being unwanted” as Mother Theresa noted) is a health determinant that is at the root of many health disparities.

In its 2014 Advancing Health Equity Report to the Minnesota Legislature, the Minnesota Department of Health (MDH) made the case for addressing the root causes of health inequities and disparities by focusing on the social, economic, and environmental conditions that create health. In addition, recognizing that health disparities and inequities are particularly stark and persistent for populations of color and American Indians, MDH chose to lead this effort with a focus on racial equity, noting that race often compounds disparities and inequities linked to gender, sexual orientation, age, and disability. Advancing health equity is now at the core of the state’s Healthy Minnesota 2020: Statewide Health Improvement Framework and MDH’s strategic plan.

To more effectively advance health equity, MDH created the Triple Aim of Health Equity - a set of practices necessary for changing the work of public health. The components of the Triple Aim of Health Equity are based on a theory of change that builds the power and capacity to improve living conditions in every community. The Aims are:
Expand the understanding about what creates health,
Implement a health in all policies approach with health equity as the goal, and
Strengthen the capacity of communities to create their own healthy future.

With this framework, efforts are underway to expand the narrative about what creates health; that ill health is not just due to lack of access to healthcare and bad personal lifestyle choices but mostly due to the policies and systems that impact economic, educational, housing, physical, criminal justice, and transportation environments. The Triple Aim of Health Equity also recognizes that health is not solely the responsibility of the healthcare and public health sectors but is impacted by the policies in all other sectors of society. This recognition highlights the need for new and expanded partnerships to advance health equity. Finally, the Triple Aim of Health Equity acknowledges the importance and necessity of strengthening civic participation so the collective voice of community members can effectively impact decisions made by institutions and government at all levels.

All these efforts are centered around building social cohesion, a prerequisite for achieving health equity. Social cohesion is defined as community force that “works toward the well-being of all community members, fights exclusion and marginalization, creates a sense of belonging, and promotes trust.”

Among the constituent elements of social cohesion are:
social capital – the resources that result from people working together toward a common goal,
social mobility – the ability to move up in social or economic status, and
social inclusion – having connection to and ownership of community goals, having a sense of belonging – being wanted and needed.

According to John A. Powell, director of the Haas Institute for a Fair and Inclusive Society, that sense of “belonging means more than just being seen. Belonging means being able to participate in the design of political, social, and cultural structures. Belonging means the right to contribute and make demands upon society and institutions.”

Social cohesion can be developed only if all parts of the Triple Aim of Health Equity are being actualized.
Expanding the understanding about what creates a thriving and prosperous community is essential for building the social capital necessary for a socially cohesive society.
An inclusive, coordinated, and accountable decision-making process that incorporates the views of all stakeholders in all sectors of the community enhances social cohesion.
Strengthening community capacity by providing community members with the opportunity to share their perspectives and impact policy decisions is fundamental to creating social capital and a sustainable, socially cohesive society. The process of policy making is often as important for building social cohesion as the policies themselves.

Public health is defined by the Institute of Medicine as “what we, as a society, do collectively to assure the conditions in which (all) people can be healthy.” Those conditions are influenced by the policy decisions made at all levels of society. If we are to change the policies to improve health equity, we must constantly ask the basic question: what would our work be like if health equity was the starting point for all policy and programmatic decisions?

Our work would be different. Our work would be shaped by the Triple Aim of Health Equity; we would expand the understanding of what creates health, implement a health in all policies approach with health equity as the goal, and strengthen the capacity of communities to create their own healthy future – all with the objective of increasing social cohesion and belonging. Our work would be to build a proper community as described by Wendell Berry: “A proper community…is a place, a resource, an economy. It answers the needs, practical as well as social and spiritual, of its members - among them the need to need one another.” Our work would be to create socially cohesive communities where no individual or group is unwanted and where everyone has a sense of belonging and the opportunity to be healthy.