I'm Dr. Camara Phyllis Jones, past
president of the American Public Health
Association. You may have heard the
saying an ounce of prevention is worth a
pound of cure. When it comes to health
and well-being, preserving health is
always best, but there's more to the
story.
Imagine that someone is walking along
and–whoops!–
they have just fallen off the cliff of
good health. And if that were you, you'd
be relieved to find an ambulance at the
bottom to speed you on to health care.
But what else can we do to protect you?
How about a net to catch people?
But nets have holes, so some people may still fall through and the net is likely to rip
over time. What else can we do?
Clearly we need to build a fence at the
top of the cliff to keep people from
falling in the first place. But if a lot
of people are near the edge of the cliff,
even a really strong fence will not be
enough. To keep everyone safe, we need to
move all the people away from the edge
of the cliff. We do that by addressing
the drivers of poor health that go
beyond our genes and beyond our personal
behaviors. Things like low wages, and
under-resourced schools, and unsafe
housing. The environments in which we
live, work, and play shape our health.
These are the social determinants of
health. These things can either propel
people toward the cliff's edge or keep
them at a safe distance from it.
But this cliff analogy is incomplete. We
need to also realize that the cliff is
really three-dimensional, and then to
notice that resources and people are not
evenly distributed along this cliff. At
some parts of the cliff the ambulance at
the bottom may have a flat tire, or maybe
there's no ambulance there at all.
Maybe there's no net, nor fence, and
usually at those parts of the cliff the
people are being pushed closer to the
edge. These are the differences that lead
to health disparities in a population.
Differences in the speed and quality of
the ambulances represent differences in
quality of care. Differences in the
presence of ambulances, nets, or fences,
these represent differences in access to
care. And differences in the distance to
the edge of the cliff represent
differences in the opportunities, and
exposures, and stressors that make some
people and communities sicker than
others. We need to ask a lot of questions:
Why is the cliff three-dimensional? Why
do some parts of the cliff lack
ambulances or nets or fences? And why are some people being pushed closer to the
edge? It's because our economic system
fails to provide an even playing field.
It's because racism, which is
foundational to our nation's history, is
still with us and continues to cause
profound harm to us all. And because
discrimination against people of color,
women, immigrants, the LGBTQ community,
poor people, and others holds back our
nation's health and well-being.
Everyone should have the opportunity to
achieve good health. If we try to address
the social determinants of health
without tackling these bigger systems of
structured inequity, like racism and
sexism, we risk moving some people away
from the cliff's edge but not others. We
risk making health disparities worse.
Experts at the Urban Institute are
exploring how local, state, and national
policies have gotten us to this point,
and what policy solutions inside and
outside the healthcare system can drive
fundamental improvements in health and
well-being for everyone. We can all play
a role. We can support our kid's teachers.
We can participate in neighborhood
cleanups. We can volunteer with community
organizations. And let's recognize and
dismantle racism, sexism, and the other
big systems that assign value and
structure opportunity in ways that
undermine some groups more than others, but hurt us all.
Doing so will radically improve health
and well-being for everyone by creating
the conditions all of us need to have
the best health possible.
