Alonzo Plough - Building a culture of health

We all want cities to thrive and we desire that, but we know and I think many of you here in the room are working on this, that urban centres face huge challenges around this ideal of thriving and particular challenges around all people in our cities thriving. So the issues of marginalisation inequities within our cities give us an unevenness of health and wellbeing that I think is the central challenge for health in the cities. So I’m going to talk about the path that my foundation took – Robert Wood Johnson Foundation – from a foundation focused largely on health and healthcare to one now largely focused on things like housing for built environment and deep community collaboration and where the issue of health equity, building a culture of health where everyone has a fair and just opportunity for the best heath outcome, drives all of the work that we do.

So, we started with this question and my IRS tax status of our foundation provides guidelines for the things that I can say around the political context. So, but what I’m going to speak about, we ask this question and we ask the question in cities, in London, what holds us back from that ideal? That is the question we ask ourselves when we began the culture of health work. What are these key challenges? And I’m going to run through just some of the things that really are particular challenges in the United States. I think most of you know that we put a lot of our public and private dollars into healthcare – 3.5 trillion dollars. 18 per cent of our gross national product, 10 million dollars per capita, so you might think, ‘Wow, that kind of investment is going to get you pretty good health outcomes.’ But it doesn’t.

And this is a chart comparing the US with the other OECD countries where the bar goes down and is red, that’s where we are not doing as well as the average OECD, that’s in the middle. So in areas like childhood obesity, life expectancy, we’re just not doing very well. Where we are number one in the world, you can see the far right is how much money we spend. We would like to, and I think part of what we’re trying to do in our culture of health and our work at the Foundation, is work on the underlying contextual factors that will help us improve in these other areas and implicitly that means transferring some of those expenditures on the health side into the social determinate side. And I’ll talk a little bit more about how we’re working on that one.

fifth of Americans live in neighbourhoods that really make it hard to be healthy. This is a corner in the south side of Chicago and these kinds of living conditions are large determinants and the largest determinants of these health disparity outcomes that we are all trying to address. About five years ago the foundation started putting out these maps and they relate to our postal codes and zip codes and I’m going to show you just a couple. This is New York City. In cities, this problem of huge differences in life expectancies within small geographies is the major challenge and you can see on this one nearly 10 years of a difference between the upper east side, Murray Hill of New York City, and Harlem. So you see this in New York City, you see the same thing in Washington DC, nearly 10 years of differences in life expectancy across a very small, a few subway stops, where I have my home in Los Angeles. A five-minute drive down the freeway from Santa Monica to South LA, 15 years of life expectancy differences.

Everyone who looks at these charts says, ‘Well, something’s wrong here’, but the question of how we get at these differences, as important as healthcare services are, we get at those differences from addressing those conditions in place, those social determinates that influence these differences. There’s nothing intrinsic around the communities, their biology, their genetics that would cause this kind of difference, and that’s a major thing that has shaped us and how the foundation is approaching our work. So we’ve started in 1972 and I would say we’ve been a fairly conventional health foundation. We’re the largest philanthropy in the States devoted to health and previously had a focus primarily on health and healthcare. But we’re moving, and I’ll give you more detail on this, into again looking at health systems, but we look at them in terms of them being an anchor organisation for work in social determinants. And we work with them on doing better connection with the communities that they serve. So working on improving the conditions in healthy communities, healthy children, a best start in life, and how do we train leaders across sectors who can manage the complexity that we see in cities, that’s a major part of what we do. So we really embrace this social determinants framework.

We call that building a culture of health and we use the term culture because that’s the deepest thing we have. Culture is like what water is to fish, it’s there, it determines everything you do. You often don’t think about it unless you’re out of your culture – right? Here you talk about lorries, I talk about trucks, it’s a cultural shift. We’re looking to build a culture of health where everyone in America has a fair and just opportunity for health and wellbeing. This has been since around 2005. So that’s our goal. Inherent in that is achieving health equity and we’re doing a lot of work in the States, and actually through our global programmes as well, to really try and norm this as a way to look at how we address health. Not around disparities but around equity, understanding and building on assets that communities have. So health equity means that everyone has a fair and just opportunity to be healthy and I want to focus on what that means. Removing obstacles such as poverty, discrimination, other consequences, issues of power, lack of access to jobs, education, housing, environments and healthcare, but we particularly have focused on some of these other factors around achieving health equity. So we’re working actually internationally now around what does it mean to understand, research and programmatic innovations that close these health gaps and not just measure them.

We’re really pleased that this Culture of Health Action Framework, this graphic here, has had some influence around the country helping people from community health workers to even some Federal Government Agencies who find this framework useful for them in the kind of work that they need to do to improve health and wellbeing. I’m not going to spend a lot of time on each of these areas, but we highlight how important it is that, this is action area one, how we make health a shared value, not just illness care but health a shared value across sectors. A correlate of working on social determinants of health of 80% of what drives health is not healthcare. How do you get those other sectors involved and the collaborations to improve health and wellbeing? Issues of air quality, environment, those are clear examples of those other kinds of influences. Action area three, health happens in places – we know that working in cities. How do we get more equitable community environments? And then how do we, in the States we have, and I think you do here, have disconnects between the different levels of care – hospital, community services, social services – and creating that kind of integration is really critical. So this framework is essential, guides our work.

I think the nicest call that I got in the early years of this was from the US Department of Defence and my first call from the Pentagon. And some person there asked if it was okay if they used this framework to think about how they could build wellbeing between their bases and the communities they reside. Well, I said, ‘Absolutely’, they don’t need our money, the Department of Defence they almost print money, but having this appeal to diverse groups like that. The State of Hawaii has adopted this as their framework for improving public health, Vermont, others, we’ve been very successful with people around the States and I think we’ve had some international influence on this as well, see this as a way to work on population health. And so when we look at what does progress look like in a culture of health, narratives are really important; the stories that we tell, the assumptions we make about people. If we have a narrative of undeservedness that those zip code maps are really based on people not taking care of themselves, that narrative is not the right narrative and it’s not as if that’s going to change those health outcomes. So we’re doing a lot of work, even research, on what it means to understand the narratives and change them around health and values.

Action – we’ve changed all of the research we fund to action research. It needs to be exquisite research, but it has to be understandable by the sectors who can make those changes. And that doesn’t mean you can’t publish in a periodic journal. I’m a recovering academic, you have to be able to do that, but you have got to make these data and these findings understandable and meaningful to the communities and the sectors that we work with. So action-oriented investments and then assessments. The conventional ways that we measure outcomes, again in disease outcomes, it has to be modified and we need more looking at our assessments in ways that, again, capture stories, capture wellbeing in ways that helps us understand thriving. We have a programme that we funded at Harvard that’s come out with a wonderful new thriving index that we’re going to be using around the impact of our work and I can share some of that with you later. So again we are approaching health and wellbeing – we have 35 national measures that we track, looking at these kind of important factors that I’m sure are going to come up throughout the day here.

Residential segregation and it’s kind of paired twin – housing inaffordability – these are tremendous drivers of inequity in the States and from the walk around that we did in South London yesterday, we see some of the same kinds of the things there. Poverty, lack of adequate education, access to healthy foods, air quality is always there and community policing. In our country, Black Lives Matters movement and other movements tell us that unless police begin to think of themselves as public health workers, we’re not going to have the kind of urban health outcomes that we want. So we work on those social determinants of health and when I was training in public health many years ago, never thought that I’d be spending time with housing advocates, architects and others. We share this problem of not having the thriving outcomes that we would like in our population. This chart put together by the Health Foundation, one of our partners in this work, is the risk of preventable death increases with deprivation. As you can see in the chart, the poorest parts of the population in England have the highest rate of mortality and as that deprivation declines. I think we know that, it’s intuitive, we see these kind of data, the point is how do we act on this?

In the United States, the work of Angus Deaton and Anne Case, groundbreaking study that shows in the States this increase in adult middle-aged populations, for the first time life expectancy in the United States is dropping as a whole, but it’s particularly dropping for men and not just white men, other data shows it’s the same for African-American, Latino men as well, these deaths of despair. No one wants to be an addict, so when people are dying from cirrhosis, suicides and the poisoning here relates to opioids, this speaks to people who are at the end of their abilities to cope because of these kind of social conditions that they are addressing.

Race and health – there’s nothing about race that causes these negative outcomes. It is racism and the discrimination related to race that influences these adverse outcomes. I worked for years when I was in public health practice on black infant mortality and we continued to have more than a two-fold difference in infant mortality rates between non-Hispanic Blacks and Whites and other groups, a very sensitive indicator of inequality and very much determined by social context. But unless we confront and name and work on the forces of racism that give you these outcomes – I mean, if you can’t name it, you can’t change it and that’s very important for the work that we do. We funded. and we did this a lot with our national public radio with Harvard, a variety of surveys that we hope get Americans thinking about what really improves health and this is a recent poll, actually, it had the biggest downloads of anything we’ve ever done around discrimination. And then discrimination is how marginalisation really is the engine of marginalisation. And you can see here 32 per cent of Black Americans, 20 per cent of Latinos, 16 per cent of LGBTQ people are believed that they were discriminated against in their ability to access healthcare services.

So we work on things like residential segregation and health. In the US, I think as well as here, people live in neighbourhoods that are largely segregated by race. There is a disproportionate relationship between exposure and this case to particular exposures for people who live in marginalised neighbourhoods compared to others. And this exposure to pollution is associated with a wide range of poor health outcomes. Our previous speaker talked all about that dynamic, I was going to compliment you on the ultra-low emissions zone work. In the States we have poor communities that live next to where diesel trucks transport things to land-based trucks. Those neighbourhoods bear the experiential cost of those business transactions. We work with community groups to act to this to eliminate that truck idling.

I’m going to run through very quickly some of the things we’re doing at the city level that are based upon this way of thinking about health. So Strong, Prosperous and Resilient Communities, SPARCC. This is a collaboration with a variety of other foundations. You see here that we invested and amplify local efforts in six cities to make sure that those cities’ investments, public and private, are really aiming to reduce racial disparities and build this culture of health and prepare for a change in climate. One of those is one example of SPARCC’s activity, this TransFormation Alliance, TFA, in Atlanta. This is really looking at the problem of housing insecurity in Atlanta, the inability of people to also have good access to rapid transit, so we work in Atlanta through SPARCC, with advocating for racial equity as a component of their transit planning and particularly making sure that community stakeholders are involved in a transparent decision-making process.

Another example of our work and again I never thought I’d be doing housing work when I was training in public health. On your left is East Lake Meadows Public Housing Project in Atlanta. Very poor health and school achievement outcomes for kids. A public private collaboration turned that picture into the villages of East Lake. The original tenants were all guaranteed spots in the new facility. One of the things we’ve been working on here in Atlanta, also in Seattle, this mixture of market rate residencies and subsidised residents, creating a thriving community. Data has shown that crime decreased and employment increased, student performance increased. So this is being able to revitalise housing in a non-gentrified way is particularly key. We think data are very important to drive these kinds of collaborations, data that are accessible to communities, this is just an example of another one of our programmes where we support cities across the country in using their data to find out what are the particular issues they need to address through a collaborative process. This is a spotlight of allocating counties data sharing alliance for health, where they’re looking at not just their heart disease rate and just the clinical factors, but they’re looking at issues of food access, built environment, smoking, environmental health. So using that data to have communities understand the social determinants of health.

We’re working with 500 cities – small and mid-sized cities – around the States with this EDC Foundation. We found that providing city and census tracking data in an accessible way is catalysing health departments, community stakeholders to understand their community challenges and collaboratively develop health programmes. An example of this is a very poor community in California, San Bernardino California, that has seen a problem in heart disease and is using some of those data and community actions to address that. I mentioned Santa Monica before. It’s leading small cities in the States around wellbeing and I won’t go into all the constructs here, but this is a community-driven approach in the city of Santa Monica to really recast wellbeing around community resilience, community, planet and place, learning, health, opportunity, with measures of outcomes that are far different than the usual health outcomes. Voter participation, volunteering, graduation rates and literacy rates. Again, these kinds of wellbeing constructs at a city level are really important. And you see this around the world, you see this in Halifax, Nova Scotia. You see a number of other cities that are beginning to take this wellbeing context.

So a lot of time with challenges here. The structural barriers that foster health inequalities, restrictive zoning policies, red-lining, restrictions of capital input into poor areas that don’t allow the kind of innovation that could come from new businesses are a major challenge in cities. Threats to climate change – I think climate change is going to be the biggest impact on health inequality. In the States we’re already talking about climate refugees in Florida, who are being taken from – where wealthy people are moving from their homes on the coast, they’re displacing people in Little Havana and other places that were traditionally communities of colour, forcing those people to move up into Northern Florida, which is not demographically diverse and again is destroying their communities. I think an issue that we all really need to address around health inequities. Gentrification and housing affordability – anyone who can solve the puzzle of reinvigorating cities and their housing and not gentrifying, that is one of the magic things that we need to do. And again, we have to deal with these cultures of despair and marginalisation that improve healthcare outcomes.

But I like to end with hope and I think this group, you’re here today because you are hopeful that these things are changing and we are changing them. I think if we heard what the Deputy Mayor of the commitment and innovation of local government in cities, absolutely essential. Trust and transparency in decision-making processes, again, trust in government to be responsive is critical. This fostering new and additional cross-sector collaborations, this work is not going to be done just by health folks alone. I can’t over-emphasise the importance of community voice and authentic community engagement. People with lived experience of these problems have the key to some of the solutions and planning processes that don’t involve them at a real level, are not going to work optimally, and we need to generate and leverage our community-level data to aid those actions. So I’ll end with my favourite quote from one of my favourite science fiction writers, William Gibson, ‘The future is already here, it’s just unevenly distributed.’ Many different pockets of innovation occur in cities around the world. We just have to understand them, scale and spread them, and move forward. So thank you very much.