Most people who live long and healthy lives in this country do so without much assistance from the U.S. health care system. In fact, a reasonable goal of most Americans is to live a life that allows us to avoid hospitalization, emergency room visits, and even our physician’s office, except for routine screening and preventive services. The best strategy for doing this is to avoid acquiring a chronic disease. The medical care costs of people with chronic diseases account for more than 75% of the nation’s $2 trillion medical care costs. Chronic diseases, (primarily heart disease, stroke, cancer, and diabetes), are the cause of seven of every 10 Americans deaths. The prevalence of chronic disease in a community is a primary driver of the demand for health care services. Much of this is preventable.
While access to a high-quality system of affordable health care is an important human right and a necessary strategy for improving health and quality of life and reducing health disparities, health care alone is not sufficient to “produce” health in populations or to drive down the prevalence of chronic disease. We know that health, disease, and death are not randomly distributed in communities. Illness concentrates among low-income people residing in certain geographical places. In Alameda County, this phenomenon is particularly stark among low-income African Americans in certain neighborhoods in Oakland, however, Native Americans, Pacific Islanders, Native Hawaiians, Latinos and other immigrant groups of color also suffer a disproportionate rate of disease based on income and geography. The primary manifestation of these health disparities is in much higher rates of chronic disease. A civilized society does not consign whole populations to foreshortened and sicker lives based on skin color and bank account size. The question for us is: Are we a civilized society? If we are, then we must solve the riddle of poor health and its linkage to race and place. The key to this riddle is health equity.
Health inequity is related both to a legacy of overt discriminatory actions on the part of the government and the larger society, as well as to present day practices and policies of public and private institutions that continue to perpetuate a system of diminished opportunity for certain populations. Inequities in the economic, social, physical and service environments continue to create and maintain clear patterns of poor health in Alameda County, statewide and nationally. Social inequity causes health inequity.
Deliberate public and private policy helped create the inequitable conditions and outcomes that confront us today. Consequently, the deliberate new policy is needed to “unmake” inequitable neighborhood conditions and to decouple health from race and place. Such action might include formal legislative policies such as laws to encourage mixed-use housing, universal preschool, or transportation funding. It might include organization-based policies that are not legally required, but designed to improve our collective ability to address health inequities. Different ways of doing business would include new partnerships between health departments working with different city and county agencies, crossing disciplines and sectors. Finally, informal policies would also influence our ability to work together to eliminate health inequities.
With sustaining current health care system being a major national priority, we have a tremendous opportunity to continue to make strategic investments in primary prevention that will reduce the burden of chronic disease and eliminate health disparities. The current health care reform debate is driven in large part by concerns about ever-growing, unsustainable costs. Immediate cost-containment efforts are necessary, but they alone will not solve the long-term problem— more lasting changes are needed. Chronic disease rates are the major force driving up the costs of health care. Primary prevention is a systematic process that promotes healthy environments and behaviors before the onset of symptoms, thus reducing the likelihood of an illness, condition, or injury occurring. The bulk of those preventive strategies, particularly the community-level strategies, occur outside of the health care system and are strongly influenced by social and economic policies particularly policies shaping land-use, employment, transportation, income, and education. California’s experience with tobacco control is arguably one of the clearest examples of the benefits of primary prevention on health status, mortality and health care costs.
Chronic disease in a population is highly amenable to individual and community-level prevention. Health and rates of chronic disease are influenced by factors such as toxins in the air, water, and soil; access to healthy foods, parks, and recreational facilities; and the walkability and safety of neighborhoods. Primary prevention—with an emphasis on improving the environments where people live, work, play, and go to school—is the prescription for reducing the health care system’s burden and thereby reducing the costs associated with paying to treat preventable conditions.
Dr. Tony Iton is Senior Vice President for Healthy Communities at The California Endowment.