In its 2017 Culture of Health prize call for applications, the Robert Wood Johnson Foundation invites communities to consider how “where we live, work, the safety of our surroundings, and the relationships we have in our families and communities” influence our health and well-being. These considerations are to to encourage organizations and groups applying to identify strategies that address the entire ecosystem necessary to promote total health.
The prize guidelines speak to a reality that many of us intuitively know: healthcare providers don’t operate in a vacuum. Stellar healthcare systems and quality access to care alone can’t guarantee the positive, lasting health outcomes that organizations like RWJF are after. A hospital may be able to provide outstanding services while a patient is under their care, but if that patient returns to an unsafe home, lacks access to healthy food, or lives in a community plagued by pollution, then the health benefits may not be sustainable. Thus, these various “social determinants of health” reflect the social, political, and economic factors that are necessary to create a culture of health.
Nevertheless, many people may be surprised that the Culture of Health Prize winners represent multi-sector stakeholders interested in addressing the multiple complex factors necessary to achieve health and well-being. The RWJF prize clearly sets out six criteria that call for a cross-sector set of stakeholders to be systems-oriented in the quest for health–to commit to equity, data use, policy change, and improved practice in service of creating environmental conditions for health and well-being. Still, practitioners working outside of the health discipline have a hard time seeing how they can have an impact on health or seeing themselves in the work of creating health and well-being for communities.
That could include an organization like Living Cities, for example. For us, economic security is at the heart of our equation, and economic prosperity is part of well-being. Our work, and the work of many of our close partners, is centered on strategies that will ensure that all people in America are earning a living wage and building wealth. And we recognize that creating the conditions for economic security requires more than job creation and wage growth. It means transforming systems so that people are healthy, housed, prepared for work, and connected to job opportunities and more – and acknowledging the impact that racial inequities have had on each of these systems. It means that people need to be socially, mentally, emotionally, and physically healthy. Just as employment is an input into the health equation, being healthy is a prerequisite for being able to enjoy steady employment and economic security.
Too often, we as social change organizations lose sight of the bigger picture, and fail to acknowledge the reality that we are pulling different levers within the same ecosystem. Likewise, health institutions must not forget that organizations transforming economic outcomes are also partners in the work of building a culture of health. When we ignore these deep ties, we each overlook opportunities to bring critical players across sectors to the table.
Our driving mission is to close racial income and wealth gaps by creating an ecosystem where people, particularly low-income people and people of color, are economically secure and ultimately building wealth. In our quest for economic security, we’ve widened the lens to look at the array of factors driving racial gaps in income and wealth:
- Low quality education and few opportunities for low-income children and children of color
- Poor health, healthcare access, and resources to maintain quality health
- Disparities in transportation (e.g. fewer stops and less mile coverage in areas with greater need)
- Limited affordable housing in places where jobs can be better accessed
- Low to no skilled labor
- Displacement due to rise in cost of living due to concentration of new businesses (especially technology-based firms) in cities
- Policies (across the spectrum) that perpetuate barriers
- Destruction of the physical environment (e.g. highways breaking up communities, hazardous plants being placed in poorer communities with large concentrations of POCs, food deserts, environmental hazards, lack of clean water and air in poor communities)
A Model for The Social Determinants of Economic Security
As you can see from the above list, many factors are predeterminants of the ability to achieve economic security. Like RWJF’s social determinants of health, we can list our own set of “social determinants of economic security.” Access to healthcare is among them, as are access to transit and technology, education, job readiness, and more, which together create an ecosystem in which people can achieve financial stability and flourish.
What we are finding in our work is that there are major gaps and disparities across social, political, and economic systems, with structural racism as a primary root cause. Let’s take a moment to imagine what our communities would look like if these disparities did not exist:
- All children would enter kindergarten ready to learn
- Black and brown boys would be on track for third grade reading
- College access, matriculation, and retention would be experienced by a diversity of racial, ethnic, income groups
- Formerly incarcerated people would be reintegrated in society and able to work, live, and vote
- Entrepreneurs of color would have access to the all types of capital (fiscal, networks, human, capacity) to start, scale, and sustain businesses for multiple employees
- Neighborhoods would be safe and welcoming
- People would be able to get to and from work efficiently and safely
- People would be healthy and have the care they need
- Local, state, and federal policy and practice would reinforce well-being
- Physical environments would be conducive to the health and well-being of people and environmental sustainability
With all of these conditions (and the other conditions of well-being we have missed) in place across racial, ethnic, and income groups, families would be economically secure and capable of building intergenerational wealth.
However, vast inequities in our systems’ policies, practices, and processes prevent people from experiencing well-being or living, working, and thriving. Racial equity is the missing key driver that is necessary to get dramatically better results for low-income people and people of color. If we don’t solve for the structural barriers that create racial disparities, we will fail at creating conditions for health and well-being for all. Some would argue that we can’t solve for “all” because it’s nearly impossible and we can’t control for personal choice and behavior. I’d offer that if we don’t shoot for “all” we will let ourselves off the hook and miss out on having the maximum impact possible. Secondly, while personal choice is a factor, we can’t use it as an excuse for perpetuating behaviors that continue to exclude chronically marginalized groups of people from participating in the social, political, and economic marketplace. And that means we can’t achieve equitable and inclusive outcomes for people.
Integrating each of the component parts needed to achieve economic security – or health, or education, or housing, for that matter – will require those of us working in each of these fields to view ourselves as part of this holistic picture. We work inside the systems that affect communities’ ability to live lives of economic security and prosperity. The fields we work in are separate, but the issues we work on are intertwined, and tackling them will require a new way of working together.
Three pieces that will be crucial in taking on these challenges are relationships, resources, and risk. Having authentic relationships that are built on trust allows stakeholders to navigate challenges, engage partners (likely and unlikely), create buy-in, and build will in service of results. Coupled with relationships, resources allow stakeholders to focus on getting the work done rather than spending their energy looking for resources. Being willing to take on a bit of risk to push beyond the status quo can accelerate progress toward results and demonstrate measurable impact along the way. Changing the way we work together requires each of us to assume a responsibility, and when we each learn to see ourselves as part of this ecosystem, we will be able to improve the lives of low-income people effectively and equitably.