For 40 years, the Robert Wood Johnson Foundation has worked to improve health and health care for all Americans. Our mission demands that we confront head-on inequalities in access to high-quality health care and other factors that contribute to health and longevity, especially for populations that are most vulnerable. As we define vulnerable children and families, poverty weighs in no matter what criteria we use.
Health status trends have paralleled the patterns of poverty over the years. Who is affected, where they live, and what their backstory is all contribute to explaining changes in health as well as wealth. Although in the United States we can claim many advances and improvements, in comparison with the rest of the developed world we are not in good health. According to the most recent United Nations data, the United States ranks 36th in life expectancy among industrialized nations.
For decades, policymakers, scholars, public health workers, community development leaders, advocates, and others have worked to address the problems of poverty or poor health. To effectively reduce poverty and poor health, however, we now know that we must address both, as well as the contributing factors they share. We have learned that factors that are integral to poverty, such as insufficient education, inadequate housing, racism, and food insecurity, are also indicators of poor health. We know that a child’s life expectancy is predicted more by his ZIP code than his genetic code.
Although it is essential, increasing access to health care is not sufficient to improve health. There is more to health than health care. In fact, health care plays a surprisingly small role among the factors that contribute to premature death, just 10 percent; in contrast, social circumstances (15 percent), environmental exposures, genetic predisposition, and personal behavior combined contribute to 90 percent of preventable deaths.1 With this in mind, we have broadened our foundation’s strategies to embrace improving health where it starts: in the places where people live, learn, work, and play.
A large and growing body of research evidence shows that the complex array of factors that are intrinsically linked with poverty make up the “social determinants” of health. As we documented in our Overcoming Obstacles to Health report,
- The higher a person’s educational attainment and income, the more likely that person is to have a longer life expectancy. In fact, those in the highest income group can expect to live at least six and a half years longer than those living in poverty.2
- Compared with adults in the highest income group, poor adults are nearly five times as likely to be in poor or fair health.3
Why is this? A few explanations exist that are both evidence based and logical: Adults with higher incomes or more education are more likely to be physically active; as a family’s income rises, their children are also less likely to be sedentary. Additionally, as a family’s income rises, the quality of their diet improves and the likelihood of smoking cigarettes decreases. And the higher the family income, the healthier their children are likely to be.
The cross-generational ties to poverty are also ties to poorer health. Here are a few examples: Babies born to mothers who did not finish high school are nearly twice as likely to die before their first birthdays as babies born to college graduates. Children in poor families are about seven times as likely to be in poor or fair health as children in the highest income families. Children whose parents did not finish high school are more than six times as likely to be in poor or fair health as children of parents who earned a college degree.
Because of the need to address these “social factors” in the most strategic way, four years ago we convened the Commission to Build a Healthier America to explore those factors outside the health care system that affect health. We charged the commissioners to craft actionable recommendations for change. The commission, led by economists Alice Rivlin and Mark McClellan and comprising leading experts from a broad range of sectors, came back with 10 recommendations that focused largely on communities rather than health or disease prevention. As they reminded us, the economic and social vitality of the neighborhood or community contributes to residents’ health and longevity. From ensuring that children have access to early childhood education, to creating public-private partnerships to open and sustain full-service grocery stores, to developing cross-sector healthy community demonstration projects, to making sure that housing and infrastructure projects consider the health impacts of their work, the commission made clear points about how we should shape our foundation’s work.
As stated in Overcoming Obstacles to Health, our background report to commissioners, “the greatest potential lies in solutions that will help people choose health. That means both strengthening individuals’ ability to make healthy choices and removing obstacles to choosing health.”4 What does this tell us? In order to improve health in this country, the health sector must work closely with those who plan and build communities, especially the community development and finance organizations that work in low-income neighborhoods to build child care centers, schools, grocery stores, community health clinics, and affordable housing. From the health perspective, our interest is less about the buildings and more about what happens in them. Are the schools providing healthful food and eliminating empty-calorie snacks? Is there daily physical activity during and after school? Are grocery stores providing and promoting healthful foods? Are health clinics providing “prescriptions” of healthy lifestyles and services such as the Supplemental Nutrition Assistance Program, in addition to medications? Is affordable housing situated in proximity to safe places to play and be physically active? Is the neighborhood walkable, with well-lighted sidewalks that lead to public transportation, jobs, and services?
Health care providers also are well aware of this need. As a physician, I generally cannot discuss health with a patient who lives in poverty without talking about the areas where community development works: affordable housing, access to nutritious food, and safe places to play and exercise. I can attest that it is important for us to ensure that health and community development work together. In fact, a recent national survey by our grantee HealthLeads5 (a program that provides to patients “prescriptions” for community services) found that four in five physicians believe that unmet social needs—lack of access to nutritious food, transportation assistance, and housing assistance—are leading to worse health among Americans. These findings send a clear message: the health care system cannot overlook social needs if we want to improve health in this country.
We have seen that despite a person’s personal motivation to practice healthy behaviors, the barriers to change are often too great. Consider, for example, a woman with diabetes. In addition to the health care she receives, she also will be counseled to modify her diet to include more fruit and vegetables, or to exercise more. But if this woman is poor, there is no accessible supermarket, and her neighborhood is unsafe, she will be much less likely to follow these recommendations. Her diabetes will likely not be abated, her health will deteriorate faster, hospitalizations will be required sooner and more often, and complications will come earlier. All of these are affected by factors outside the medical care system.
Improving America’s health requires leadership and action from every sector, public, private, and nonprofit, including people who work in public health and health care, education, transportation, community planning, business, and other areas. As Opportunity Finance Network President and CEO Mark Pinsky and I wrote in a joint column in early 2012, “building new collaborations also makes fiscal sense since improving low-income communities yields both health and economic benefits.”6
OUR PERSPECTIVE ON THE ROLE OF PHILANTHROPY
Let me be clear: the work of the Robert Wood Johnson Foundation is laser-focused on improving health and health care. But we know that to do so, we must expand the scope of our vision and work. We understand that neither improving health nor reducing poverty is the endgame. Our vision is to create opportunities for all Americans to lead long, healthy, and productive lives. At the foundation, this outlook has led to an evolution in how we work: changes in grant making, how we use our assets, and how we work with others.
First, the focus of grant making is evolving: we are investing in research and data, policy advocacy, and infrastructure building that strengthens communities. A recent example of this involves our County Health Rankings,7 which rank the health of every county in the United States, in part on the basis of social factors. These rankings have inspired change. Two years ago, Wyandotte County, KS, was ranked last in the state because of factors including high levels of violent crime and unemployment, deteriorating neighborhoods, and a high percentage of families living below the poverty line. When he saw how badly the county was doing, Kansas City Mayor Joe Reardon tapped county officials and stakeholders to address the social problems that were at the root of the health problems. This community is now cited as a national example of partners working together on social determinants of health to create effective change.
A related project and another grantee of our foundation, Roadmaps to Health,8 funds community partners to address the impact of social factors identified in the County Health Rankings, such as employment or education. In Alameda County, CA, for example, the project will make consumer-focused banking services available to residents of low-income neighborhoods and educate them about the benefits of these services, such as using bank accounts without minimum balance requirements instead of check-cashing or bill-payment services with fees. In New Mexico, they will advocate for policies that create, fund, and sustain a high-quality, universally accessible continuum of early childhood care, health, and education services.
The foundation also funds the Health Impact Project,9 which promotes the use of health impact assessments to help local decision makers to identify and address the health impacts of a policy decision or project such as building a major roadway or planning community improvements. In Minnesota, an assessment10 of the possible health impacts of changing public transportation lines indicated “serious potential threats” to more than 1,000 small businesses as well as to health, housing, and job access for the large low-income and minority communities in the affected area. The foundation was also an early supporter of work to build grocery stores in “food deserts” that helped to shape the Healthy Food Financing Initiative (HFFI), which will improve access to healthful foods in similar food deserts across the country. A partnership between the Community Development Financial Institutions Fund in the U.S. Treasury Department and the U.S. Departments of Agriculture and Health and Human Services, HFFI is investing $500 million annually to subsidize grocery stores in low-income neighborhoods. This increases access to healthy foods and creates jobs, and these stores are profitable.
Our Healthy Kids, Healthy Communities11 program supports local action to increase opportunities for physical activity and access to healthful, affordable foods for children and families. The goal is to catalyze policy and environmental changes that can make a lasting difference and be replicated across the country. The program is part of the foundation’s $500 million commitment to help reverse the childhood obesity epidemic in the United States by 2015.
We are also broadening the ways that we use our financial assets. In 2011, we announced a $100 million capital impact fund to leverage funding and nonfinancial resources from other foundations, government, and nontraditional funding partners, including private capital from individual and institutional investors. By building on growing interest in using investments to address issues such as economic development, education, housing, and the environment, we intend to be among the foundations leading the way, sending a market signal that health is the new frontier for impact investing.