This supplement to the Stanford Social Innovation Review explores the diverse social factors that affect population health and health equity. The articles move far beyond focusing on the obvious weaknesses in our health systems to examine how socioeconomics and culture, environment and geography, race, sexual identity, and more influence population health. They illuminate the heart of the health equity challenge and reveal a common perspective: that solutions will come not from a single source, but rather from the combined forces of policymakers, legislators, national and community leaders, private companies, nonprofits, foundations, and many other stakeholders.
This special supplement examines the organizations and programs that are addressing social inequalities in housing, transportation, work, and other parts of society that create disparate health outcomes.
We’re proud to sponsor this supplement because at the Aetna Foundation, we view all of our initiatives, partnerships, and grantmaking activities through the lens of health equity; we concentrate on innovations that can improve the health of underserved populations. We hope the articles you are about to read will help to enrich the dialogue surrounding one of the most serious challenges our nation faces today—and spark potential solutions to it.
Where You Live Is How Long You Live
It’s startling how strongly a person’s health and longevity correlate with where he or she lives—a person’s ZIP code is a stronger predictor of overall health than many other factors, including race and genetics.1 For example, the life expectancy for a child born in New Orleans can vary by as much as 25 years between neighborhoods that are only a few miles apart.2 In Boston, one census tract in the Roxbury community has the city’s lowest life expectancy,3 and at 58.9 years it’s similar to how long the average American lived in the early 1920s. In Back Bay, just a neighborhood away, the life expectancy is 91.9 years. Premature death, lower worker productivity from illness, and more treatment of medical conditions constitute the economic cost of health disparities—up to $309 billion annually in the United States.4
Solutions will come from the combined forces of policymakers,
legislators, national and community leaders, private
companies, nonprofits, foundations, and other stakeholders.
Access to care and health information, as well as to basic necessities such as affordable, healthy foods and safe places to engage in physical activity, influence quality of life and well-being. Our health is significantly affected by the social, economic, and environmental conditions of the communities where we live. Because disparities vary with geography, we must reach people in the places where they spend time—in their homes, schools, jobs, neighborhoods, and faith-based groups. We must work to strengthen community-based infrastructure and find innovative ways to affect people in their daily lives. From different vantage points, and with different strengths, we must pursue a variety of strategies that complement one another. Here are three of the strategies that the Aetna Foundation is investing in to achieve health equity.
Using Data To Drive the Right Strategies
Some US states experience lower premature death rates from various causes than others. If all states were to achieve the lowest observed mortality rates for the top five causes of premature death (for people under 80 years old), we could prevent 250,000 deaths annually.5 But with myriad economic, social, and policy factors affecting these outcomes, it is challenging to draft strategies that will achieve the lowest premature death rates in every state and community. A critical first step is gaining a comprehensive understanding of the root causes of health disparities at the community level, to inform the decision making that will result in meaningful changes in health laws, policies, programs, and educational institutions.
The Camden Coalition of Healthcare Providers is testing one model for how we can achieve such understanding. The Coalition works in Camden, N.J., one of the nation’s poorest cities, where an estimated 30 percent of health-care costs are devoted to 1 percent of the population.
With the Aetna Foundation’s support, the Camden Coalition is creating a social determinants of health database (SDD) that collects health data and integrates them with social data from agencies serving the Camden community. Aggregated social data include educational attainment, law enforcement records, employment status, and homelessness. Analyzing the SDD data will profile vulnerable groups and reveal social issues that affect care. By clarifying the flow of services across Camden, the SDD will also generate cost savings by revealing how service providers might distribute limited resources more efficiently. The database will be accessible by researchers, policymakers, community leaders, advocacy groups, the media, private foundations, and most important, the public.
The Aetna Foundation is also investing in digital health technology. According to data from the Pew Research Center, a majority of low-income adults have access to a mobile phone (84 percent)6 or a smart phone (50 percent),7 and nearly two-thirds (62 percent) of smart phone owners report having used the phone to look up health information.8 The increased use of mobile technology in these communities may facilitate the spread of information and tools helpful for making good health-related decisions. In addition, as mobile technology continues to improve, health policies and initiatives will benefit from the data generated by sensors that can monitor, among other things, heart rate, steps taken, and routes traveled, and also whether a user is running, walking, ascending, or descending.
An important first step in adopting healthy behaviors is to have clarity about one’s current health status and disease risks. To this end, the Washington University School of Medicine in St. Louis has published an evidence- based smart phone app called Zuum. The app asks each user to complete a brief survey and then lists the individual user’s healthy habits alongside lifestyle modifications that could further reduce her various disease risks. Users can send these results to doctors, family members, or friends, thereby enabling positive reinforcement. With Aetna Foundation support, Washington University is assessing the feasibility of integrating Zuum into various clinical care settings in urban St. Louis and rural Illinois, where the population is largely low-income and underinsured.
The Aetna Foundation also recognizes that healthy eating is an important component of healthy living. Residents in areas with the highest economic need often have the least access to affordable healthy food. To improve the availability of healthy foods in these communities, the Fair Food Network is drawing on Aetna Foundation funding to test a smart phone app that processes food assistance benefits more simply and affordably at farmers’ markets. This method may allow for widespread adoption of Supplemental Nutrition Assistance Program (SNAP) benefits by individual farmers, thereby increasing the demand for fresh foods while also increasing the likelihood that they reach dinner tables.
At the Aetna Foundation, we believe so strongly in the potential benefits of emerging technology that we also recently dedicated significant funding to an initiative designed to highlight and elevate some of the most promising innovations. The “Healthier World Innovation Challenge” is designed to support digital health innovations that measurably improve chronic health outcomes in underserved communities. This challenge is part of a larger, three-year commitment to digital health innovations that the Aetna Foundation is making to address public health concerns.
Community Focused Funding
The third strategy we employ to promote health equity is community focused funding. Our funding model includes partnerships with both national and local organizations to stimulate positive impact at both the population and community levels. With greater health equity as the common goal, our partners and grantees are advancing new models or expanding on standard practices for chronic disease prevention and management; promoting community-centered health systems that integrate data from public health, social services, health care, and other sources to improve chronic disease outcomes; and elevating promising practices that build racial and ethnic diversity in health leadership.
Beyond a fundamental focus on underserved populations, we look at every funding or partnering decision through two different lenses. The first is impact. We challenge our partners with this question: How will this project effect change and for whom? Part of this exercise is to define specific goals, strategies, and tools and to use well-defined metrics to measure progress and success. The second lens is scalability. Here the challenge for partners is to answer this question: If this project works out well, how can we replicate it elsewhere? We want success to spawn numerous other successes, working from models that are proven, flexible, and sustainable. The combination of impact and scalability has the potential to deliver results that are exponentially more profound than projects that don’t have this focus, changing lives in communities far removed from those where an original approach was invented.
As the Aetna Foundation has intensified its focus on funding innovation, we have learned several lessons that may be useful to other funders seeking novel solutions to the health equity problem. We have learned to:
- Accept heightened risk. Innovation naturally involves exploring new ideas, which means that funders must be comfortable with risk. Nevertheless, it’s important not to get swept up in the hype surrounding new technologies, but instead to concentrate on whether an innovation will truly meet a community’s needs.
- Be flexible with the innovators. True game-changers can be difficult to find, so funders themselves must be innovative in how they solicit novel concepts from the field and engage prospective grantees. Finding game-changers requires an iterative process: If you don’t find what you are looking for right away, refine your methods and try again.
- Consider strategic and human dimensions. When you are funding innovation, it’s important to consider both the broader strategy—evaluating it rigorously through multiple methods—and the human interface, ensuring that disruptive practices are developed with the end user’s complex needs always at the forefront.
- Design with the best available insights. Addressing health equity through innovation should include community-centered design and implementation strategies, as well as a cross-sectoral approach that takes into account social determinants of health.
Broadening the Conversation
The health equity challenge is complex because it is not just about health and medical care. As the authors contributing to this supplement aptly demonstrate, it is intertwined with advocacy, social justice, grassroots organizing, environmental health, workers’ rights and safety, community development, racial equity, LGBT health, housing, transportation, and an array of other issues. The conversation about health equity, then, must be broad. And everyone has a role to play in carrying it out.