Dying and Living in the Neighborhood: A Street-Level View of America's Healthcare Promise
Prabhjot Singh, MD
292 pages, Johns Hopkins University Press, 2016
In Dying and Living in the Neighborhood, physician Prabhjot Singh asks us to “imagine a perfect world in which a high-performing healthcare system and a healthier life in the neighborhood are synonymous. …” And he provides realistic guidance for achieving this goal, based on his research in communities around the country and his experiences living and practicing in Harlem, New York City.
The book is a welcome contribution to the current conversation about improving health at the population level, especially in poor communities. Spurred by the death of one of his Harlem neighbors and patients, who suffered from uncontrolled diabetes and other chronic conditions, Singh seeks change in a field where “most healthcare system operations, financial assets, and information systems are completely disconnected from the support people need outside a clinical network.” Currently, Singh argues, health workers and systems don’t have the experience, mandate, or relationships to address social factors like low income and insufficient education that can lead to chronic medical conditions and early death. But it doesn’t have to be this way, he shows us.
Throughout the book, Singh, who works in New York City as chair of Mount Sinai’s Department of Health System Design and Global Health, highlights a variety of emerging models—many of them promising, even if they sometimes fall short of the goal of truly connecting health systems and neighborhoods. He shows how at Parkland Health and Hospital System in Dallas County, Texas, care teams are using a technological tool called Pieces to track and share information about patients between different health departments and social organizations, allowing them to better support and even predict patient needs outside the hospital and reduce readmissions. Meanwhile, ISAIAH, a racially and ethnically diverse, faith-based program in Minneapolis, is bringing together churches, public health practitioners, and street-level community organizers to address health inequities between demographic groups and pursue policy changes that can shape the social influences on health.
A growing body of evidence demonstrates the value of these new approaches, especially given the United States’ disappointing track record of racial and ethnic health disparities. Like many health trends that Singh documents, these disparities result not only from inequities in medical care but also from neighborhood factors—such as poor schools, limited access to healthy food, and environmental pollution—that affect community members’ health in complex ways.
However, Singh’s otherwise comprehensive review of the current state of health care innovation lacks a serious discussion of these issues of race, ethnicity, and health equity. His case study of ISAIAH in Minneapolis provides a taste of this perspective, but he overlooks other exciting examples of US programs addressing this issue, such as Building Healthy Communities in California, Healthy Places North Carolina, and Project Health Colorado, to name just three of several philanthropic initiatives that incorporate health equity goals.
Indeed, health philanthropy is increasingly recognizing that equity is a vital element in any effort to improve health care. The Aetna Foundation’s community focused funding strategy, for example, takes greater health equity as its main goal and is working with partners and grantees to improve chronic disease outcomes and promote racial and ethnic diversity in health leadership. Aetna’s strategy, and those of many health funders, is based on abundant evidence that social and economic factors related to race and ethnicity profoundly aff ect neighborhoods, health outcomes, and people’s experience of the US health care system. Singh’s book would benefit from likewise acknowledging that serious proposals to improve health at the neighborhood level must take these factors into account.
Still, I was energized by several aspects of the book: Singh’s awareness as a physician that health is more than health care; the innovative thinkers and programs he documents; and his contagious optimism about healthcare systems’ ability to genuinely support healthier lives at the neighborhood level.
To accelerate progress in this area, Singh calls for increased investments from multiple sources to strengthen public health systems, so that “healthcare will have a reliable partner in improving total population health.” He determines, however, that greater funding alone is not enough, because solutions that are primarily driven by the decisions of public healthcare systems, rather than the social situations of the people they serve, cannot keep pace with ever-evolving community dynamics. And so he returns to the idea that for efforts to be successful at the population level, they must first connect health care more closely with neighborhoods.
Healthcare systems in other countries already place this focus on communities, Singh points out. Drawing on his past medical work in sub-Saharan Africa, he notes that for many countries in that region, “the concept of community-based accompaniment is integral, not ancillary, to how healthcare systems function.” To really improve the US system, he believes, Americans, too, need to see neighborhoods and communities as “the primary infrastructure for improving health.”