The ABC of Life Expectancy

As America’s life expectancy continues to recover from its pandemic-induced drop,1 the conversation has inevitably returned to why it remains below that of other wealthy nations. Despite the growing appreciation that social conditions are fundamental to health, there is a lack of consensus on what to do.2 Indeed, finding that consensus is difficult when Healthy People 2030, the federal government’s program to identify public health priorities, has set 358 “evidence-based” objectives, promising more on the way.3 Compounding the inertia is the growing appreciation that our social conditions are not natural, organic phenomena but the product of historic and contemporary social, economic and political forces enacted through the laws, policies, systems, and institutions that shape our lives.4 In 2008, the California Endowment, a foundation dedicated to improving the health status of Califor-nians, decided to try to tackle inequities in health by supporting 14 low-income communities to influence political and institutional leaders to enact stronger health protective policies across the full spectrum of the social determinants of health. Our idea was to increase the efficacy of these communities to influence decision makers and change policies and policy priorities. The work was inspired by the recognition that life expectancy, a key measure of health status, can vary as much as three decades across neighborhoods in the same American city. This variation is not readily explained by health behaviors,5 genetics,6 or access to health care,7 but appears more closely tied to socioeconomic variables like education and income,8 and community resource access.9 The expression that when it comes to your health, your zip code matters more than your genetic code, is a reflection of the fact that where you live shapes your health in ways over which you have little individual control.10 In health, place matters. The California Endowment’s initiative, called Building Healthy Communities (BHC), was a decade long place-conscious11 initiative designed to sever the tight relationship between zip code and health in low income- communities. The work involved supporting a critical mass of local residents to become informed, engaged and active participants in local, regional, and statewide political and administrative processes. Four years into our work, we began to see promising results. Residents had forced a chronic polluter in Kern County to clean up its act and hotel owners in Long Beach to pay workers a living wage.12 Mindful of the obesity and chronic disease epidemic, young residents focused on issues such as improving parks in Fresno and San Diego, reopening the community pool in Merced, and making school lunches in Del Norte healthier. Several sites collaborated to create successful movements to end the statewide school-to-prison pipeline, and push for universal healthcare to include undocumented Californians. As the initiative progressed, we got clearer on what terms like “influence,” “efficacy,” and “engaged” were referring to – the agency of a community or, alternatively, its power. Ultimately, we were building the power of historically excluded adults and youth to hold systems accountable for health equity. Len Syme, the noted social epidemiologist, described the concept of ‘control of destiny’13 – the ability of people to deal with the issues that confront them in their daily lives – as a significant health factor for individuals and communities. His theory derived in part from the discovery of social gradient in health, which was first described by Syme’s former student, Sir Michael Marmot, in the famous Whitehall Study.14 Our work embraced Syme’s theory of control and sought to enhance community-level agency through investments in robust community organizing. Confronting the legacy of America’s long and invidious history of racial segregation, disinvestment, and oppressive policing is a central challenge for community health improvement initiatives that are committed to deep community engagement. BHC was no different. As the work progressed some deep-seated tensions began to emerge, often between community members and systems leaders (eg, Sheriff, police, city planners) but also between different racial groups who had differing perspectives on issues like policing, education reform, and economic development. It very quickly became clear that we needed to slow down and create more deliberate time and space for addressing these tensions. Many community members spoke of unresolved trauma resulting from the unjust historical actions of government, police, political leaders, and private businesses, including redlining, neighborhood disinvestment, school segregation, and racially discriminatory policing. John Powell, a renowned civil rights scholar and public intellectual, describes one prominent way in which racism manifests in America as fundamentally a struggle over who belongs.15 Different racial groups with different histories and experiences in their community may develop differing perspectives, but what is shared by many is the experience of racism as a collective trauma and a sense of being treated as if they do not belong. This trauma creates chronic injury which, if ignored, can often flare up acutely and deepen distrust of government and institutional leaders and exacerbate inter-group conflict among community members. Like any physical trauma, the collective trauma incurred from years of experiencing racial dehumanization, marginalization, and maltreatment, requires substantial healing. Belonging encompasses feeling valued, respected, and understood for one’s unique identity, background, and contributions. In our work, we began to think of belonging as an antidote to the collective impact of racism. By working to create stronger sense of belonging in our communities, we saw an opportunity to help heal the trauma of racism and create bridges across different racial groups and foster more trust for institutional leaders. That work entailed creating spaces and opportunities for community members to speak about their cultural histories and experiences, as well as hear and reflect on others. The goal was to help community residents create a stronger shared identity and to co-create a new narrative of their community. While addressing the collective trauma of racism is critical to improving community health, structural racism presents a different type of challenge insofar as it manifests primarily in the policy realm. Structural racism often presents as the absence of affirmative policy in the face of abject need and/or the failure of critical institutions to facilitate access to opportunity, such as in education, housing, and employment. It often leads to a skewed distribution of health protective resources and opportunities, favoring the wealthy and creating gaping holes in the social safety net. We recognized that while many early policy wins had been at the city and county level, some changes could not be achieved locally.16 The 14 local communities needed to combine their power to bring about region-wide and state-wide changes and ultimately work to change local conditions by strengthening the statewide policy landscape. In essence, we needed to work with our communities to repair our basic social contract, the idea that we collectively institute a government in return for an equal opportunity to pursue fulfilling lives. We were aware that the work of policy and systems change is often highly specialized, involving actors such as communications experts and skilled legislative and legal advocates, so to repair our social contract in California, we needed to bring residents, organizers, and professional advocates together, groups often of very different backgrounds and ways of working. Over a decade of BHC, hundreds of policy changes were achieved with many at the statewide level, including significant progress towards universal health insurance coverage,17 a dramatic reduction in school suspensions and expulsions,18 significant reductions in mass incarceration,19 and sustained progress in environmental justice.20 Since 2020, we have been exploring how to create a state-wide ecosystem conducive to resident power. We are learning that it requires an infrastructure of forums, coalitions, alliances, and communications channels, all powered by a shared analysis of the root causes of inequity and shared belief in justice.16 By the end of our initial 10-year commitment, we’d spent $1.8bn, a lot more than the $1bn we’d initially committed. In 2021, we committed a further $2bn over the next 10 years and expanded our work from the 14 communities to the whole of California. Looking back, our work has taken us to the very source of inequity – the power imbalances that are rooted in our society. It is the less powerful, after all, that have the worst health outcomes. This unjust arrangement betrays America’s social contract. The absence of proven universal policies, such as healthcare, childcare, and paid parental leave, represents a reneging on that contract. Racism and its legacy of dysfunctional institutional arrangements and our pockmarked opportunity landscape lies at the heart of our country’s health inequity. All in all, despite the 358-part complexity of Healthy People 2030, our work has shown us that the core recipe for achieving health equity by strengthening social determinants of health may be described as ABC – only communities with sufficient agency and a strong sense of belonging can reweave and ultimately enforce the social contract that underpins our health and life expectancy.