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Most recent site update: 11/8/09
Most recent blog post: 11/4/09

Place-based policy

I recently had the privilege to attend the semi-annual CCLHO (California Conference of Local Health Officers) meeting in Oakland, California. This meeting represents an opportunity for county public health officers (often physicians) to collaborate with each other face-to-face. It is a time for those involved in the day-to-day work of public health to connect withpeers, discuss county-wide approaches to current public health issues (like H1N1 flu), and to attend educational sessions about new or alternative approaches to improving the health of Californians. An incredible amount of thought, hard work, and creativity filled our three-day conference, and there was no shortage of discussions about H1N1 preparedness, vaccine distribution and disaster planning. However, one portion of the conference focused our energies toward a more fundamental topic: that of health inequities in California.

Health inequities are probably best defined as "differences in population health status and mortality rates that are systemic, patterned, unfair, unjust, and actionable, as opposed to random differences or differences caused by those who become ill" (1). The implication is that there are structural or system effects in our society which are borne out by how we each live our daily lives. If you think about it, "health" is a result of not only what we choose to do on a daily basis (eat healthy food, exercise, connect with our family and friends), but what we are able to do based on our surroundings. For example, can everyone readily obtain daily servings of fruits and vegetables? Do we have time to sit down and enjoy our lunch with co-workers? Are we able to go jogging every other day? Can we take our kids out to the park on the weekends for some fresh air?

These questions bring us to the idea of place. What role do our physical surroundings play in our health decisions and our health status? If you consider that for some of us it is easier to obtain locally grown fresh fruits, and that for some of us going jogging in the evening is considered extremely unsafe, then place has a lot to do with our daily health choices, and with our overall health status both as individuals and as members of a larger community. This is not a new idea, but it is becoming continually important as local health departments and public health officials seek to reduce rates of chronic disease and mortality in their own communities. It might not be "health policy" as we usually think of it (changing how we deliver care in community clinics or reducing health insurance premiums), but it turns out that small changes in certain place-based policies can have a profound effect on health status. The 2008 report Health Inequities in the Bay Area, produced by a collaboration of public health departments, elegantly demonstrates that our collective health status and life expectancy is directly tied to where we live, our levels of income and wealth, our ethnicity, immigration status, educational attainment and the degree of inequality in our surrounding communities (2). Other data suggest that only approximately ten percent of our health can be directly attributed to improvements in health delivery; in one study reviewing data from the years 1991 - 2000, an estimated 177,000 deaths in the U.S. were averted because of advances in medical technology. However, that same study estimated that if we were to eliminate the disparity between African Americans and Whites, we would have avoided over 886,000 deaths (3).

Many people have written on this topic and it is a well-known concept in many public health departments in California, but the applicability of the ideas are only slowly being realized in state legislation or county regulations. Not that any of this is easy; it takes true collaboration and coalition building to make our communities into healthy places for all. The essential point that I want to reiterate with this blog post is that we can't necessarily get better health outcomes if we focus solely on changing health care delivery, health care institutional policy, or health insurance policy. We need to think about health in broader terms, because health policy is education policy as well as insurance policy; it is social policy as well as health care delivery. It is how we live our lives, and how we are able to live our lives that determines the degree to which we use and need the current health care system. If we consider the current national health reform process in the context of place-based policy, it is clear that health insurance is only one of the determinants that affect our overall health.

(1) Whitehead, Margaret M. 1992. The Concepts and Principles of Equity and Health. International Journal of Health Services 22(3):429.
(2) Health Inequities in the Bay Area. BARHII 2008. Available at: Accessed 11/3/09.
(3) Wilkinson R., Marmot M. (eds). Social Determinants of Health: The Solid Facts. 2nd Edition, Copenhagen: World Health Organization, 2003.

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