Putting Communities in Context for Better Health Philanthropy

posted on: April 15, 2011

Did you know that geography, poverty, literacy rates and other social factors have greater cumulative influence on someone’s health outcome in the U.S. than do disease, injury or mortality? And yet, many health grantmakers fail to take into account these social determinants and base their domestic health grantmaking using a medical lens alone.

Below is an excerpt from chapter two of Towards Transformative Change in Health Care: High Impact Strategies for Philanthropy by renowned health philanthropy expert Terri Langston. Langston argues for the importance of putting communities – and people – in context in our grantmaking.
Communities: People in Context
Imagine two communities in the midwestern United States. If you grow up in one, you can reasonably expect to live approximately 88 years or more. But if you grow up in the other, less than nine miles away, you can expect to live approximately 64 years. You would not think an 18-minute drive could take 24 years, but that is the very real difference in life expectancy between someone who grows up in Lyndhurst, a suburb of Cleveland, and someone who grows up in Hough, a neighborhood in the inner city of Cleveland.[8]Unfortunately, inequities like these persist across communities throughout the country even today. Health outcomes clearly mirror the social determinants of health – the public health framework incorporating social and economic factors in the understanding of the health of people and of communities. The simple truth is, your zip code is predictive of your health and your longevity more than any factor known. As a result, inequities are starkly magnified at the community-level and it is here that the health care system succeeds or fails.

Dr. Anthony Iton of The California Endowment has challenged his colleagues to look into the eyes of the children to assess the health of a community. The kind of pattern recognition that a skilled clinician uses to assess and begin to diagnose a person’s psychological and physical condition by looking at them has been imitated in recent years through research that diagnoses the health status of communities.[9] Such research has resulted in an understanding of the role of place in the health outcomes of Americans.
“Systemic, avoidable, unfair and unjust” are Dr. Iton’s words for the inequities that result from “socio-ecological” factors, including including discrimination, institutional power and neighborhood conditions. These social determinants of health play a larger part in health outcomes than do risk behaviors, disease or injury, or mortality, which comprise the usual measures of the “medical model” that has dominated the country’s public health and medical care. The medical model fails to see people in context.[10]

Context helps us understand the root causes of health outcomes. For instance, social “stressors” have biochemical effects. The body releases cortisol in response to stress.[11] Higher levels of cortisol are correlated with lower life expectancy. Take away the negative stressors in people’s communities – poor housing, the inability to read, discrimination, powerlessness, violence and poverty – and you improve health outcomes.[12]

While traditional medical care is critical and must be reformed, it can no longer be our sole focus. Dr. David Satcher, former U.S. surgeon general, notes that between 1991 and 2000, advances in medical technology averted 177,000 deaths, but he also notes that the elimination of disparities between African Americans and whites could have averted 886,000 deaths. He contends, “If we can achieve health equity and create healthy communities, we can do more to improve the overall health of the nation than is likely from advances in medicine.”[13]

8. Martha Halko, Michele Benko, and The Land Use Committee, 2009 Cuyahoga County Health and Land Use Summit Report, http://www.ccbh.net/ccbh/opencms/CCBH/pdf/communityhealth/2009SummitReport.pdf.
9. Bay Area Regional Health Inequities Initiative (2008), http://www.barhii.org/press/download/barhii_report08.pdf.
10. Anthony Iton, presentation at Consumer Health Foundation Annual Meeting, May 20, 2010.
11. Ibid.
12. David Williams, Manuela V. Costa, A. O. Odunlami and S. A. Mohammed, “Moving Upstream: How Interventions that Address Social Determinants of Health Can Improve Health and Reduce Disparities,” Journal of Public Health Management and Practice, 14 (6) S8 – S17 (2008).
13. Bay Area Regional Health Inequities Initiative, Op.Cit., p. 8.


What are concrete ways for funders to incorporate social factors in their health grantmaking?