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Community Development & Health By Mariana Arcaya and Xavier de Souza Briggs doi: 10.1377/hlthaff.2011.0778 HEALTH AFFAIRS 30, NO. 11 (2011): 2064–2071 ANALYSIS & COMMENTARY ©2011 Project HOPE— The People-to-People Health Foundation, Inc. Despite Obstacles, Considerable Potential Exists For More Robust Federal Policy On Community Development And Health Mariana Arcaya (marcaya@ hsph.harvard.edu) is a doctoral ABSTRACT The implementation of the Affordable Care Act of 2010 and the candidateintheDepartment Obama administration’s urban policy create an opportunity to link of Society, Human Development, and Health at community development with health in new and powerful ways. The the Harvard School of Public ’ Health, in Boston, administration s policy emphasizes improved access to and quality of care Massachusetts. through coordinated local and regional approaches, expansion of access — Xavier de Souza Briggs is an to healthy food, and the support of environmental health including associate professor of clean air, water, and soil—and healthy homes. New federal programs, sociology and planning at the ’ Massachusetts Institute of such as the Affordable Care Act s Community Transformation Grants, Technology, in Cambridge. seek to prevent death and disability through policy, environmental, programmatic, and infrastructure changes. But fragmented congressional jurisdiction and budget “scoring” rules pose challenges to needed reform. We argue that government agencies need to adopt so-called systems of innovation, or organizational practices and support mechanisms that seek continuously to test new models, refine promising ones, bring to scale those that work best, and restructure or terminate what does not. We also argue that a strong and well-focused policy advocacy coalition is needed to help drive reform focused on the social determinants of health. he implementation of the Afford- demands coupled with little decision-making able Care Act of 2010 and the im- power or control at work—is linked to poor car- perative to reduce the cost of health diovascular health.2 Low and unstable income care while improving outcomes cre- predicts worse cognitive, physical, and psycho- ate the opportunity to forge closer logical functioning over time, compared to the Tlinks between community development and functioning of people who do not suffer eco- health. Fortunately, the evidence base is now nomic hardship.3 Discrimination is a known risk strong enough to warrant a major focus on shap- factor for unhealthy behavior, psychological dis- ing the social determinants of health through tress, and high blood pressure.4 community development. More proximate social determinants of health, Researchers have established that the social such as living conditions in the home and neigh- and physical environment, not just genetic borhood, can affect exposure to both environ- makeup and individual behavior, influences mental and social risk factors for poor health. health outcomes. It is clear, for example, that For example, both allergens and violence in the structural determinants of health such as socio- home increase the risk of developing childhood economic status have serious health conse- asthma.5 Similarly, material exposures—such as quences.1 Stress—including as a result of high air quality and food access—and psychosocial 2064 Health Affairs November 2011 30:11 Downloaded from content.healthaffairs.org by Health Affairs on November 28, 2011 by Rachel McCartney exposures—such as social support and fear of large and persistent differences across socioeco- crime—can increase residents’ chances of suffer- nomic and racial or ethnic groups in health, ing mental health problems, becoming obese, income, educational attainment, and other out- engaging in unhealthy behavior, and even comes. That is, both community development dying.6,7 and efforts to address social determinants of In addition, it is clear that social factors influ- health seek to move beyond resolving individ- ence what happens when someone does get sick. ual-level problems and symptoms case by case For example, racial and ethnic minorities have to increasing opportunities for health and well- been shown to receive worse health care than being across the population as a whole. non-Hispanic whites, even after income, age, and health status differences are accounted for.8 Community development can be a useful tool A Framework To Shape Health for effecting change, especially in improving liv- Outcomes ing conditions in homes and neighborhoods. With so many possible interventions, it is impor- There is much that we do not yet know about tant to identify those areas in which community which health-oriented interventions are most development is best—even uniquely—positioned promising for particular populations in particu- to shape positive health outcomes. It will be lar community settings. Equally, we need more necessary to design rigorous, actionable frame- information about the scale of return on invest- works that accommodate organizing principles ment in community development.9,10 But during from both community development and health. the past decade, encouraging evidence has accu- Four Pathways From Social Context To mulated that well-run community-based inter- Health Finn Diderichsen, Timothy Evans, and ventions can effectively serve a number of at-risk Margaret Whitehead offer the foundation for populations, including the frail elderly,11 low- one such framework by categorizing the major income children,12 those in the criminal justice social determinants of health.25 They propose system,13 people with HIV/AIDS,14,15 and the four pathways from social context to health: up- chronically homeless.16,17 stream structural drivers of social position; These are overlapping populations that face health-relevant exposures; vulnerability to expo- multiple risks, and they account for a dispropor- sures; and reactive processes that mitigate or tionate share of costs in the health care and other exacerbate the consequences of poor health. support systems.18 The evidence underscores, Applying this model to childhood lead poison- in particular, the value of supportive housing, ing as an example, community development which includes targeted social services and might intervene along the first pathway by in- care.19 creasing residents’ incomes—through increased Community development should not be earnings, access to subsidies, or both—so that thought of as limited to improving conditions families could afford better-quality food and in poor urban neighborhoods or rural areas, housing. But neighborhood-level intervention or advancing the health and well-being only of per se is typically able to raise incomes only vulnerable populations. The general public also somewhat, since the larger workforce system, stands to gain from the broader benefits of tax code, capital markets, and other factors drive healthier neighborhoods and housing and what incomes. Access is just a part of the equation. has been termed a broader “geography of oppor- An intervention along the second pathway tunity.”20,21 Results can include improved indoor would be requiring lead paint removal from af- air quality; safer and more walkable streets; fordable housing. Such an intervention could greater access to fresh food; mentoring pro- reduce lead exposure for people living in such grams and other efforts that buffer young people housing. from violence; and networks of active and en- Providing education about hand washing (fre- gaged neighbors who press for these priorities quent washing makes it less likely that a child and also provide direct social support for indi- will unintentionally ingest lead in dust) and viduals and families in need. Each is a vital con- child nutrition (proper nutrition can reduce tributor to the health of the public,6 and together the amount of lead that the body absorbs) is they achieve the goals that community develop- an intervention along the third pathway. It could ment has long pursued.22–24 reduce vulnerability to lead poisoning for chil- Community development and evolving efforts dren in homes with lead-based paint. to promote reforms that reflect the social deter- Along the fourth pathway, examples of inter- minants of health share a social movement ori- ventions include improved health care, special entation, and both have social equity as a core education services, and disability insurance. value. More concretely, both seek to tackle the These interventions, although not usually prod- unfair structures of opportunity that produce ucts of community development, could all miti- November 2011 30:11 Health Affairs 2065 Downloaded from content.healthaffairs.org by Health Affairs on November 28, 2011 by Rachel McCartney Community Development & Health gate the consequences of experiencing lead poi- tandem with our three intervention types, soning. specific solutions emerge, including some with Three Intervention Types To build on this potentially large and wide-ranging impacts. For basic framework of multiple pathways, one example, federal health policy could explicitly needs an “intervention type” dimension to help encourage the promotion of decent, safe, and specify how community development policy and affordable housing as part of improving health. programs can affect each pathway. Three inter- The outlines of what constitutes smart funding vention types are particularly important. The mechanisms are also becoming clear. One first is policy change to create a population-level example of a promising funding