Most parents would be dismayed to see their child come home with a "D" on their report card. They would want to know how they and the school can work together to improve the child's scholastic performance.
With the announcement that the Baltimore City Health Department has given the very same grade to the city's efforts to reduce health inequities, will residents demand accountability, involvement and improvement?
In a remarkable report, the agency reviewed trends regarding a number of health indicators of residents of the city and the state and found that Baltimore's inhabitants fared worse than the state on 13 of 14 indicators.
The largest of these health inequities are between residents of different income and education levels, a finding replicated in almost every other major study investigating why some groups enjoy better health than others. The Health Department's study found that people with lower levels of education and income had poorer health than more advantaged groups in the form of higher infant mortality, higher rates of disease and disability, and premature mortality — and this was true across all age groups. Indeed, income and education disparities received "F"s on most of the report's indicators.
Racial and ethnic disparities are also persistent, with African-Americans faring worse than whites on about two out of three indicators. Indeed, on some measures, these disparities are getting worse: Since 2000, white mortality has declined at a pace that is 5 percent faster than that for African-Americans.
Why do these health gaps persist? Most might assume that a lack of access to quality health care or poor health habits are the prime culprits. These factors are clearly important. But a growing body of public health research demonstrates that neighborhood conditions — such as the quality of housing, food, transportation and the environment — play a major role in shaping the health of the community. They directly influence health through the kinds of risks that people are exposed to on a daily basis, such as pollution, violence and overcrowding, and indirectly influence health by shaping health behaviors, such as the kinds of food people eat and their level of physical activity.
These health inequities, as the report points out, are unjust and avoidable — that is, with good policy and planning, we can help everyone enjoy equal opportunities for good health.
But too many Baltimore neighborhoods are toxic to their residents' health. They lack stores selling fresh fruits and vegetables but are overrun with liquor and tobacco vendors. They are littered with crumbling, dilapidated homes. They share space with polluting industrial sites. And their streets are not safe for play or exercise.
These problems are less the fault of the people who live in these communities than of those who have the power to increase investments in neighborhoods and make them healthier and safer for all.
The Baltimore City Health Department's report is a call to action. The report makes clear that health inequities are not just a problem for city health officials. Because these inequities are rooted in policy decisions around land use, housing, education, transportation and the like, local and state government agencies need to work together with communities in multi-sector partnerships to determine neighborhood health risks and resources. Community groups must shape the agenda.
Fortunately, there are signs of change in Baltimore that offer hope to reverse these trends. The Health Department is developing new initiatives to tackle health inequities, such as the Virtual Supermarket Project, which seeks to improve access to healthy foods for residents of the city's "food deserts." A coalition of leaders in public health, housing, business and other sectors, named EQUITY MATTERS, has been working to raise awareness of how inequitable educational and housing opportunities in the city contribute to health inequities, and to point to effective policy solutions.
The Health Department plans to release its Health Disparities Report Cards bi-annually in order to monitor progress and raise awareness of the problem. And more private foundations are focusing on building the capacity of communities to address neighborhood conditions that shape health.
These strategies are an important start. The real challenge and need is to mobilize communities across the city to demand a fair chance for good health, with a focus on creating healthier neighborhoods. BCHD's report card might serve as the wake-up call needed to spur this movement.
Brian D. Smedley is vice president and director of the Joint Center for Political and Economic Studies Health Policy Institute. His e-mail is hpi-smedley@jointcenter.org.