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Redefining public health

Redefining public health

It's well known that the most important health indicators of communities are often closely related to their demographics. People living in wealthy communities generally tend to live longer, be more active and have fewer serious chronic diseases than people living in poor communities. From a public health standpoint, that means some communities are healthier on average than others, and the differences can be stark. In Baltimore, for example, residents of the city's wealthiest neighborhoods can expect to live up to 20 years longer than their less affluent peers, even though their homes may be only a few miles apart.

The huge disparities that exist along racial and class lines in Baltimore represent the biggest challenge facing public health officials. But closing the gap in health outcomes between the city's most privileged and most disadvantaged residents isn't just a matter of visits to the doctor's office or emergency room admissions. Instead, it's related to a complex interaction of social, economic and environmental factors that together help determine people's overall physical and mental well being. And as a result it's not a problem that can be "treated" without also addressing the barriers that keep people trapped in unhealthy situations.

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Baltimore City Health Commissioner Dr. Leana Wen recognizes that public health workers aren't social engineers. They can't wave a magic wand that will suddenly make the results of decades-old discrimination and structural inequalities disappear. But she also recognizes that improving public health involves more than just better medical care (though that certainly is also needed). To be effective, public health must also address the issues of equity and social justice that the disparities in health outcomes reflect. It's simply not realistic to expect people to be able to lift themselves out of poverty if they're so ill they can't work, or so traumatized by their experiences that they can't be good parents.

That is why the long-term plan Dr. Wen released this week is not so much a programmatic blueprint as a comprehensive strategy statement for tackling the social determinants of Baltimore's health disparities. The plan, dubbed Healthy Baltimore 2020, frankly acknowledges the role that race and class have played in creating those disparities and proposes to cut them in half over the next decade by focusing on four areas: behavioral health, violence prevention, chronic disease and "life course," including the gap in life expectancy between the city's wealthiest and poorest neighborhoods. (Though the goals run for a decade, the health department plans to evaluate progress much sooner, hence Healthy Baltimore 2020 rather than 2026.)

The plan is designed to identify the areas where the health department can make the biggest difference for residents, but it also recognizes the complexity of the task because of how closely each of the elements overlaps with all the others. Behavioral health, for example, focuses on addiction and substance abuse, but it's also tied to issues of violence, poverty, mental illness and the criminal justice system. Similarly, life expectancy is a function not just of income but of chronic illnesses like heart disease and diabetes as well as drug overdoses and violent crime.

Dr. Wen considers all those factors public health issues. A preventive strategy to reduce youth violence, for example, might mean investing more in early childhood education, providing eyeglasses to every child who needs them (as the city is now doing) or intervening to keep chronically truant students in school. Reducing cardio-vascular illness, still the city's number one killer, might involve weight-loss or smoking cessation programs, while closing the gap in life course disparities could involve initiatives to protect young children from lead paint poisoning or more effective responses to infections like Zika and HIV.

Obviously, the health department can't do all this on its own. The strategy behind Dr. Wen's plan is to set citywide goals on which all the area's hospitals, clinics, social service agencies and nonprofits can collaborate. Modern medicine can perform miracles when it comes to saving the lives of accident victims or critically ill patients. But that doesn't always translate into healthier communities. Most of what keeps people alive doesn't happen in a doctor's office or a hospital operating room. Baltimore's plan recognizes that reducing the disparities in long-term health outcomes along racial and class lines requires a commitment to equity and justice as well as to medical science, and the health department should be commended for taking on the huge challenge of addressing them both.

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