History tells us that the past is often prologue. Indeed, the recent focus on community health and social determinants of health (SDH) — non-medical influences on health status — is not new or innovative. Florence Nightingale's work as a nurse in Crimean War hospitals and, later in London institutions, focused on contaminated water and foul air as the basis of disease. A modern equivalent to those earlier public health efforts resulted from the efforts of civil rights workers and President Lyndon B. Johnson's "War on Poverty." This movement consisted of a steely focus on nutrition, clean water and sanitation systems in economically underdeveloped areas as a way to improve the population's health.
Individual physicians and nurses such as E. Phyllis Cunningham, as well as advocacy groups such as the Black Panthers and Young Lords, founded over 100 community health centers (CHC) throughout the nation to provide cost-effective yet meaningful care to vulnerable populations. Grants from the Office of Economic Opportunity provided fiscal support for CHCs that provided public health services as well as medical care in local communities. Other CHCs relied on private funding. Many founders, such as physican H.Jack Geiger, were part of the modern Civil Rights movement and believed that addressing SDH could help individuals and communities in their pursuit of health as a part of a civil rights agenda. The Delta Health Center located in Mound Bayou, Mississippi, still provides services today.
In October 1971, a six-year-old girl with severe dysentery from poor nutrition and contaminated water was brought to a community health center in Jackson, Mississippi. Dr. Aaron Shirley, the director of Jackson-Hinds Comprehensive Health Center, frustrated by the child's preventable illness, created a revolutionary program that targeted the environmental source of illness and poor health, focusing on nearby Hinds County, a rural, low-income, multiracial community. Doctors, nurses, and sanitation experts worked with the public and went into homes to fix problems ranging from inadequate sanitation to rotting food, mold and asbestos.
SDH-based offers many benefits. Access to early education can help kids with developmental delays catch up; healthy diets rich in iron, calcium and Vitamin C can mitigate lead's worst effects; and regular doctor visits can identify early warnings of some major chronic illnesses.
Contaminated drinking water has led to a particularly well-known SDH-related consequence — children's exposure to lead. The effects were clear in Flint, Michigan, a city where 57 percent of its residents are black and 42 percent live below the nation's poverty level. Many of its 100,000 residents were exposed to high levels of lead in the drinking water after officials changed the water source in 2014. Unfortunately, there is no quick cure for lead exposure. Estimates for remediating the lead in the water system for Flint range from $400 million to $275 billion. Yet the biggest consequence is the thousands of cumulative years of poor health, including fertility rates down 12 percent and an increase in fetal deaths to learning disabilities and increased crime rates from lead's impact on developing brains and nervous systems.
Recent major initiatives both nationally and locally have highlighted the importance of addressing SDH. Healthy People 2020, an initiative from the U.S. Department of Health and Human Services, lists increasing education, reducing crime and eliminating food insecurity as major ways of improving public health as a whole. In Philadelphia, Penn Medicine's IMPaCT model has shown that patients supported by community health workers to "help them deal with issues such as trauma and hunger" had 30 percent fewer hospital admissions than patients without these interactions. Under health commissioner Donald Schwarz, the city implemented major anti-obesity and anti-smoking campaigns, increased permanent housing and established a health center and library complex in some neighborhoods, with positive results.
Healthcare initiatives during the modern Civil Rights movement of the 1960s revealed the successes from targeting SDH to improve public health. It also underscored the need to address policy and funding obstacles that may limit the expansion of SDH and community-based care. We have effective plans, such as Healthy People 2020, and effective models, such as those applied in Philadelphia. What is needed are the resources to support them. In the Civil Rights era, the federal government funded over 100 CHCs. Later, federal funding was phased out for health centers and many of them closed, to the detriment of their surrounding populations.
Looking ahead, we need to find ways to take lessons from past successful efforts to address SDH and turn them into new initiatives. This will take funding and popular support and will yield important benefits to our citizens and communities.