Mending the Social Fabric

This article is from our Fall 2019 issue.

What makes us who we are? Beyond the genes that code for our eye color and skin tone, what determines all the nuances that make us…us? Are we strong because we inherited our grandmother’s sturdy build, or is it because we go to the neighborhood gym every day? Do we have asthma because our father had it, or because we grew up next to a busy highway?

When it comes to our health, how much of our destiny is within our control, and how much does our zip code come into play in deciding who is healthy and who is sick?

"This Is the Inner City."

When Dr. Tony Iton, the senior vice president of Building Healthy Communities, The California Endowment, left his hometown to attend medical school at Johns Hopkins University in the 1980s, he was shocked by what he saw. East Baltimore was nothing like Montreal, Canada, where he grew up. Row houses were vacant or hollowed out. Streets were silent; there was no green space, no shops, no life.

“When was there a war here?” he stammered. The upperclassman who had been showing him around said, “What did you expect, this is the inner city.”

Growing up in Montreal, there were community parks, museums, libraries, high-quality housing, and state of the art transportation. “I felt nurtured by the city,” Iton says.

But it was clear that children growing up in East Baltimore were getting no such nurturing. In fact, what Iton saw in their eyes when they showed up at the clinics was a flatness that comes from the absence of hope.

“These children were barraged every single day of their lives with the message that they didn’t matter,” says Iton. “And they internalized that. You could see the light literally turn off in their eyes.”

It Gets Under Your Skin

Dr. Iton called the conditions that he saw in East Baltimore, “dehumanizing.” He began to wonder how his life might have been different if he had grown up in a place like that.

He wondered, when it comes to health, does your zip code actually matter more than your genetic code?

The children living in East Baltimore had no role in creating that environment. But they had to navigate it every single day of their lives. And it was, literally, killing them. In fact, recent research has shown that by serving as an incubator of chronic diseases like heart disease and diabetes, stress actually changes a person’s physiology.

So it isn’t that poor people have worse habits than healthy people. It’s that we’ve created environments that are so stressful, so devoid of all the things humans need to thrive, that it alters their genetic code.

“That’s how the outside world gets under the skin,” says Iton.

A Map of Health

After graduating medical school, Iton became the health officer of Alameda County in California. In that role he was responsible for signing death certificates. That gave him access to data that he used to compile a map of the average life expectancy based on neighborhood.

The results were shocking.

Within the city of Oakland, there were neighborhoods, just a few miles from one another, in which the life expectancy between them differed by more than 20 years. Subsequent analyses of cities around the country revealed the phenomenon was not isolated to Alameda County. In some areas, the difference between neighboring zip codes was as much as 30 years.

So, what exactly was happening in these communities? Why was their population’s lifespan so short? “These communities were incubators of chronic stress,” says Iton.

These communities lacked good educational systems and jobs, experienced high crime rates, and lacked access to grocery stores, parks, transportation, and, in some cases, clean drinking water. “Any human being placed under these circumstances would experience high levels of stress,” says Iton.

This means that people living in these communities experience more illnesses than their counterparts in wealthier communities. And it’s not based on food choices or willingness to exercise. It’s based on a lack of social support.

Barn Raising

In the 18th and 19th centuries, it was common in rural North America for community members to come together to build a barn for a member of the community. A barn was necessary for a farmer to keep animals and store food. But to build one was expensive and too difficult for one family to do on their own. So, members of the community helped build the barn, knowing the favor would eventually be returned.

For early Americans, life would not have been feasible without the help of community members. Their survival literally depended on it. They saw themselves as responsible for others, not just their own needs and wants. They knew that the well-being of their fellow community members was integral to their own well-being.

Today, technology has made it possible for healthy individuals to carry out most activities of daily living without the help of anyone. But do we know the value of what we’ve given up in exchange for this record level of independence?

Lions Understand the Power of Community

It’s why they talk about the power of "We." It’s why they know their real power is in boosting each other up. It’s why they start school lunch programs and community gardens. It’s why they build parks and sponsor educational scholarships.

“It’s not rocket science,” says Iton. “We know what to do. There just needs to be the will to do it.”

But what’s becoming more clear is that in creating services for their communities, Lions are doing more than simply providing eyeglasses or planting trees in a park. They are helping to repair the fabric of community, something that is essential to health.

By filling the social gaps in communities, Lions are working to improve the health of their neighbors. By helping to stock a local library or by cleaning up an old city lot and turning it into a park, Lions are weaving a tighter bond between themselves and their neighbors, helping to improve the odds for people in their community. They are making it less likely that their neighbors (and themselves) will have diabetes, and more likely that they will live longer, healthier lives.

It works

In 2017 the Journal of the American Medical Association published a study that looked at all 50 states over a 26-year period and ranked them according to health, including the “probability of death.” Over the time of the study, California was one of two states with the most improvement on probability of death, meaning, the state had significantly increased the life expectancy for its residents.

Iton believes that’s in large part to several factors. During that time period California had a great influx of wealth with the tech boom. And wealth, as Iton says, tends to breed health. But California also has a large immigrant population, and immigrants are almost always healthier than their native-born counterparts. In fact, research from the 1960s identified that Latinos who came to the U.S. were healthier than Americans, despite having lower incomes, lower educational levels, and highly stressful living conditions.

Researchers still aren’t sure why this paradox exists, but one popular theory is that it’s due to the tight social bonds of immigrant communities.

"The ability to see ourselves interconnected and our fates inextricably intertwined is the variable that will determine whether we succeed or fail in this moment."

“Immigrants bring to this country aspects of culture, of tradition, of tight family social networks and community social networks that essentially form a shield around them,” says Iton, in the documentary “Becoming American.” The other thing that has helped California improve the death rate for its citizens is related to policy.

“We know that one of the things that correlates to a decrease in diabetes rates is access to parks and recreational space,” says Iton. In places like Fresno, which has one of the poorest congressional districts in the country, trusts set aside for public lands has helped increase the health status for Fresno citizens. California also removed soda from schools and enhanced physical education programs, investing in the health of kids before they become adults with health conditions.

California Isn't Alone

In Chicago, a huge movement is underway to help residents of some of the poorest communities get better health.

North Lawndale has long been known as one of the most troubled neighborhoods on Chicago’s south side. Not only were residents struggling with poverty, joblessness, and violence, but in 2003 the residents of North Lawndale had twice the average rate of diabetes, and a 62% higher diabetes mortality rate compared to the rest of the United States.

In 2009 Sinai Urban Health Institute was awarded a grant by the National Institutes of Health to undertake the Block by Block North Lawndale Diabetes Community Action Program. The program was intended to address the high rates of diabetes in the community and focused on awareness, education, self-management, and community engagement.

They sent community health educators block by block, knocking on doors to ask after people’s health and encourage them to get involved in the program. Community health educators helped people find doctors, drove them to appointments, and followed up with small incentives to keep up with their treatment plans. They held cooking demonstrations, participated in health fairs, community meetings, and civic gatherings, offering free A1C testing, doctor referrals, and information on community services. They taught diabetes self-management leaderships courses in order to “grow” more leaders that could help spread information in the community, and they also taught self-management classes on nutrition that promoted social support and teamwork.

And it’s working.

"I Ain't Crazy, I'm Just Blue."

“Mr. Peel” is one community member described by study author Joseph West. He is a long-standing member of the Lawndale community and was one of the first participants in the program. After the study was underway West ran into Peel on the way to a nearby grocery store that stocked fresh fruits and vegetables. Peel seemed to already be benefiting. “I could tell he was feeling better,” says West. “His blood sugar was down considerably, he told me.”

Mr. Peel said his changed diet, exercise, and health plan has made a big difference. But then he also told West that he’d been struggling emotionally. He had recently lost his brother to diabetes and “was scared out of my mind,” he said. When he felt down, he would reach for his comfort foods: soda, cookies, fast food, ice cream. He said he needed it to cope.

But when the community health worker would come by to check on him, she listened. He shared his feelings, and when he was done talking, she asked if he wanted a referral to a mental health professional. He told her, “I ain’t crazy, just blue.” It turned out, having someone to talk to was all he needed. It kept him on track with his diet and motivated to keep up with his health.

It’s these kinds of social ties that are so integral to human well-being. They form the fabric of a community. A fabric that catches people at risk of falling; that shields people exposed to stress. And this is why where you live matters in health.

Health is not defined by seeing doctors or taking medicine. It’s defined by the full spectrum of your life circumstances.* Where you are on the planet matters because of who you are surrounded by and how that community has chosen to invest—or not—in people.

“We’re in a period of profound social despair,” says Iton. “The past has shown us that as a country we do have the ability to rally when facing an existential threat. What matters most is whether we see solidarity across communities or not. The ability to see ourselves interconnected and our fates inextricably intertwined is the variable that will determine whether we succeed or fail in this moment.”

*From “Well: What We Talk About When We Talk About Health,” by Sandro Galea.

Special thanks to Dr. Anthony Iton for his participation and generosity in sharing his story. Much of this was taken from his Ted Talk “Change the Odds for Health.”