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Why Advancing a Culture of Health Is Bigger Than You Think

A robust and relevant culture of health frame requires an understanding of how differently situated people experience the world and how their experiences impact their behaviors. It must begin and end with authentic resident engagement that builds upon the resiliency of disadvantaged communities.
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When I think of the resilience of disadvantaged communities disproportionately affected by health disparities, I think of the Arabbers of Baltimore, MD. They are not Arabic speaking people from the Middle East or North Africa, but scrappy African American entrepreneurs who started selling fresh foods in Baltimore's underserved communities in the aftermath of the Civil War.

Their relevance continued into the modern era as supermarkets divested from low-income neighborhoods, leaving struggling residents with few options aside from unhealthy fast food and carry out restaurants. Driving horses with carts laden with colorful fresh fruits and vegetables -- Arabbers sold their produce to residents literally starving for nutritious food.

Today, the number of Arabbers selling their goods on the streets of Baltimore's inner city neighborhoods have dramatically declined amid run-ins with health department regulators and increased competition from discount supermarkets, farmers' markets and other fresh food outlets incentivized by renewed city efforts to address high rates of obesity and related preventable health conditions among residents in Baltimore's food desert communities.

And while the city's response to a public health crisis was appropriate and necessary, I can't help but wonder about the lost livelihoods of the Arabbers -- a group that valued the purchasing power and nutritional needs of low-income residents even when mainstream markets did not -- and how they might have fared if the response had been framed as a broader opportunity crisis instead.

What do I mean? It's no secret that poor health outcomes experienced by low-income residents are driven by the interrelated circumstances of poverty, lack of education, and civic disenfranchisement that serve to isolate and marginalize people, often along lines of class, race, and ethnicity.

These social inequities are created and reinforced by policies and practices, such as residential segregation and the maldistribution of public resources, which drive disparities in the areas of health, education, economic security and civic power. Ultimately, these socially determined and spatially designated inequities are the reason why zip codes are a great predictor of population health, longevity, and wealth.

As new efforts to build a culture of health in America take root, it will be important to uplift "Opportunity Communities" or win-win, place-based strategies that engage and support the resilience of marginalized residents by speaking to their health, economic, environmental, and educational needs as well as the viability of their neighborhoods and indigenous institutions.

In this scenario, for example, Arabbers could have been viewed as partners in the effort to address food deserts, economic development and carbon emissions. Simple policy incentives for their businesses could have supported the distribution of more fruits and vegetables, the availability of more jobs, and the convenient and environmentally-friendly practice of delivering produce directly to consumers using horses, instead of cars.

Equity should be another central tenant for effectively advancing a culture of health. Challenging the distorted values and deconstructing and reconfiguring the policies and practices that shape our social and spatial hierarchies can help reverse centuries of structured disadvantage. Yet, centering equity within a culture of health requires attention to the following concerns:

1. Don't put lipstick on a pig. Community development is an important strategy for supporting a culture of health. Yet, while the lure of new or renovated buildings, sidewalks, or redesigned master plans can feel like positive progress, these efforts to reshape the built environment will likely remain purely cosmetic -- making little difference for the wellbeing of underserved communities -- if they fail to address the structural factors that limit opportunities.

2. Disrupt inequitable systems. There are policy, systems and environmental factors that reinforce disadvantage and, if not properly addressed, could undermine efforts to achieve a culture of health. From residential segregation and inequitable public financing schemes that determine access to vital services and amenities to disparities in access to quality care, there are significant systems that need to be changed. For example, although dense, mixed-use and transit-oriented development has been a focus of New Urbanists and Smart Growth advocates for some time, adding mixed-income housing opportunities to the equation would go a long way towards disrupting isolating residential patterns that reinforce disadvantage.

3. Address psychosocial stressors. You can't optimize your health or embrace a culture of health if you fear for your life or the lives of your loved ones due to domestic, community or state-sponsored violence; or if daily microagressions based on race, class, or gender leave you feeling depressed and unable to cope; or if economic circumstances dictate a constant struggle for food, shelter, and survival. When these factors shape your every day lived experiences, as they do for many living in vulnerable communities, then alienation and cynicism is increased, engagement with important societal institutions is reduced, and hope is shattered.

A robust and relevant culture of health frame requires an understanding of how differently situated people experience the world and how their experiences impact their behaviors. It must begin and end with authentic resident engagement that builds upon the resiliency of disadvantaged communities. And, ultimately, it must embrace comprehensive strategies that move our nation towards a healthier and more inclusive future.

This article originally appeared on the Robert Wood Johnson Foundation's Culture of Health Blog.

Dr. Maya Rockeymoore is President of the Center for Global Policy Solutions, a nonprofit dedicated to advancing health, education, economic and civic success for vulnerable populations.