The study was small, the authors noted, and its participants were relatively old and thus less likely to change their habits. Still, it suggests that simply altering the built environment isn't enough. "If people have grown up in a community without access to parks and green space," says the Joint Center's Smedley, "suddenly putting it there is not going to make people use it."
Ask Dan Taylor, a pediatrician at the St. Christopher's clinic, where Hill's family is treated, what he thinks is needed to improve the neighborhood's health, and his answers are big. Decrease child poverty. Invest more in education. Provide jobs that pay a living wage. He worries about a growing body of research showing that the stresses of living in poverty — the many ways it undermines families and communities — damage children's brains and their long-term health.
A landmark study of thousands of adult Californians, begun in the mid-1990s at Kaiser Permanente, found that "adverse childhood experiences," such as domestic violence or abuse, had a cumulative effect on people's health. The 6 percent of participants who had four or more such experiences were far more likely as adults to be obese or to have cancer, heart disease, depression, or substance abuse. Most of the participants were white and had attended college, prompting two Philadelphia groups, the Institute for Safe Families and the Public Health Management Corp., to survey the City of Brotherly Love in 2012-13. They found that 37 percent of all participants — and more of the black respondents — reported at least four adverse experiences.
"You do what you can," Taylor says, but once a family exits the clinic, "they're going back to a toxic environment that really doesn't focus on children, that doesn't put children first."
Philadelphia is looking hard at the factors that create such an environment. During his first term as mayor, Nutter pledged to improve education and reduce violence. As he started his second term last year, his administration realized that to make progress on those goals it needed to focus more broadly on poverty, explains Eva Gladstein, who leads the new Office of Community Empowerment and Opportunity.
A year in, the office is setting up centers to help people apply for public benefits. It is bringing people together to advocate for more state and federal funding for early education, to increase services for people struggling to stay in their homes, to do more financial counseling and promote savings accounts, and to create 25,000 jobs in the city by 2015. Implicitly, Gladstein says, all of those goals are about health.
Columbia researchers Link and Phelan theorize that disparities persist from generation to generation because people have unequal access to the resources they need to protect their health — money, power, prestige, and positive social connections. Yet Link considers this shift in thinking — looking beyond health care to the context in which people live — a source of hope. It's hard to measure the effect of this change in perspective, he says, but "you can imagine building something like a movement."
The writer is features editor at Maine's Portland Press Herald and covered health care for The Boston Globe.