Review: How Neighborhoods Make Us Sick

How Our Neighborhoods Make Us Sick

How Neighborhoods Make Us SickVeronica Squires and Breanna Lathrop. Downers Grove: InterVarsity Press, 2019.

Summary: A case study showing how social determinants impacting health outcomes work in different zip codes and how these manifest in an urban neighborhood in southwest Atlanta.

Perhaps the single most sobering insight to arise from How Neighborhoods Make Us Sick is that life expectancy within different zip codes in the same city and metro area can widely vary–by a decade or more in some cases. There are a complex of factors in which these areas vary–social determinants–that profoundly affect the wellness and longevity of the residents in those neighborhoods.

The co-authors of this book, Veronica Squires and Breanna Lathrop, take academic discussion in the public health community and narrate how they personally experienced the realities of the factors that shape health outcomes. Their argument is that these social determinants go far beyond personal choices and “bootstrap” solutions. Much of this came through their personal realization that the presence and community involvement advocated in community development circles just weren’t enough. The first half of this book describes the journey of each of them in coming to this realization. Each chapter contains a sections describing the journey of each author around the impacts on health of poverty, employment (mostly in low wage jobs), food insecurity and nutrition, education and child development, housing availability, environmental issues (mold, lead), and homelessness, and health care access.

Breanna, a health care provider at the Good Samaritan Health Center in urban southwest Atlanta, came face to face with the reality that all her efforts at appropriate health interventions and care plans were being undone by these social determinants. Her patients were not getting better. Veronica and her husband moved into the neighborhood, lived out the commitments they had learned in community development, but little changed and both saw their own health deteriorate, despite having good educations and jobs. After nine years, they had to move out. Veronica writes:

“I left with severe anxiety, major depression, and recurrent panic attack episodes. Eric left with panic attacks too, along with high blood pressure and heart palpitations. We both left with psoriasis. Yet, even though I knew we were doing the right thing for the health of our family, I was grieving the loss of a vision and hope that community development alone could repair communities in a holistic, lasting, and scalable manner. As we pulled onto the highway, I turned around to look at the exit I had taken thousands of times to get home and thought, There has to be a better way to restore our communities.” (p. 89)

Part Two of the book begins with the co-authors writing about how they leaned into their faith in addressing these challenges. Their study of Jesus opened their eyes to his commitment to healing and overturning oppressive systems and structures that undermined the health and lives of the poor. They saw that to pursue this work was kingdom work.

Both describe the transformative practices they’ve had a part in implementing at the Good Samaritan Health Center, a donor-funded effort. Veronica is the chief administrative officer, and Breanna, the chief operating officer. They make some challenging statements about some of the mantras surrounding charitable giving in church circles, including volunteering as a substitute for giving, and “diversifying.” The health center itself offers a “full circle” of health care including medical and dental care, behavioral health care, health education, and healthy living practices.

Most strategic though are the partnerships they have developed to address housing issues, employment, health care for the homeless, nutrition (through neighborhood food initiatives and gardens), and a focus on early child development and education. They stress the importance of partnering with the community, listening to the community for its advice about what will be most helpful. They also address the issue of health access and insurance in the U.S. and the current decisions that exclude many from access to good health care, particularly preventive care. They argue that many of the interventions they have pursued save money, or even return money to communities, compared to the current alternatives that often result in repeat incarceration, emergency room usage, and hospitalizations.

It struck me that these women, and those they work with did not stop with the many reasons why things weren’t changing in southwest Atlanta, but looked for smart and biblical ways to pursue health equity, addressing the other factors that often undermined their patients’ health. They hit bottom, were honest about what that looked like for them, and then persisted.

The book also raises questions about whether we will recognize that equality is not enough when the playing field is not level. They advocate for health equity, recognizing that those at the bottom of the hill face a much harder task than those at the top to achieve the same outcome. Will a nation graced with so many resources rise to this kind of greatness? And to come back to the sobering insight with which I began, how will we respond to the fact that some of our near neighbors in the same city have a shorter life expectancy than we do? How is this not a pro-life issue? These were the questions I’m pondering after reading this book.

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Disclosure of Material Connection: I received this book free from the publisher. I was not required to write a positive review. The opinions I have expressed are my own.

Preparing for an Earlier Death

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A Silent Calling, by Alyssa L Miller, CC BY 2.0, unedited via Flickr

One of trends I’ve watched through my lifetime is lengthening life expectancy. When I was young, life expectancy was around 70. Now in the U.S, it is 78.8 years. Both of my parents lived into their nineties. A significant reason is treatments for cancer and heart disease, and, in general, advances in both preventive care, and treatments for many diseases, that if not curative, allow for longer life. Both of my parents recovered from illnesses from which they might have died in earlier times. My wife is a cancer survivor. I’ve recovered from an infection from which I might have died. My son had a heart procedure that cured an arrythmia that might have killed him.

All this was possible not only because of research advances and access to good medical care, but health insurance that allowed us to contribute to our health care costs without bankrupting us or exceeding our means. For many years, we and our employers paid health premiums, and my parents had medicare and supplemental coverage. In the case of my family, a job loss during one of these health crises might have led to very different outcomes.

Might we be facing the possibility of declining life expectancy, and the possibility that we might die sooner? Will it be the fate, at least for some of us in the U.S. to have life expectancies much more like those of the past? Will families see more deaths of infants and children (in my own city, infant mortality already is a function of zip code, with those in more prosperous zip codes seeing fewer deaths)? Will middle age people with treatable cancers die because they lack the coverage to afford the needed treatments, or bankrupt themselves trying to pay for it themselves, at higher rates than insurers pay?

It appears to me that as a country we are saying that it is morally acceptable to contemplate the possibility that some of our citizens, those whose employers don’t provide health coverage and cannot afford it, those with pre-existing conditions, those who have exceeded or cannot afford COBRA coverage, and perhaps the aged, may die earlier, simply because they cannot afford the health care and medications available to the more prosperous, that would extend their lives.

Truthfully, we’ve been saying that for a long time, and the latest health care measures only seem to enlarge the number of people who may not be able to afford treatments that may save or extend their lives. And I think it is likely that more of our citizens will need to face the sobering reality that death will come to them or those they love earlier than it might have. What will it do to the fabric of our society when the prosperous few receive care for which the rest can only hope?

I think part of how this happens is the illusion that “it can’t happen to me.” Yet for many, they may be one job loss, family crisis, accident, or illness, or chronic condition from facing this reality. The truth of it is that, no matter how much you feel in control, no matter how much money you have (for most of us), you are vulnerable.

Yes, health care is complicated. I’m glad our president finally figured this out. I’ll admit that I’m not an expert on this, but it seems we need to have a national conversation and solutions that are not partisan efforts if we are truly going to address the issues of health coverage in our country. It seems we need to talk about:

  • Whether we consider it morally acceptable to have the inequities that exist in our health care system, particularly when these impact the most vulnerable–children, the unemployed, the aged.
  • What good health care for all costs and how we will pay for it. It is true that we have been asking government to provide more than we are willing to pay for and this cannot continue indefinitely.
  • Ensuring that those who provide health care services and products and insurance receive a reasonable return for their work or investment allowing them to sustain their efforts without exorbitant profits.
  • What responsibility we have for our health choices — diet, exercise, preventive care, lifestyle.
  • A better understanding and compassionate stewardship of good end of life care that neither hastens nor prolongs dying.

If we can’t figure out how to have that conversation, then it seems that we need to figure out how to talk about the fact that many of us may be dying sooner. It may be that we have to face the reality of dying sooner ourselves, or desperately using all our resources to save our lives. It may be that we have to figure out how we are going to remain one people when some receive care denied to others.  Are we ready for that?