A Perspective on the Purpose and Practice of Public Health from the Bay Area Regional Health Inequities Initiative (BARHII)*

The aftermath of Hurricane Katrina exposed an underside of life in the United States that surfaced in the floodwaters of New Orleans. In a city with a population that is two-thirds African-American, over a third of whom live below the federal poverty level, the storm did not exact its toll uniformly. Rather, it unleashed its fury on a terrain configured along lines of race and class—a deeply troubling picture that was available for all to see.

For those of us who work in public health, New Orleans is a disturbing reminder of what we observe more generally, a constant hurricane, more deadly than Katrina, that goes largely unreported. In the United States, African American babies are more than twice as likely as white babies to die in their first year. Overall, African Americans have shorter lives than whites—an African American man can expect to live on average about seven years less than his white counterpart. African Americans have higher rates of heart disease, stroke, hypertension, diabetes, asthma and certain cancers.

While much attention is deservedly focused on the failure of our health care system to provide universal access to quality medical care, it is also true that many of these conditions are eminently preventable, and their causal roots lie embedded in our social and physical environments. Like Hurricane Katrina, the forces that most influence our health as a nation blow over a landscape shaped by social inequalities, and the consequences are revealed in an inequitable distribution of disease and premature death.

As local public health officials, we take great pride in the achievements of the last century. Largely as a result of public health measures, the generation born at the beginning of the 21st century will live on average 30 years longer than those born at the beginning of the 20th century. However, the benefits of these achievements have not been realized equitably. In an article published in the American Journal of Public Health, former U.S. Surgeon General David Satcher and his colleagues calculated that over a 10-year period, nearly 177,000 deaths were averted because of advances in medical technology, but if we were to eliminate the disparity between African Americans and whites, we would have avoided over 886,000 deaths. They concluded that achieving health equity could accomplish more to improve the health of the nation than advances in medicine.

But, where do we begin to make inroads on such a great challenge? At the turn of the last century, public health was concerned largely with control of infectious diseases through food and water safety, sanitation and, with advances in bio-medical science, vaccines and antibiotics. As we enter the 21st century, growing rates of obesity, diabetes and asthma, and the prospects of reversing gains we have made in reducing heart disease, stroke and some cancers, reflect a nation that is still smoking, albeit less, and increasingly overweight, sedentary and living in a chemical environment that did not exist even fifty years ago. These factors are certainly influenced by lifestyle and individual behavior, but if we are to improve health overall, we must, as the Institute of Medicine declared in its influential report on The Future of Public Health, assure the conditions in which people can be healthy. More particularly, if we are to improve health in a way that also reduces inequities, we must focus attention on the conditions in low-income neighborhoods where increasingly multi-ethnic populations disproportionately live—neighborhoods where living conditions erode good health through an overabundance of stores specializing in alcohol, tobacco and junk foods, a scarcity of grocers that sell fresh produce at reasonable prices, a lack of open space and recreational facilities, highways and ports that serve as trucking and other transportation corridors, multiple sources of industrial pollution and high levels of community violence.

We harbor no illusions. Health equity will most likely be achieved only in concert with greater social equity. The neighborhood conditions that erode good health are associated with the systematic deprivation of important social resources such as good schools, living wage jobs, decent and affordable housing, strong environmental policies and access to quality healthcare. The task is beyond the bounds of what public health can do alone.

Nonetheless, it is past time to make the link with social inequalities part of the community dialogue on health. Local public health departments, on their own and through the Bay Area Regional Health Inequities Initiative, are working with planning and transportation agencies to make health a priority in land use and transportation decisions, especially as they affect low-income communities. Asthma and environmental justice groups have joined together in the Ditching Dirty Diesel Collaborative to reduce the sources of diesel pollution in neighborhoods which bear the brunt of port and truck traffic while having high rates of asthma hospitalizations. In low-income communities throughout the Bay Area, there are campaigns to make healthy foods more easily available, increase the number of parks and open spaces, make schools healthier places, improve traffic safety, reduce community violence and more generally make neighborhoods healthier places to live. Especially in the absence of a national commitment to reducing health inequities, local health departments, communities and their allies in public and private agencies and organizations must pick up the slack to make social justice central to our understanding of health.

Whether it is the immediate consequence of natural disasters or the burden of chronic disease that accumulates over the course of generations, we cannot allow Katrina to be the image that prevails over the nation's—or the Bay Area's—health.

BARHII is a collaboration among senior officials and staff from eight San Francisco Bay Area health departments with a common mission to "...transform public health practice for the purpose of eliminating health inequities using a broad spectrum of approaches that create healthy communities."