Understanding health equity: A conversation with Dr. Jason Purnell March 6, 2019

Profile: Dr. Jason Purnell, Health Equity Works

Dr. Jason Purnell is a leading expert on health equity. Driven by his belief that “every child deserves the best start and opportunity possible,” he directs Washington University’s Health Equity Works initiative in St. Louis. The team uncovers and shines a light on the effects of social factors – for example, where we live – on how long and well we live. Their findings have been widely cited, including in Vice and on St. Louis Public Radio. Purnell also contributes extensively to community efforts focused on creating school-based health centers and advancing fair housing across Missouri. He has received numerous community and leadership awards and serves on IFF’s St. Louis Advisory Committee. He holds a BA in government and philosophy from Harvard University, a master’s in public health from the University of Rochester, and a PhD in counseling psychology from Ohio State University.

Purnell sat down with IFF to share his thoughts on what health equity means, some of the misconceptions keeping us from reaching it, and strategies for change.

IFF: A lot of people in the nonprofit sector are talking about health equity, but we don’t always mean the same thing. How do you define it?

Purnell: At its most basic level, health equity is the ability to live a long, high-quality life regardless of your background or circumstances. And that’s not happening in America. We spend a lot of time, energy, and money on health care, yet our health outcomes are pretty terrible when you look at how we compare to other wealthy nations of the world. Americans are experiencing an increase in our mortality rate and a decline in life expectancy.

We must get outside the doctor’s office or the hospital room to understand why. Health equity is really about a whole set of social determinants driving our health outcomes – things like the quality and duration of education, the availability of early childhood supports and programming, the quality of neighborhoods and housing, and the availability of jobs and other economic opportunities. That’s why you can see stark differences in life expectancy between neighboring areas in the same metro area; for example, we reported on an 18-year gap in life expectancy between two zip codes in the St. Louis region that are separated by less than 10 miles.

Conversations about health equity also involve addressing the ways in which racism and other forms of structural inequality are baked into systems and institutions. A great deal of the population is struggling just to stay above water, and that’s juxtaposed against an increasingly insulated class of advantaged, higher-income individuals. Those individuals are walling off opportunities to an extent that where you live and who you’re born to, in terms of their race and socioeconomic status, have an outsized impact on your later life outcomes. This whole notion of bootstraps and the American Dream – it’s just not the case.

IFF: What other misconceptions do you think Americans need to come to terms with?

Purnell: There’s one that’s become an obsession of mine. It’s this almost religious article of faith in individual effort and personal responsibility as supposedly the only explanation for people’s life outcomes. I’ve heard and seen it across racial and ethnic groups, I’ve heard and seen it across income groups. It’s the go-to explanation when you point to structural disparities: “Well, isn’t it just people’s poor choices or lack of effort?”

I’m convinced this is partly why we’re seeing, for instance, an increase in suicides among whites in the United States – a group that occupies a privileged status in society when we’re talking about the historical ways in which we’ve stratified opportunity and access to resources by race. Imagine you’re a white male in a rural area where the factory is gone, jobs are gone, and a lot of the people are gone or not getting ahead. If your only explanation is that you didn’t try hard enough – and not that there are these deeper structural problems in our society and in our economy – it becomes really easy to turn on yourself.

Our inability as a country to grapple with the fact that life outcomes are dually determined by one’s individual effort and one’s context leads us to a whole set of policy decisions that end up stifling people instead of supporting them. It’s threatening both our democracy and our economy in the long term, where you’re seeing the middle class vanish and more and more people fall into lower economic status. It’s contributed to a distribution of wealth with a lot concentrated at the top, leading to the recycling of privilege. It’s not sustainable.

IFF: What’s a more balanced and productive way of thinking about structural disparities?

Purnell: We need to look beyond individual choices and consider choice sets. I once heard the former CEO of the Robert Wood Johnson Foundation, Risa Lavizzo-Mourey, say that the choices you make are based upon the choices you have. Sometimes you need to step back and consider what created that set of choices.

Take the school choices available to our families. We need to ask: Why do property taxes determine how much money goes to our schools? Richard Rothstein – a Fellow of the Economic Policy Institute, Thurgood Marshall Institute of the NAACP Legal Defense Fund, and of the Haas Institute at the University of California (Berkeley) – has an interesting solution. He points out that a lot of upper-middle class families obsess over the quality of schools so that they can get their kids into selective colleges and give them advantages in the workforce. So, he asks, why not make entrance into selective colleges based on whether you grew up in an integrated neighborhood? You’d see a change in housing patterns overnight. It would be very difficult to do, but what a cool idea.

It gets at what’s really going on. You collect a bunch of affluent kids, who have every advantage in the world, in a building. Then, you congratulate them on their stellar outcomes. Then, you assume those outcomes had something to do with what happened in the building. Meanwhile, you condemn children who come to school without having eaten, who are facing trauma, and who might not know where they’re going to sleep that night. You assume that the seven hours they spend at school explains poor academic outcomes. In both cases, you’re missing the point.

IFF: On top of conducting research, you produce reports that are easy for non-academics to understand. You also partner with the St. Louis community to drive change. Could you share why and how Health Equity Works brings together research, communication, and action?

Purnell: One of the things that we worry about in the academy is this notion that we have some sense of what works, and yet that doesn’t lead to action as quickly as we would like. So, my real interest is not in research for the sake of research, but research that can advance important societal change. And that’s part of the ethos at the Brown School at Washington University. We are interested in impact. We try to follow and apply the best available evidence.

I think where a lot of people who do research have fallen down has been in translating their findings to audiences outside of the academy. They don’t always have the skill set to do that in digestible, usable ways.

It’s also easy to overestimate data’s ability to motivate people. You can’t come to a values fight armed solely with data. Instead, you’ve got to be able to use data in the service of a narrative, of a story. Stories are how humans process the world.

So, we try to be really intentional about making our communication accessible. We try to consider how to tell a story about equity that involves everybody, so that we can increase opportunity and achieve better outcomes for folks.  And we partner with community. We know the things we co-create with community are the things that stick. The attitude of “I’ve found the answer locked up in my office and I’m going to go out and offer it to you” doesn’t work.

IFF: Which results from community partnerships are you especially excited about?

Purnell: Two areas of work come to mind. First, there’s what we’re doing around school health in the St. Louis region. It started with a recommendation based on the bi-directional relationship between health and education: people with more education lead healthier and longer lives, and healthy students are in a better position to benefit from education. So, putting health centers in the schools where kids spend most of their day seemed like an intuitive way to have an impact, particularly in schools serving vulnerable populations.

From there, we’ve been partnering with health systems, Federally Qualified Health Centers, schools, and community organizations to make it happen. Initially, we established a new health center in a high school serving a high-need district in St. Louis. And now we’re doing the hard work of creating a statewide affiliate of an organization called the School-Based Health Alliance, which will support school-based health centers throughout the entire state. It’s not easy, and there’s a whole set of financial and other logistical constraints, but we’re getting traction.

A more recent focus area has been around housing in the St. Louis region. In April 2018, we and several other housing and low-income advocacy organizations released a report called Segregation in St. Louis: Dismantling the Divide. What I like most about the report is many of the recommendations came out of consultation with those partners on the ground doing the work. They included folks at the Equal Housing and Opportunity Council, who are tasked with making sure fair housing is enforced in the St. Louis region, Ascend STL, which helps move families into rental housing in areas of opportunity, and Invest STL, which invests in community development in St. Louis neighborhoods, as well as advocates with Empower Missouri, ArchCity Defenders, and Team TIF.

We’re excited to see the County Executive taking up the recommendation that St. Louis County establish an affordable trust fund and appoint a task force to recommend how that could be done. We’re pushing for a greenlining fund, subsidized in partnership with banks, for parts of the region where it’s difficult to get financing for housing and housing rehabs. And we’re starting to see a deeper understanding of the impact and ongoing manifestations of residential segregation in St. Louis.

IFF: What do you think the groups who care about this work – government, nonprofits, community groups, funders – could do better?

Purnell: There are a few missteps I’ll certainly own. We sometimes try to do too much. At one point, our team had workgroups in seven different areas. I think being able to focus on three at a time, at most, is probably more beneficial. Another mistake we’ve made is not doing a thorough enough assessment of the existing landscape, organizations, and activities associated with a new area of work.

But what I keep coming back to in my career is the centrality of relationships and relationship building – and how the breakdown of relationships can keep important work from moving forward. I think relationship management is an underappreciated factor in bringing about community change. I’ve always said that the two essential things we get hardly any instruction in at school are managing money and having healthy relationships.

You can’t get through adult life without them. And if you’re going to engage in what is long-haul, arduous, generational change work, you can’t do it outside of a relationship of trust and the kind of grace that provides, because you’re going to make mistakes. Sometimes when community partners try some splashy, marquee thing and it doesn’t work out, we all go to our separate corners and grouse about how the other person screwed up. That’s not a healthy or sustainable way to make change.

IFF: What are your thoughts on working toward equity in the current social and political environment?

Purnell: We’ve reached an interesting moment. On the one hand, I think we’re seeing a new societal shift saying that exploitation and inequality are no longer acceptable. We’re not going to just live with the status quo. There are any number of instances of that, like #BlackLivesMatter and #MeToo. There’s a sense of “you can’t put the toothpaste back in the tube.” People just aren’t going to be satisfied with old explanations for what’s wrong and why certain populations suffer.

At the same time, you have a really toxic environment politically and socially, where we’re seeing a retrenchment in terms of what seemed to have been settled issues around civil rights and other forms of equality.

It’s a big inflection point. And there’s nothing inevitable about which way we might turn. Before he died, Dr. King asked if we were going toward chaos or community. I think it’s still up in the air. It certainly feels like we’re in the middle of chaos, but there’s a possibility for community. There’s a hope that we can finally include everybody when we say “American.” That’s our project in these early years of the 21st century.

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