An Upstream View of Population Health

The Upstream Imperative, Volume 2

This article is part of “The Upstream Imperative,” a series exploring the challenges and opportunities facing the social services sector.

By Adair Mosley, President and CEO, Pillsbury United Communities

If you’re like me, you want to solve the stubborn disparities that exist in our community. It can be daunting to talk about, and there are no easy answers. But I believe the change we want is possible if we are willing to zoom out. Only by tackling the root causes that brought us to this place can we get past them as a society. 

This is what I mean by the Upstream Imperative: elevating our strategy to engage the systems — not merely the symptoms — that hold back people’s lives across generations. 

Facing the factors

Nowhere is this upstream response more needed than in population health. We know that the health of our community is shaped to the greatest extent by social determinants: factors including neighborhood livability, housing, education, and economic prosperity. These factors influence people’s lifelong wellbeing more than any hospital, doctor, or medication. 

Why does Minnesota have some of the largest racial disparities in the nation? Because life in black and brown communities has long been adversely impacted by systemic racism and inequity. This context affects everything: people’s access to nutritious food and health education, their exposure to environmental hazards, and their likelihood of living in substandard housing. It imposes extra costs and barriers when they access healthcare and produces toxic stress that puts people at risk for lifelong health problems.

If we’re serious about closing these gaps, we need to think at the scale of this systemic challenge. That means bringing all stakeholders to the table to innovate with an inclusive approach. 

Assessing root causes

We can’t solve problems we don’t clearly understand. Which is why the Affordable Care Act mandated that non-profit health systems conduct health assessments in the communities they serve. Such assessments can unite payers, providers, and policymakers around the same goal — be it care access, nutrition, housing, education, or all of the above — and guide a coordinated response. 

Without a mandate to address social needs and root causes, the efforts of health systems to date have been largely reactive and disconnected from the people they’re meant to help. As that mandate changes, organizations like Pillsbury United have an essential role to play. As a connector between healthcare systems and our communities, we can help produce a truer picture of life and health in our neighborhoods — the first step in creating an effective response based on the community’s real needs and assets.

Human connections

Foremost among these assets are people. In communities of color, there have always been navigators — people who deeply understand their neighbors’ perspective and help them navigate their critical social needs, from health care to housing. The role they play is usually hidden and seldom compensated, but their impact is no less important than that of doctors. They guide people to overcome cultural and economic barriers to better health in ways the traditional healthcare model cannot. 

That’s an opportunity. By investing in the capacity of these navigators and elevating their role as true Community Health Workers, we can empower our communities’ human resources to do even more. They deserve better tools and support and to have a voice in matters than affect their families and neighbors. Despite proof that such a model works, it is not as well funded as it should be. Policymakers, payers, and healthcare systems can help change that. 

Convener and conduit

Health has been at the center of our work for over 140 years. Supporting whole people in whole communities is part of our Settlement House roots. We understand the importance of working in, for, and with community, listening to people most affected and giving them tools to create solutions relevant to their lives.

As healthcare systems begin to embrace more encompassing, community-based solutions, agencies like Pillsbury United are poised to make them successful. As intentional partners, we can ensure an intersecting regional response big enough to create historic change aligned with the goals of stakeholders and needs on the ground.

We envision a future where people achieve greater personal health and wellbeing together. For the communities we serve, this future can’t wait.

Planting Our Flag

The Upstream Imperative, Volume 1

This is the first article in “The Upstream Imperative,” a series of articles exploring the challenges and opportunities facing the social services sector.

By Adair Mosley, President and CEO, Pillsbury United Communities

Here’s a hard truth: our systems are failing our communities. The black and brown families we see every day inhabit a society where they are in last place. Minnesota is 49th or 50th nationally for disparities in earning high school diplomas. We are 49th for racial gaps in home ownership. Mortality rates for African-American and Native residents are up to 3.5 times higher than for other racial and ethnic groups.

While these challenges disproportionately affect people of color and families living in poverty, they are a legacy of choices we’ve made as a community. So how will we respond to these shared problems as a society?

Will we focus on providing services that ease suffering in the short term, while ignoring the systemic causes that have brought us to this point? Or will we embrace deeper, more lasting solutions?

Make no mistake, traditional human services are a lifeline our communities can’t do without. Our sector improves millions of lives in thousands of communities by working to close gaps in food, housing, education and beyond. These efforts must be preserved and strengthened.

But on their own, they are not enough. Beyond delivering programs and services, it’s time to re-envision the ecosystem and impact of our work as a whole. To remove systemic barriers that hold back people’s lives, we need to embrace radical and disruptive innovation. And urgently.

Social needs: widening the scope

Agencies often say they address social determinants of health when in reality they treat symptoms. Food shelves help feed families, but they don’t solve the financial and transportation burdens that put grocery stores out of reach for many communities. Health education can save lives, but it only succeeds when supported by healthcare infrastructure that makes the knowledge actionable to people where they live.

While providing near-term services to individuals is necessary, it does little to change the systemic issues on the ground — most importantly the long-term economic disadvantages faced by families living in poverty. Until we confront that social reality, food, housing and health assistance will be a temporary salve at best.

Responding only to individual needs can give us a false sense of progress. We celebrate the number of people we’ve served through our programs while ignoring the conditions that make these programs necessary.

To move the needle on a population scale, we must take a broader view. If we are serious about addressing social determinants of health, we must dismantle the systems that perpetuate inequities and hold people back across generations.

Changing the ecosystem

Shifting the context in which people live their lives is hard work. System-wide solutions take more effort, money, and political will. They require cross-sector partnerships that can reform complicated entities like our health care and education system. They require us to ask difficult questions, demand more of ourselves and our partners, and refuse to be complacent.

The social services sector can’t be expected to move these mountains on its own. Partners in government, philanthropic community, and businesses must also step up. When money is restricted to incremental solutions, entrenched problems fester and our communities remain unstable. We need brave financial partners willing to collaborate on ambitious solutions — and allow those with proximity to the community to focus dollars and energy where it matters most.

In over a century working with and for our community, we have learned that the best solutions flow from the community itself. But only when we understand the lives behind the challenges and stay anchored in their dreams and aspirations.

This is where we plant our flag as an agency. We envision communities where people achieve greater personal health and wellbeing together. Where cultural understanding creates social connections. Where prosperity is shared by all through equitable education and employment opportunities.

This is our motivation: going upstream to reform entrenched systems that can meaningfully change people’s lives long term. As an agency, as a sector, and as a society, we must be willing to think bigger and do the hard things. Only then can we realize a healthier, happier, more prosperous future for everyone in our community, no exceptions.

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