As Jacob, one of the three Old Testament patriarchs, flees from his brother Esau, he stops for the night at Bethel, where he dreams of a ladder going from earth to heaven with the angels of God ascending and descending the ladder (Genesis 28:11-19). There is extensive biblical commentary on this dream and particularly on why the angels are first ascending and then descending.
However, as anyone who follows the research on economic mobility and social determinants of health knows, you are always better off ascending the ladder rather than descending it. The spiritual “Jacob’s Ladder” also used the imagery of the ladder to symbolize the climb out of slavery and into freedom.
In the past several months, there have been several noteworthy developments in the philanthropy world supporting research into economic mobility in the United States and the social determinants of health. Foundations and their investigators have explored why the United States seems lagging in measures of both positive health outcomes and economic mobility. The United States has fallen from the highest rungs in these measures during the past thirty years, which is also a period marked by growing income inequality in the United States. The connection between the two was also explored in a recent New York Times article by Robert Pear.
The Brookings Institution, with the support of the Pew Charitable Trusts, released a report about the fraying of economic mobility in America in the past thirty years, “Getting Ahead or Losing Ground: Economic Mobility in America.” This report, which did not discuss health care, did have some parallel findings with research into disparities and social determinants of health. Just as the U.S. no longer ranks in the top five or ten of industrialized countries in measurements of health status, we also no longer rank at the top in economic mobility, contrary to the dearly held notion of the United States as the land of golden opportunity regardless of birth. Instead, even in the United Kingdom, a country and civilization seemingly marked by great class divisions, a child born to parents in the lowest quintile of income had greater opportunity to move up than a comparable child born in the U.S. in the same time period.
The Brookings research also shows how opportunity is not evenly distributed across the United States, with education and race playing significant roles in predicting movement up or down the economic ladder. These social determinants of health and how they are distributed unequally and play different roles among various ethnic and racial groups are also discussed in the recent Health Affairs issue on disparities in health, in separate papers by Ellen Meara and by Rachel Kimbro and colleagues.
Foundations that particularly focus on the health care system have also turned their attention to the persistent disparities that mark American health care and want to focus on identifying programs that help people move up from the lowest rungs of the social and economic gradient. For many of the foundations, identifying existing programs and getting them to work both within and outside the formal health care system to improve health status is imperative. Under current economic constraints, funding new programs is unlikely, so identifying programs in education, housing, employment opportunities, and other venues that also promote better health status is vital.
In November 2007 Grantmakers In Health held a forum on exploring the complex connections between poverty and poor health. The forum’s deliberations are explored in more detail in the March/April Health Affairs GrantWatch column.
The W.K. Kellogg Foundation has retooled its focus to spotlight how to help vulnerable children by supporting neighborhoods, families, and other social determinants of health. Kellogg has supported work presented by Dolores Acevedo-Garcia and colleagues in the recent Health Affairs issue on how poor, segregated neighborhoods impoverish the future opportunities of poor children of color and the need to create “opportunity neighborhoods.”
The MacArthur Foundation Research Network on Socioeconomic Status and Health, chaired by Nancy Adler, also released a report, Reaching for a Healthier Life: Facts on Socioeconomic Status and Health in the U.S.
The Robert Wood Johnson Foundation unveiled its new Commission to Build a Healthier America on February 28 and released its report, Overcoming Obstacles to Health. The Robert Wood Johnson Foundation also supported the recent Health Affairs issue.
The Commonwealth Fund, on March 24, released Eliminating Racial and Ethnic Disparities in Health Care: A New Chartbook.
The renewed commitment of foundations to focus on the social disparities of health builds on ongoing programs like those of the California Endowment. The California Endowment currently has initiatives in six communities to support healthy eating and physical exercise and, with the support of the Rockefeller Foundation, has been supporting efforts in four communities to help residents ascend the career ladder and achieve better health outcomes.
Many of the foundations and their primary investigators, as well as authors such as David Williams and Leonard Syme, in our recent Health Affairs issue on disparities, have their work presented in the upcoming PBS series “Unnatural Causes: Is Inequality Making Us Sick?” The series, which will air over four weeks, begins on March 27 or 28, depending on your local PBS station. It graphically introduces viewers to the concept of a gradient in health as it traces the health of Louisville residents in different council districts of the city. While most health care policy analysts are well acquainted with the concept of social determinants, it’s less clear how well this is understood by the general public. This is a wonderful opportunity for people generally interested in health and in policy to get an illustrated introduction to the world of social determinants and the metaphor of the ladder. While not quite a biblical commentator, another great philosopher, Charles M. Schulz, had his prophet Lucy say, “Well-informed laymen make up the foundation of a healthy society.”