[MUSIC] Health is not the whole story, but health is an important consideration in a variety of policy decisions. So I want to switch gears a bit here and talk about the framework of health in all policies. And why I would argue that it's an important framework for us to have in mind when we're thinking through the possible interventions that we might develop and implement in order to address health disparities. So what is health in all policies? Here is the definition of Health in All Policies that I've pulled from Pekka Puska who was a Director of the National Public Health Institute of the European Union. This definition is that the core of health in all policies is to examine health determinants that are mainly controlled by policies of sectors other than health. The wish is to address policies in the context of policy-making at all levels of governance. So this idea of Health in All Policies is really tied to policy-making processes. I think of it as not necessarily health being the paramount consideration in policies outside the health sector, but a critical and important part of the story. This approach requires health experts and I would argue health disparities experts in particular having a seat at the table in a variety of policy discussions. Interestingly, I think of this health in all policies framework also as having a bent towards health equity. That is with an eye towards how health conditions that are disproportionately negative for some can be addressed. Who are some of the research partners and stakeholders that we need to engage in order to be effective in implementing health in all policies framework? I think of this in two domains. One is the academic domain. Who are the cross disciplinary research team partners that we need to ensure that we have a nuanced understanding of social policy and the ways that it might affect health? In my own work, I have collaborated with sociologists, criminologists, people in economics. Obviously, colleagues in public health and myself, am duly trained in pubic health and in medicine. But other researchers that need to be at the table in these discussions or part of our teams to help us understand the priorities of policies in other sectors,. Would include people in the business school communities, in education, the list goes on and on. But this particular set of academics I think are all addressing questions relevant to policies that would have impacts on social determinants of health. The other piece of the puzzle are the policymakers. These are the people who might actually be considering a particular policy approach or implementing a particular policy. And may not be thinking about the ways it could impact health, both positive and negative. Some of the sectors listed here map directly onto the areas of evidence around social determinants of health. That suggests that these might be positive places to intervene to produce positive results on health disparities. So policymakers working in the housing sector, community development, business development, education, crime and policing. The list could go on and on. I think the big question is, how do we engage effectively so that people are receptive? Both policymakers and our research colleagues are receptive to adding health considerations to the long list of other considerations that are paramount to them. That may be the primary reason or driver behind a particular policy approach or policy debate. The other piece of the puzzle is how can we be creative about thinking through the types of data sources we can use in our research? Within the health sector or within healthcare and public health to ensure that we are characterizing the social determinants exposures that are populations of interest experience. This can help us get a better picture of what types of conditions people are exposed to that might be perpetuating disparities or maintaining disparities for certain populations. Among the data sources that I often think of are census data, data from the Department of Justice. Or from local police departments, which oftentimes have sophisticated systems for tracking and publicizing crime. The National Neighborhood Indicators Partnership, one of the sites is located here in Baltimore. It's the Baltimore Neighborhood Indicators Alliance, which maintains and compiles information on our local environment. Specifically relevant to housing conditions, abandonment, health conditions, and nutrition conditions in local neighborhoods. This type of data can give us a richer picture of the context in which people live. Which allows us to develop a more nuanced understanding of what might be the full list of fundamental drivers of health disparities. So that we can think through the extent to which we might be able to intervene on some of these. County health rankings can be helpful in understanding where your particular county fits in in your state overall in terms of health and health disparities. And there are trade and industry databases that can help us get an understanding of the types of businesses available. These types of databases are often used, for example, in obesity research. Where people try to characterize the nutrition environment in neighborhoods using proprietary business databases. To identify the presence or absence of grocery stores or corner stores or fast food restaurants. And then there are a variety of administrative data sources. These can come from your health system, from the medical record, or they could be an administrative data source that's available in another sector. I'm not going to pretend that there aren't often obstacles to combining data across sectors. But for example, there are administrative data sources within the education sector. That might have a lot of relevance to understanding the health and well-being of children in the school system. Or administrative data sources from a planning department or a housing authority in your local area. That give you a sense of the population that's accessing a service in one of these other domains. Or benefiting from a policy in another domain, that might be important to know. I want to switch gears a little bit here and give an example from my own work. That I think will help me to illustrate what the strategies are for engaging other stakeholders and other types of policymakers and researchers. In work with an emphasis on achieving health equity or ameliorating health disparities. The case example that I want to walk through here is called zoning for a healthy Baltimore. Our goal through this project was to influence the final version of Baltimore's new zoning code. By producing revisions to the draft new code that improved its potential to promote health and mitigated its potential to have negative health consequences. That likely were unanticipated. I think this is a really quintessential example of the concept of health in all policies, the policy of interest and urban planning policy. Our goal, not necessarily to usurp the objectives of the urban planning policy and make health paramount, but rather to be critical about understanding the extent to which this policy might already have implications for health, both positive and negative. How did we go about doing this? The method we used is called Health Impact Assessment. Health Impact Assessment really has a fundamental emphasis on health equity. So not just looking at the potential health impacts of a policy, but specifically looking at the extent to which those health impacts are likely to be felt or experienced in an equitable fashion across a community. It's a multi phase process and I'm not going to go into the details of how you actually conduct a health impact assessment in my lecture today. But suffice you to say that it involves and in depth review of the literature and assessment of the relationships that baseline and after policy implementation between the policy and health. And engagement and feedback from stakeholders who understand the policy landscape. And it concludes with a set of recommendations on how the policy could be optimized to achieve desired health benefits in an equitable fashion and minimize or mitigate potential health harms. What did we find in our health impact assessment of the zoning code? In fact, in our review of the literature, we found what I think is relatively well established which is that there is a consistent association between the density and proximity of alcohol outlets to population and violent crime. Here we drew from the criminology literature and more fortunate to have a research colleague with expertise in that area. In our analysis of the draft zoning policy, we also had concerns that the percent of residents in neighborhoods allowing liquor stores had the potential to triple from 9 to 27%. And there were set of serious equity concerns about how that liquor store density and that proliferation in liquor store might be distributed across the city. Such that residents and high poverty neighborhoods or neighborhoods that are already experienced disadvantage would be more likely than low poverty neighborhoods to experience some increase in the number of liquor stores, or at least in the allowance of liquor stores. Just to be clear, zoning policy does not change the neighborhood environment. It just creates conditions for future development. And so what we were looking at was the extent to which changing the conditions in local neighborhoods could be associated with changes in what's on the ground in those neighborhoods, but the zoning policy itself doesn't create a business in a particular place. Beyond this emphasis on alcohol outlets, we found a variety of other things and we're able to create a tiered list of recommendations for the planning department. That acknowledged that in fact, without it being a primary priority of there's some of the changes they were proposing to Baltimore zoning code might actually potentially create good health conditions in neighborhoods. Things like expanding the number of zones where urban gardens were allowed or where farmers markets could be located. Things like ensuring that new development complies with a set of standards related to first floor transparency and landscaping standards. That were likely to make places, healthier, more appealing places to walk and be active and could have positive benefits on crime prevention by increasing the number of eyes on the street so to speak. So we were able to identify things that they were already doing that while health wasn't the reason they were doing them, we found that they were likely to have health benefits based on the existing public health literature. We found another set of things where there was the potential for there to be positive health impacts, but there was more work to do. Things like specifying in those landscape standards exactly how much green space was required. And then there were other areas where we found cause for reservations around how the policy was designed in terms of its potential for exacerbating health inequity, or contributing to a potential increase in health harms for certain communities. The most well substantiated of these in the literature was alcohol outlets. But another important area that we discussed with them had to do with access to healthy food. I want to talk a little bit more about the alcohol outlet piece because we made a set of recommendations in our health impact assessment to the planning department around what could be done to reduce the risk of this perpetuation of liquor stores and neighborhoods, and the likelihood that that could be associated with increased crime. The recommendations we initially made were very poorly received by the planning department. We made a set of recommendations around specific mechanisms for reducing liquor store density. One of them being something called a deemed to approve process and the planning department felt that that particular process would be difficult to implement. So we got at the table with them and sat down with them because of the goodwill we had built in supporting and informing their policy and informing its potential health implications, and worked out some other strategies that would have hopefully the desired effect on liquor store density in the city. Ultimately, the planning department, in collaboration with the city health department and the city solicitor's office, came up with three provisions that were included within transform Baltimore that were directly informed by the health impact assessment work we had done. The first was that liquor stores that were located in residential neighborhoods. So an example of that is this photo. You can see that the photo shows a residential neighborhood. And next door the several front yards is a paved in set of front yards of a liquor store. The idea being that there are some places in the city which even since before 1971, when the prior zoning code was ratified, weren't locations where an alcohol outlet or a liquor store was really allowed, but some of these stores were already there. So this particular provision was designed to require liquor stores in these residential zone neighborhoods. To stop selling alcoholic beverages within two years after the effective date at the ordinance. The second provision was specific to taverns in Baltimore, which would be required to meet a zoning definition of a tavern within two years after the ordinance. And the third was a dispersal zoning ordinance, basically intended to decrease further overconcentration of liquor stores in areas of the city where those stores are an allowable use. This code was actually ratified in 2016 by the Baltimore City Council, including these three provisions. I will tell you that engaging with policymakers requires acceptance of a very different timeline of events than we might hope for in our academic research. In fact, the Health Impact Assessment work that we did Was published and shared with the city agencies in 2010. And it was not until 2016 that the legislation actually passed. So it's a different type of process, a different way of engaging, but being at the table and being part of policy debates and bringing health information to bear can be very powerful. Particularly when you identify a combination of impacts that the policy may have on health including some unanticipated positive impacts at baseline. It really creates the goodwill and the collaborative engagement with policymakers. To push the envelope a bit on some of the other areas where there may be the potential for a policy to have suboptimal impacts on health. So what was our strategy for engaging with policymakers throughout this process from the health impact assessment to ultimately policy development? The first thing I'll say is we jumped in through a window of opportunity. We had collaborators at the health department, there were students who were active on this issue who knew that there was an urban planning policy being developed and refined. And we saw that as an opportunity to think about where health fit into the conversation. We also spend a lot of time building relationships with policymakers outside of the health sector and in engaging our research colleagues from criminology from urban planning and law. So that we were able to be thoughtful about the primary goals of the policy while also pushing the envelope on how this policy might be used to impact health. We had to gain buy in from city leadership. That means building relationships. It's a different type of engagement than conducting a traditional intervention might be. Although I think that relationship building is sort of a key part of what we do. And it optimizes our ability to have impact when we build relationships that might allow for our work to become sustained through some structural change, like a policy change. And we had to link our interest in promoting health equity to cross-sector priorities. One of these that was paramount was crime reduction and crime has clear links to health. The other was effective use of communication and media. Some of this had to do with helping figures in the media helping reporters understand the connection between zoning in health. So you'll see picture this article in the Baltimore Sun on zoning for zucchini. This was really partially influenced by media advocacy work that our team did to raise this connection. Because it wasn't an intuitive connection for most people involved in the process. And it highlighted the fact that zoning impacts the distribution of urban gardens and urban gardens can potentially impact people's access to fresh fruit and vegetables. We communicated through other mechanisms through Citizens Planning and Housing Association at the time, which was a conglomerate representing a variety of community associations. And we partnered with Philanthropy to produce a report that more broadly discussed some of the relationships between urban planning and liquor store distribution in particular and health in our city. We were also really sensitive to the fact that the messenger matters, right? An academic messenger isn't always the right person to be upfront on an issue. But the information and the research that we can bring to bear and sensitize for our colleagues functioning on other spheres was helpful in their messaging. So what are really the take home points from my talk today? The first is addressing impacts of social determinants on health is imperative, but it's not impossible. The second is that partnering with researchers in other disciplines is a critical ingredient. This partnering makes things messier, more complicated, but that more complicated, messier version of the relationships. Gets you closer to a comprehensive understanding of the complexities of the competing priorities in people's lives. And translating that research into action whether it's policy change or whether it's just scaling up an intervention. That you've developed and determined is effective in reducing disparities requires buy-in across sectors. Whether that's sectors within a health system, different divisions within a public health department, or whether that really is different sectors outside of health. And that health can be a shared priority, but it's not always going to be the top priority. So if we can let go of the idea that health should always be the number one concern on people's mind. Which I think it is for me as a health professional and when people come to my office, they're coming because they have a concern about their health. But life is much broader and more complicated than that. Sometimes the top priority is having a safe place to live. Sometimes the top priority is being able to put food on the table or keep the heat on in your apartment. If we can keep in mind that other things may trump health for people at certain points in time. We can grow our partnerships with other sectors and we can identify for them how meeting their priorities also improves health. A great example of this I think in the clinical context is the extent to which clinicians and healthcare delivery systems partner with social work or volunteer organizations. Like health leads to ensure that they are taking advantage of every opportunity to connect people to social resources that may be available to them. Identifying parents of newborns who haven't yet accessed the WIC program and ensuring they access that benefit. Identifying families who are living in housing with lead paint or that's lacking heat or that is structurally unsound. And ensuring that we're doing what we can to support them in requesting and demanding the remediations to their property that make it safe place to live. And then I think the final conclusion I would have is that an equity lens is a critical part of this. Not every intervention, policy, or otherwise is destined to decrease disparities. It matters how the benefits of that intervention are distributed. Meaning that an intervention, such as some of the income supplement interventions I discussed earlier. Which has been demonstrated to have a disproportionate positive impact on those experiencing the highest degrees of disadvantage is a critical element for reducing disparities. Otherwise we may perpetuate or even exacerbate them depending on how the benefits of an intervention are distributed across the population. I'll stop here and conclude just by acknowledging the broad array of colleagues and co-authors, mentors, collaborators, who have contributed to the work that's presented here. And the funders and partners that make my work possible. And here are some key references that were mentioned during the course of the talk. That either relate to my specific work or to the broad work around social determinants as a mechanism for reducing disparities. I would just point your attention to the last article listed from Health Affairs. Which I think provides a detailed and comprehensive summary of the social determinants interventions In the sector's described earlier in this talk. So if you want more details on any of those intervention domains, take a closer look at that article. Thank you. [MUSIC]
