May 3, 2016

Anthony Iton, MD, JD, MPH, was born in Baltimore, but grew up in Montreal, Canada –a life path that positioned him to recognize the stark inequities that can result from geography. Thanks to the generous social contract that has long been policy in Canada, Iton enjoyed the benefits of universal health care, universal dental care through age 10, as well as free preschool and a free college education. When he returned the city of his birth for medical school, he was stunned by the condition of the neighborhoods surrounding Johns Hopkins. He saw a young boy wandering the streets of dilapidated housing and asked "What is the social contract with this kid – and when was there a war here?"

His companion said it was "just the inner city." But Iton wondered how such destitute circumstances could have become part of what America is. For three decades since then, he’s been trying to figure out how to change the conditions that made the life chances of a child on the streets of Baltimore so different from his own.

At the Drexel Urban Health Collaborative Speaker Series on April 19, Iton took attendees through his analysis of the reasons and remedies for health inequity, and introduced the audience to his work on the California Endowment’s Building Healthy Communities initiative: a $1 billion, 10-year project that aims to improve health status in 14 California counties, by dedicating its resources exclusively to addressing social determinants rather than paying for health care.

Looking across the last half century, Iton laid out an argument that social factors – including geography, racism and behavior – carry more weight than genetics and access to medical care when it comes to health status. Noting that blacks actually lived longer than whites in the 1950s – he said that white life expectancy grew to 8 years longer than black life expectancy by 2005, despite rapid advances in medical technology during that period. The gap, he argues, is largely the result of the growing prevalence of chronic conditions, such as cardiovascular disease, diabetes and obesity among African Americans, driven significantly by stresses related to chronic poverty and lack of hope.

"Chronic diseases are manageable," Iton said. "But when people don’t see a future for themselves, they blunt the stress and pain of the moment with drugs, alcohol and comfort food." Ultimately, Iton added, stressful environmental and life conditions get “under the skin and change physiology.”

There’s also a resource allocation issue, said Iton, pointing to lower spending on social services in the United States compared to other Organisation for Economic Co-operation and Development (OECD) nations. Member countries spend an average two dollars on social services for every dollar on health care; the US spends fifty-five cents on social supports for every dollar spent health care, though Americans live shorter lives and spend more on medicine that people in other developed countries.

"Health equity is not only about outcomes – it’s about process and the fight: the ability of communities to take charge and hold systems accountable," said Iton. The accomplishments of the Building Healthy Communities project so far include convincing the state of California to provide undocumented children with health care; reducing the number of school expulsions by as much as 40 percent in some areas, and ensuring that the health policy perspective is included in land use decisions. "Health is political: If you want to improve health status, you have to look at environment, and fix opportunity – by increasing the power of people to make choices."

Iton believes that to drive change, you must gather evidence and facts and also craft narratives that allow people individuals and communities to tell their stories, because ultimately those narratives can help to build policies that advance equity.

"You can change the narrative by investing in a new narrative, and letting it take hold," he said.