In the fall of 1985, I left home and travelled to an unfamiliar country. I landed in Baltimore, Maryland — a place that radically changed my life trajectory. I grew up in Montreal Canada, a beautiful cosmopolitan and diverse city that’s rich in parks and open space, outdoor cafes, public art, street theatre, high quality housing and a state-of-the-art public transportation system. My brothers and I grew up in Montreal in the 60’s and 70’s and we felt nurtured by that city.
Canada has a strong social compact with its citizens. We all know Canada has universal healthcare but it’s also got a universal child care benefit, paid vacation, guaranteed sick leave, high-quality community resources, parks and recreation centers, community infrastructure, and highly subsidized post-secondary education. I went to McGill University basically for free. Canada invests in its citizens.
When I graduated college I was told that Johns Hopkins was the best medical school in the world. In fact there’s a saying at Hopkins which is “we may not be the best, but there’s nobody better.” When I landed at Hopkins I was delighted. But when I walked through the doors out into the community, I was dumbfounded. I had never seen anything like East Baltimore. I was being toured around by an upperclassman and he saw the look of shock on my face and asked me what was wrong. I managed to stammer, “When was there a war here?” I’ll never forget what he said to me. He looked at me with this look of utter disdain and said, “What do you expect? It’s the inner-city.”
Was I supposed to expect this these atrocious and dehumanizing conditions? I saw children in the clinics at Johns Hopkins and I couldn’t help but wonder what would’ve happened to me if I’d grown up in East Baltimore. Would I have been able to attend medical school and become a doctor? These kids I saw didn’t create this environment, yet they had to navigate it every single day of their lives.
What is the American social compact? US doesn’t have much by way of universal social benefit policies at all. What are the fundamental agreements that underlie
the American Dream? As I looked around I had a hard time imagining any social compact whatsoever and I wondered for the low-income residents of East Baltimore whether they really ever had a meaningful shot at the American dream. This question started to incubate in my mind. In America when it comes to your health, does your zip code matter more than your genetic code?
After I graduated Hopkins trained in internal medicine I subsequently ended up being the health officer of Alameda county. The health officer’s job and it’s a great job is to be the registrar of all deaths in Alameda county. There are about 10,000 deaths in Alameda county every year, and each of those deaths has a death certificate that I signed. We took every part of the county and we calculated on average how long people could expect to live in based on their neighborhood. In the city of Oakland we found neighborhoods that were close together, within a couple miles of each other where the life expectancy difference was greater than 20 years. We found that it wasn’t just in Alameda county. This also played out in Baltimore where in some neighborhoods, life expectancy was only 58 years on average.
Minneapolis, St. Paul, Seattle, Philadelphia, Boston, New York, Cleveland, LA. Everywhere we looked, we found life expectancy differences discrepancies of 15, 20, 25 years in the same city. What’s happening in these low life expectancy communities? Simply put these communities are functioning like incubators of chronic stress. Our fractured social compact has rendered these places without the basic social political and economic infrastructure. Chronic stress makes it much more likely for one to develop cardiovascular, disease, diabetes. The outside world gets under the skin and changes our physiology. In this country low-income people are physiologically different than high-income people not because they were born that way but because we made them that way with our policies. But perhaps it’s more at often the absence of policy in the face of abject need that creates a high degree of social vulnerability so that these communities like East Baltimore are susceptible to any threat that comes along whether it be a foreclosure crisis, HIV/AIDS, a heroin epidemic, or even a hurricane. Our policies are literally making people sick and killing them prematurely.
Physiologically, the body perceives a stressor through the brain and sends a message to the pituitary gland which sends message to the adrenal glands which release a cascade of hormones amongst which is cortisol. Low income people in this country are awash in cortisol. Chronic stress actually changes physiology. It changes behavior. It changes how our genes are expressed. Chronic stress, which is driven by the policies that we’ve created is as lethal as any knife or any gun. The U.S. is 43rd in life expectancy and slipping. We still operate through the medical model which says that bad behavior produces disease which produces premature death. S we use ambulance and emergency rooms to try to prevent death.It’s time for a new prescription.
When it comes to health, rather than asking people to beat the odds, let’s change them. We’re working to create a whole new approach to health in California. We’ve put a billion dollars on the table. A billion-dollar bet that we can prove that there’s a better way. We’re organizing people to come together to reweave California’s social compact.
Take Fresno, the 20th congressional district, one of the poorest in the United States. It also feeds the world through its vast agricultural exports. In 2014 the Board of Supervisors decided that they wanted to cut off healthcare to 5600 low income undocumented workers, many who work on the very farms that feed us every day. But something happened. People stood up and advocated and activist said no, not on our watch. They organized and advocated and the Board of Supervisors backed down. In cities all across California, ordinary people are actively changing the course of their lives.
In Long Beach, there was a plan to extend rail yards to run 8,000 trucks through a neighborhood that already had high rates of asthma, cardiovascular disease, emphysema. People organized and succeeded in persuading the port to back down. It’s happening now. People are agents of the change that will allow them to live longer and fuller lives.
The odds are changing in California. 50,000 people working together to create a new social compact and its yielding results. Hundreds of policies all over the State. 300,000 fewer suspensions and expulsions in California over the past three years. 5 million people newly insured. A million people now eligible to reclassify their felonies into misdemeanors. A quarter of a million undocumented kids eligible for full scope health benefits. California is changing the narrative. We’re building a social compact for everyone.
Dr. Tony Iton is Senior Vice President for Healthy Communities at The California Endowment.
