Commentary: health and economics in the Mississippi Delta: problems, opportunities.
Of course, the health data cited in these papers, of necessity, tell only a part of the story, the "tip of the iceberg." Underlying the specific problems listed are a host of less visible issues including poor nutrition, infectious diseases, stress reactions, and mental health and behavioral dysfunctions that take much more from life, although, in some sense, more subtly or less obviously than cardiovascular disease and diabetes. In other words, there is a much higher human cost to living in an "unhealthy place" than traditional mortality and morbidity statistics convey.
Capturing this human cost more accurately, of course, is challenging. The Disability Adjusted Life Year (DALY) is one useful attempt to do this, capturing both years of life lost to premature death (PYLL) and years of "healthy" life lost in "states of less than full health." Even such measures do not tell the full story, which must include a "suffering" cost, as well as the cost of lost human potential, and in an economic sense, income potential. Many people in the Delta are experiencing a very high total cost by such measures.
The problem is clear. What to do about it is less clear. Does one go for economic development first assuming not unreasonably that health improvements will follow? Alternatively, as David Mirvis, Cyril Chang, and Arthur Cosby suggest in this symposium, does one invest in health first because evidence has shown that " ... improved population health increases economic growth through impacts on education, savings, business and community investments, trade and population demographics, as well as effects on personal and business productivity?" This is the World Health Organization's (WHO) "health as economic engine" paradigm, and its applicability to the Delta region is the central question of this symposium.
As to promoting economic development as the approach to improving health indices, as Bloom and Bowser point out in their paper, "The relationship between health and income has been well established." If so, then programs designed to improve the economics should be reflected in improved health parameters. The fact, however, remains that despite some improvement in the economics of the Delta, with almost all counties and thousands of households experiencing decreases in poverty rates between 1980 and 2000, the disparities in health have grown and not narrowed as described here by Cosby and Bowser. Of course, there is still much to be done on the economic side, as pointed out by John Gnuschke and his associates. New initiatives are necessary, and they need to avoid the failings of earlier programs, including factors such as the absence of local support, narrow focus, undercapitalization, and failure to consider the complex and unique market forces of the Delta as described by Gnushke and coworkers.
The alternative approach in which direct investments in health are used to produce subsequent economic improvements is certainly appealing, but has its own limitations. The answer is that both approaches are needed. As Mirvis, Chang, and Cosby put it in this symposium, the role of health as economic engine does not supplant, but rather extends the conventional view of economic development as a precursor to improved health. The links between health and wealth are clearly bidirectional and create the "virtuous cycle" referred to by David Bloom and David Canning (2000, 2003) in which improved health leads to improved economics and an improved economy leads to better health.
Recognizing that we must come at the problem of the well-being of the people of the Delta using both of the above approaches in an integrated fashion, I would like to focus the remainder of these comments on the nature of the health interventions required to ensure their effectiveness. A critical issue at the outset is the definition of health we are to use. As defined by WHO, and adopted in its Constitution in 1946, "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." This is an important starting point, because it suggests the breadth of interventions necessary for a program that impacts population health and not simply levels of blood pressure, cholesterol, or blood sugar, i.e., efforts aimed only at specific health or disease problems. It also makes quality of life an important health measure. There is nothing per se wrong with programs targeting specific health problems or issues, but they will not accomplish the broad, sustainable and progressive improvements in health and quality of life that are necessary if we are to see the health disparities that characterize the Delta lessen and, even better, disappear.
If we take the WHO definition of health and also a second and necessary proposition that health is not only a thing unto itself but, perhaps even more importantly, a product of a particular community or society and its level of function, then any intervention we plan must be broad-based. It must involve not only the traditional health sector but also multiple other aspects and sectors of society including its culture (and other parts of the definition of "place" described by Neaves and her associates), education, religious institutions, housing, transportation, local businesses, and, of course, government.
Absolutely critical, I believe, is the incorporation of the people themselves into the intervention, not as passive recipients of the program but as critical actors who will ultimately make the program a success or a failure, and, if successful, make it sustainable by virtue of having taken it on as their own and woven it into the fabric of their community. In a very important sense, the people with the health problems or the less-than desirable health profiles become a key part of the solution, and not the problem itself. All too often in the past, the "people" have been regarded as the problem and passive recipients of what outsiders "know" to be right.
Involvement of the people themselves as an active part of the public health system to be developed or enhanced is not only essential, but also cost-effective in both the short and long term. While there are some health problems that require the interventions of health professionals with specialized training and specific therapeutic agents or procedures, a large portion of the better-health spectrum can be handled by the people themselves in both compensated and non-compensated capacities. "Expertise" from within a community, which is the best kind of local knowledge, along with the provision of whatever training and tools are necessary, can make the difference between failed and successful interventions.
Is it possible to involve the people directly as actors or agents of change for health issues? Yes. The experience of the Dreyfus Health Foundation in more than 30 countries around the world (including the U.S. and the Mississippi Delta) over the past 20 years with its Problem Solving for Better Health[R](PSBH[R]) (Smith, 1993) program has demonstrated this to be the case. In this program, people from all sectors of a community or society bring the problems as they see them to a process in which they are trained to solve and implement the solutions they themselves design.
Approximately 60,000 people have been involved in this process and have generated and completed some 40,000 better health projects with measurable and quantifiable impact on human health and, in some cases, local economics as well. The process is not "magic" by itself, and it is not the only way to achieve integration of the people into health interventions. Importantly, it has been shown to work. Of course, it must be integrated into coordinated multisectoral efforts mentioned above. The design and implementation of such programs is not trivial by any means, but it is necessary. PSBH[R] is, at the least, one way to ensure that any larger, more complex, higher-level program stays grounded in the people themselves.
PSBH[R] has been active in the Mississippi Delta for four years now. It has had some dramatic successes but needs to be taken to a higher level and integrated into more macro approaches to overall development of the Delta, if it is to achieve its full potential to help. That integration is a challenge, but it is a challenge that presents a major opportunity, i.e., the design of a truly multisectoral, multilevel approach to improving both health and economics in the Delta. The model that results, I believe, will not only be useful in the Delta, but also, with modifications to fit local realities, in other disadvantaged rural areas in the United States.
The present symposium and the contributions to it discussed above are a positive step toward developing such a model. They are also a call to action, not only to speed the development of the model, but also to implement it to the benefit of the health and quality of life of the people of the Delta. Finally, I believe that the people of the Delta have much to teach those of us in other parts of the United States about these same issues. The more quickly we move forward together, the more quickly we all will benefit, no matter where we live.
Bloom, D.E., & Canning, D. (2000). The health and wealth of nations. Science, 287, 1207-9.
Bloom D.E., & Canning, D. (2003). The health and poverty of nations: from theory to practice. Journal of Human Development, 4, 47-71.
Smith, B.H. (1993). Optimizing the use of available resources: Problem solving for better health. World Health Forum, 15, 9-15.
BARRY H. SMITH
Dreyfus Health Foundation
The Rogosin Institute
New York-Presbyterian Hospital/Weill Cornell Medical Center