New York Times columnist David Brooks’ book, The Second Mountain, documents how he moved from midlife despair to personal fulfillment by seeking out individuals and groups who are rebuilding their communities through empathy-driven community action.
There’s nothing unique about the conservative-turned-never-Trumper’s critique of an America now wallowing in tribalism, anger and despair. Decades ago, prominent sociologists like Christopher Lasch (The Culture of Narcissism) and Robert Putnam (Bowling Alone) sounded alarm bells about the long-term consequences of rampant individualism. They feared the evisceration of the institutions that brought people together would undermine democracy.
Those seeking to build a better healthcare system need to internalize that message. Our healthcare institutions routinely perform miracles for individuals who are sick. But it will remain a Sisyphean task as long as the patient pipeline is constantly refilled by social conditions that breed chronic disease, and providers’ sole strategy is to cure those ills one patient at a time.
Why is there so much obesity in our society? Why so much asthma? Why so much drug and alcohol abuse? Despite the lowest unemployment rate in over half a century, why are people easily misled into blaming immigrants or foreign trade for the shortcomings in contemporary economic arrangements?
Researchers have given us the answers. These are not individual flaws. Key outcomes like overall health and longevity are directly related to education, income, living conditions and social status. The average life expectancy of someone living in a high-income suburb is as high as anywhere in the world. But a person living in rural Appalachia or the inner city can expect to live anywhere from five to 10 years less.
Healthcare leaders are stepping up their efforts to redress the social conditions that lead to ill health. Modern Healthcare will hold an important conference in Cleveland that will highlight programs addressing inadequate housing, food deserts, air pollution and economic insecurity, all of which breed chronic disease like a slum building breeds rats.
Healthcare institutions need partners for these programs. For one thing, systems whose revenue depends on people getting sick will never have sufficient resources to tackle the problems that make people ill. Indeed, as long as they get fee-for-service payment, they will always have a perverse incentive to underinvest in programs that prevent disease.
In theory, full capitation would help, since providers or insurers would then have an incentive to invest in prevention that reduced total costs. But the reality is that the returns from most prevention measures take years to materialize, while providers and insurers operate under annual or even quarterly timelines.
Only government has the resources and the long-term perspective necessary for successfully investing in community-based prevention programs, whether it’s improved housing, cleaner air or universal pre-kindergarten education. Sadly, the U.S. spends far less societal resources on social programs than other advanced industrial countries.
Moreover, federal, state and local authorities have been steadily reducing the size and scope of public health agencies. That has led to the weakening of an important voice for helping elected leaders understand the connection between social conditions and ill health.
Healthcare systems also need community-based partners. Local housing groups, food pantries, and not-for-profit social service agencies have a wealth of knowledge about local conditions. They have the capacity, when adequately funded, to deliver critical services in a timely manner, which can have both an immediate and long-term impact on health. Yet here, too, there has been a steady erosion of capacity, exacerbated recently by a tax law that ended the deductibility of donations for many upper-middle-class supporters.
Volunteerism has a long, proud history in America and, as Brooks notes, has the potential to help rebuild our democracy. But when it comes to public health and creating a healthier society, it will never be enough.
