We explored the ways in which people think about community health with Christopher Holliday. Holliday is the director of the Adler School of Professional Psychology’s Center of Excellence for the Social Determinants of Mental Health.
Andrew Benedict-Nelson: I’d like to start with a sort of thought experiment. Let’s say that you encounter a community of people that understands individual health perfectly well, but when you talk to them about “collective health” or “community health,” they look at you as if you’re speaking a foreign language. How would you explain those concepts to them? How would you demonstrate that they exist?
Christopher Holliday: When I talk about public health or population-level health to an audience that may not understand the concept, one of the things I would point to is neighborhoods or significant groups within a county or some geographical area that are experiencing rates of sickness or death due to things that may not be happening in other parts of that area. From an epidemiological perspective, those things must be tracked at the population level.
So from an individual perspective, you may present at the doctor’s office with diabetes or chronic pain or some other illness. But you may not know that others within your area may also be experiencing those same illnesses or symptoms. When you look at the population, you may find that there are structural or systematic or even policy factors that foster those conditions. So looking at the population level helps you to see these illnesses as well as the structures that might affect them, whether it’s crime or poverty or a lack of access to fruits and vegetables. A public health professional would also see how to intervene on those levels.
Andrew Benedict-Nelson: What I hear in what you’re saying is a concept of collective health that is mainly about information. In this model, the “collective health” actually consists of someone saying, “Well you got sick and you got sick and you got sick, so we have a collective sickness.” That’s not so unusual – it’s what people have been doing since John Snow tracked down that nasty water pump.
But I wonder if there are other ways that people actually experience collective health? What about a sort of empathetic model? For example, I can’t really feel healthy if my wife isn’t healthy. Do you think relational effects like that are a part of how we think about collective health?
Christopher Holliday: Absolutely, particularly when we are talking about mental health. Population-level mental health is one of the new and emerging fields where we are looking at the effect of social structures on the overall well-being on the community. So think about a person presenting issues of depression to a clinical psychologist. We believe — and studies show — that large groups of people (particularly those who are marginalized, whether they are limited English proficiency or people of color or LGBT or some other type of group that is experiencing stigma) can experience collective deficits to their well-being as a result of these social determinants. So there is a social connection between and among people by which a lot of sickness or illness can affect the global well-being.
Andrew Benedict-Nelson: I remember there was a study a few years back that found a relationship between a couple of factors — income, blood pressure levels, etc. — and skin color among recent immigrants to the U.S. What the study was demonstrating was that the effects of racism weren’t just things like employment or housing being denied to particularly categories of people, but an across-the-board increase in stress as skin color darkened.
To me, the relevance of that to our discussion is that when we’re talking about the intersection of race and health, we’re not just talking about things like decreased access to care. We’re talking about health outcomes that are embedded in people’s identities and the way they live in society. If you’re an epidemiologist, you’re never going to find that water pump.
Christopher Holliday: Exactly. There is no handle to be removed. It’s the whole context of racism, of highlighting difference and treating people differently based on difference.
The premise of this coalition was to listen to the community before it acted on the community.
When we talk about population-level mental health, some of our interventions are on the structural level. We look at policies, structure, or environments that foster or highlight or unintentionally cause greater mental disfunction because of the ways that they marginalize different groups. One of the ways we can do that are through tools that we call Mental Health Impact Assessments. If there is going to be a proposed change in a policy, we study that to determine if there is doing to be an impact on one population and its mental health in particular. Then we use that information in an advocacy role to engage policymakers. We try to think about health outcomes in all policies, not just health policies.
Andrew Benedict-Nelson: That also strikes me as another path you could use to move from individual health to collective health. If you go back to the original thought experiment, you could demonstrate the existence of collective health to people by saying, “Look, if twenty percent of you are sick, we’ll have to grow less wheat or make fewer widgets, and that will ultimately have political consequences.” The point is that the way those people would experience those health outcomes would have nothing to do with epidemiology as such.
Christopher Holliday: Right. That’s another significant way that we talk about community health – we don’t just talk about morbidity or mortality in a population, but also the effects of disease burdens on things like productivity or the ability to provide for others in the community. There’s plenty of research that shows that high morbidity leads to lower productivity, for example. So you don’t just want better well-being, but things like higher productivity and lower crime in a neighborhood.
Andrew Benedict-Nelson: Can you sometimes discover physical or mental illness by observing those social effects first? Do epidemiologists ever see, say, an increase in crime and start asking if there is a health problem at the root of it?
Christopher Holliday: Yeah – an epidemiologist tends to come in because of some problem that triggers an investigation. So if there is any baseline measurement and you see a change, a scientist is going to be interested in finding out why.
Andrew Benedict-Nelson: So we’ve been conducting an abstract thought experiment. But are there any actual situations where you’ve had to do something like this, persuading a group that collective health is a real thing that can be acted upon?
Christopher Holliday: I once worked in a community called Clarkston in a fairly urban-suburan area of the Southeast. It had a high level of diversity, which can be a recipe for challenges. One in three people in this small city were foreign-born; people from all over the globe had settled there, but there was also a long-standing white community and a substantial African-American community.
The public health department was at the time doing things like tracking disease rates and making sure people were educated about prevention – the typical things a public health department does. But then a unique set of circumstances gave them the opportunity to be a part of a community coalition. I happened to be the facilitator of that coalition for a time. A lot of that work involved trying to get people to see things from a community perspective rather than focusing on their individual needs.
Over five to seven years, this particular coalition looked at ways that the community could become more healthy by eating more fruits and vegetables and getting more physical activity. Many people suggested interventions that focused on individual behaviors and responsibilities. That’s what has been traditionally been done – a group of public health officials sets up a program, where they say, “Come here, and I’ll teach you how to do this.” Armed with our morbidity and mortality rates, we go in and say, “Here’s how we’re going to fix you.”
But the premise of this coalition was to listen to the community before it acted on the community. We had a very out-of-the-box director who said we were going to engage the community around things they already felt strongly about. It was almost Freirean in a way. I facilitated the conversation through which we listened to the community to find out what they cared about.
Out of this set of listening sessions, we discovered several “generative themes” that emerged from the community discourse. One of the things we asked was what sort of things the entire community needed to be more healthy. We discovered that they were saying things like, “We need a place to play soccer.” As a newly minted Master’s in Public Health, my reaction was something like, “Soccer? Are you sure you don’t need an immunization program or something that encourages people to do tai chi or something?” But we listened to what they were saying, then used some resources inside the community as well as some from outside to get a regulation soccer field built in the heart of the community. About ten years later, that field has blossomed – it has people of all ages playing sports there, it has a community garden, and it is encouraging physical activity.
So what we learned from this listening model is that people have the answers to their own issues if they’re given the opportunity to speak on their behalf. Now they have a fully functioning set of programs at the heart of their community because they were given that initial opportunity. That opportunity changed the dynamic of a very fractured, very segregated community. They were able to come up with many of the things we were trying to get at as public health officials on their own.
Andrew Benedict-Nelson: I recently heard a story on NPR about the obesity epidemic. The reporter was asking why doctors are so reluctant to tell patients to lose weight, even if it is their primary health issue. There were a number of reasons, but one of them was that patients usually aren’t going to follow through on weight loss unless they have independently decided that it is time to change their lifestyle – once they’ve reached that point, the doctor actually has a lot to offer. And so one implication of the story was that doctors needed to think about the patient’s lifestyle in a broader sense, perhaps thinking, “What would motivate this person to want to lose weight?” rather than just providing technical advice.
Health care providers have more reasons now to collaborate with both the usual and unusual suspects.
Well, to me it sounds as if you’re describing something similar on a community level. Sure, there are a dozen public health interventions you could imagine for most communities. But you figured out how to tie them to this thing that they were already deeply motivated to do. And that involved a process of the community taking a look at itself and its values as a whole. It seems like a process that is not quite within the realm of public health as we currently understand it.
Christopher Holliday: In actuality, it’s something that we are trying to bring into public health. We’re talking with communities about the ways in which they can change the policies, systems, and environments that preclude healthy behaviors. We’re trying to build relationships with non-traditional partners like urban planners and people in community development. We’re trying to get beyond the usual suspects and look at everyone who makes decisions that affect people’s health.
Think about something like the designs of neighborhoods. Communities ought to be laid out with cut-throughs so people can walk to a grocery store if they want to. They shouldn’t have to get in the car and drive several miles to get out of their subdivision just so they can get to a store that is right behind their house. So it’s really thinking about health in all aspects of policy.
Andrew Benedict-Nelson: I wonder how exactly you add that to the toolkit of the individual physician. If you go back to the thought-experiment, one way that people might discover the existence of community health is by seeing that some diseases just can’t be treated individually. The obvious example is infectious diseases – there is no meaningful way to eliminate something like malaria, for instance, from a community by just treating individual cases and never thinking about the population.
Christopher Holliday: And in the real world, individual physicians understand that there are in fact reporting requirements for diseases like malaria. They would know they have to call the public health department.
Andrew Benedict-Nelson: Right – but it feels as if there is no equivalent move for ailment like obesity that might be in part socially determined. There is no equivalent way for the practitioner to “level up” from individual medicine to community medicine.
You could imagine a situation where the physicians of one hundred years from now are looking back at us and laughing because we were still trying to treat obesity individually and not socially, just as we look back at physicians who failed to recognize the epidemiological vectors of infectious diseases in their time.
Christopher Holliday: I think that realization is already occurring. But how it would need to transform the health care system is in the training of the clinicians doing this work. They need a better understanding of the social determinants of health and how they affect the patient standing there before them. So if I were treating a case of chronic obesity, yes, I would want to know about the individual’s genetics and behavior, but I would also want to know about the environment that that person goes back to. I’d like to know what might encourage or prevent the behaviors I had recommended. Understanding those things simply helps clinicians practice better medicine.
Andrew Benedict-Nelson: What do you think are some of the barriers that can prevent clinicians from seeing or thinking about collective health in that way?
Christopher Holliday: I think people are taught from the beginning of their professional career about individual health and individual responsibility. They’re thinking about the individual almost exclusively from the time they enter the hallowed halls of whatever institution they’re at. Because of the way we’re trained, people in public health tend to think of that as fairly “downstream.”
Andrew Benedict-Nelson: I would think the same principle would apply to patients. For good reasons, we’ve got lots of aspects of our culture that reinforce individual responsibility. But I think that also leads to people saying, “How can I get sick? I worked hard and payed my taxes and did everything right.”
Christopher Holliday: Sure, there is a culture in our society of individual responsibility. It makes people think, “This could have been prevented but for something I did” as opposed to “This is something that is happening among our population.”
Andrew Benedict-Nelson: Is there some specific thing you could remove from our culture that would help people see the ways disease works in a population more accurately?
Christopher Holliday: There are many good policies and practices in place in society that protect public health or regulate our interactions in society, so I don’t think removing one of them is a very useful strategy. But I think it’s important to understand what kinds of health implications they all have. If they’re detrimental to the health of the general population or a marginalized population, we need to be aware of that and fix it.
Andrew Benedict-Nelson: I’d like to learn a little bit more about the problem of collective health is processed by institutions. So my dad is a surgeon. He is primarily concerned with individual patients. But he treats them through this institution called a medical practice, and over the years the rules of how a practice works have changed somewhat. What are some of the recent changes in institutions and organizations that have changed the way we address a society’s collective health?
Christopher Holliday: Institutions have been forced to collaborate across silos. Some of this comes from funding streams changing; there are mandates on the parts of funders that say that if you are going to work on the health of a population, you need partners in the community who will help you achieve “wraparound” effects on the population. So we talk much more about care coordination now. There are many more funding incentives as well as policies that demand connections with things like social services and rehabilitation.
You shouldn’t go to a community with a bunch of resources, dump them in, and say “Be fixed.”
That’s embedded into all sorts of policies, like the rule in the new health care law about 30-day re-admission. For some conditions, if a person is admitted to the hospital and then discharged, then re-admitted within thirty days, the hospital will be reimbursed less from Medicare. That has hospitals and medical practices thinking much more about what they do the first time they have the patient, as well as how they can discharge patients into an environment that is more healthy so they won’t be re-admitted. That’s just one of many reasons why health care providers have more reasons now to collaborate with both the usual and unusual suspects to achieve better outcomes.
Andrew Benedict-Nelson: In a few weeks, we’ll be doing a Lab with Harvard Medical School’s Family Van program, which operates mobile clinics in Boston. On one level, this upcoming Lab is going to be about some of the abstract concepts of collective health that we’ve been discussing. But on another level, it’s about people who practice medicine out of the backs of vans. When you think about the range of activities going on in community mental health now, is there some situation for which mobile clinics seem like a useful tool?
Christopher Holliday: Part of understanding a population’s context is being able to engage them where they are. So anything that puts people in communities talking to people, hearing their concerns, letting people speak on their own behalf, is an important precursor to any intervention. The main advantage of a mobile resource for physical health or mental health is that it actually goes into those communities. Ideally it would also be run or driven by people who were also from those communities.
As for its use in a specific kind of intervention, the closest thing I can think of is a program we have been involved with that provides art therapy for teenage boys who have been the victims of gun violence or some other type of violence. That’s not technically a mobile program, but we did find that it was important for them to experience that therapy in their homes and in their communities.
Andrew Benedict-Nelson: Sure, it makes sense that that sort of thing could also be accomplished through a kind of mobile clinic. I wonder if we could further explore this using the imagination, though. Let’s say that the president of Ford Motor Company came to you tomorrow and say, “Hey, turns out we over-produced vans this year – we have 10,000 to spare and we’d like to use them to develop a mobile community mental health program.” What do you think would be the highest and best use of that resource?
Christopher Holliday: Coming from the perspective I’ve shared with you, my first inclination would not be prescriptive. It would be to ask the community what we could with 10,000 vans that would improve their health and well-being.
Andrew Benedict-Nelson: Huh, that’s kind of brilliant. Because it may very well be that many of them want to start moving companies or have existing transportation needs that the system isn’t meeting.
Christopher Holliday: The things they would come up with would probably not be what I would think of. Somebody else might say that we need to put acupuncturists and candles in them and just drive around inviting people in, but I doubt that’s going to do much. The community has the answers to its own issues. It just may not feel empowered to share them, or it may not have access to someone asking the right questions.
Andrew Benedict-Nelson: One way or another, this Lab is going to address the way people think about collective health. That’s not so different from the work you’ve done throughout your career and that you’re going to be doing with this center. So tell me, what are some of the superficially appealing but incorrect conclusions you really hope we avoid? What are the sorts of things you get sick of hearing from panels and reports over and over again?
Christopher Holliday: One of the things that is most frustrating to me is the idea that people just have to be given something, or that some project or some program is all that needs to be provided to help or cure someone. I think there are two ways to deal with population-based health interventions. In one, I am a professional and an expert, and I come in with all of my data on morbidity and mortality, and I give you things like pills, or I tell you to do things. That has the consequence of breeding dependence. There isn’t really a change in the status quo.
The other way of helping is to start from a place of listening, understanding that I have some information, but it’s the community that has the lived experiences and knows the contextual factors. Together, we can utilize the evidence I have and the evidence they have to work toward real solutions that are sustainable and transformative. In the end, they will say, “We did this ourselves.”
Andrew Benedict-Nelson: Even if an outside group may have provided the resources of a key piece of expertise.
Christopher Holliday: The important thing is that it is asked for. You shouldn’t go to a community with a bunch of resources, dump them in, and say “Be fixed.” They need to make the decisions about what kinds of outside resources they would want to use, as well as to decide what kind of community assets are important to the solution (which outsiders might miss). So when I hear about someone who does something prescriptive without this kind of prior work, I usually say, “Don’t they get it yet?”