Your Degree, Job, and Chronic Stress: Addressing the Social Determinants of Health

Today is the first post from our 2017-18 Autry Fellow, Rishi Jaswaney. We’re happy to have him at MDC and writing for the State of the South blog!

We’ve all felt it before. That sinking feeling before a big exam, an interview, or when your favorite character on Game of Thrones is “removed from casting” in the throes of battle.

Stress. Side-effects may include: nausea, indigestion, headaches and excessive perspiration.

In limited amounts, stress can motivate us to pursue our personal and professional goals. As stressors pass in and out of our lives, the stress hormone, cortisol, naturally fluctuates, but as challenges persist, cortisol levels remain elevated. When stress is a chronic condition, it can be linked to anxiety, depression, and other developmental and psychological issues. Research documenting income-based patterns in health outcomes—including disparities in who is more likely to experience chronic stress—raises new questions regarding the state of health equity in our nation.

As seen in the Centers for Disease Control and Prevention (CDC) chart below, serious psychological distress is associated with severe health problems, including chronic obstructive pulmonary disease (COPD), heart disease, and diabetes. Even more concerning is the disproportionate clustering of these conditions in high-poverty communities, as reported by the CDC: “A total of 8.7 percent of adults with income below the federal poverty level had serious psychological distress, compared with 1.2 percent of adults with incomes at or above 400 percent of the poverty level.”

The daily economic, educational, and social challenges facing those in poverty can create barriers to health services and lead to poorer health outcomes. This idea is captured in the Social Determinants of Health framework, which The World Health Organization (WHO) has defined as the “the conditions in which people are born, grow, live, work and age.” The general argument is that people in high poverty communities are more susceptible to certain illnesses, have less access to health care providers, and are frequently forced to delay care or medicine for financial reasons. The proximity of clinics, public transportation options, and the quality of food vendors, all affect one’s ability to address health concerns and seek care. As the social determinants of health concept has taken hold, organizations like Kaiser Family Foundation have adopted more nuanced definitions, incorporating more detailed categories, as shown below.

The WHO and others have emphasized how money, power, and the distribution of resources (through institutional decisions and policy implementation) shape community conditions and drive health outcomes. In places where education, employment, and accessibility are falling behind national averages, health outcomes are trailing along with them. For example, in North Carolina, counties with the lowest rates of postsecondary attainment and employment (Robeson and Warren counties) also rank poorly on measures of low birthweight, obesity, and diabetes prevalence. Counties with the highest rates of postsecondary attainment and employment (Wake and Orange counties) have the lowest rates of these indicators.

Source: National County Health Rankings

Source: National County Health Rankings

If education and employment are key drivers of upward economic mobility, then people must be healthy enough to take advantage of these opportunities. There are many narratives about educational attainment as a predictor of health outcomes. Formal education often provides foundational principles of nutrition, healthy behaviors, and general health literacy. Education is also an avenue for insurance benefits through school plans or future employment opportunities.  Lastly, education provides individuals with an intangible set of resources such as social networks, norms, and relationships that can cultivate healthy practices.

It is important to recognize that poorer health outcomes in high poverty areas have been driven by policy that marginalizes low-income communities. The provisions of the Affordable Care Act made strides in addressing issues of healthcare access, but in order to holistically address health equity, we must also consider the underlying environmental, social, and economic factors that enable good health. Improving preventative initiatives, health education, and access to nutritious foods are a few measures that could begin to eliminate these disparities, improve public health, and encourage, rather than hinder, economic mobility. Throughout my Autry year with MDC, I hope to continue shedding light on the social determinants of health that persistently marginalize low-income communities. Stay tuned for more posts on how these issues play out in Southern communities!

Changing the Narrative to Change the Odds: Improving Upward Economic Mobility in Fayetteville

We’re in a special season here at MDC: it’s the time of year when we select our new Autry Fellow, a recent college graduate who will spend one year learning from and contributing to MDC’s programs that help bring people and places closer to opportunity and success. As MDC staff members review applications each year, we keep in mind that an ideal Fellow brings to MDC a spirit of both reflection and hope: they critically examine systems that produce inequitable outcomes, but also firmly believe in the potential and strength of leaders and communities to make those systems better. Indeed, this determined mix of examination and encouragement is a crucial asset in any community working towards change. My colleagues and I saw this spirit first-hand when we discussed economic mobility with leaders in Fayetteville last month.

Our discussion with a cross-section of leaders in Fayetteville was the last in a series of community work sessions that MDC and the John M. Belk Endowment held throughout the state in 2016 to disseminate the report, North Carolina’s Economic Imperative: Building an Infrastructure of Opportunity. In these sessions, representatives from MDC, the Endowment, and various sectors in each locality examined data related to economic mobility in North Carolina and discussed strategies for changing the odds for success, rather than merely helping individuals beating the odds.

FTCC BryantIn mid-December, we traveled to Fayetteville: a mid-sized city in the Sandhills of North Carolina with strong higher education institutions and a notable military population, thanks to the presence of Fort Bragg. As we learned from session participants, some of Fayetteville’s greatest strengths lie in community leaders’ ability to come together and speak honestly and reflect about community challenges. But, participants told us, all too often, a thorough examination of the issues leads to exhaustion and discouragement, distracting from the great work—often of national recognition—done by dedicated leaders in education, government, philanthropy, public service, and more.

But the leaders gathered at Fayetteville Technical Community College’s Horticulture Education Center that Tuesday afternoon collectively refuted the persistent whisper of discouragement. “There’s a lot to be proud of, and we need to tell our story more effectively,” Dr. Larry Keen, President of FTCC, told the group. Keen and others acknowledged the barriers that can keep people in Fayetteville stuck at the bottom of the economic ladder: competition for limited resources, a cradle-to-career continuum with room for increased collaboration, and difficulty getting new perspectives involved in planning and design. But they also acknowledged that they had significant work to build on and resources to tap, including what they shared during our afternoon session: a group of knowledgeable leaders, their honesty and self-reflection, and their determined belief in the potential of Fayetteville’s residents and institutions. And they were ready to put these strengths into action: “We’ve got a lot of work to do,” Keen said. “We have an obligation and a responsibility to step in.”

Thank you, Fayetteville, for showing us at MDC what it looks like to have difficult conversations with compassion and integrity, without becoming discouraged or apathetic. Economic mobility requires having high expectations for what can be achieved—and those expectations are too often stolen by the hopelessness of poverty. With continued courageous conversations like this one, Fayetteville can begin changing the odds in their community.

A big thank-you to all the communities and leaders who spoke frankly with us this past year about the economic mobility opportunities and challenges in their communities. You can read here on the State of the South blog about our time in Western N.C., in the North Central Prosperity Zone, in Monroe, N.C. and Wilkes County, and in the Northeast and Southeast region.

We Need to Look Forward: Shared Mobility Challenges & Potential in Urban and Rural NC

monroe-connection

These Monroe community work session participants say #NCMobilityMatters because connection = success!

Earlier this year, MDC and the John M. Belk Endowment released a report examining economic mobility across North Carolina and how communities are responding to recent Equality of Opportunity research showing that intergenerational poverty is particularly dire in the South compared to other U.S. regions. We’ve documented several community work sessions discussing the findings from that report here on the blog. As we crossed all of North Carolina’s prosperity zones, we saw unique challenges facing rural and metro areas, but we also witnessed similarities.

Take the community work sessions that were held in Monroe and Wilkesboro. Monroe is a growing city, part of Union County (which has a significant rural population), on the edge of the Charlotte metropolis. Wilkes County is a rural county on the edge of the Blue Ridge Mountains, with its population spread across 757 square miles. But in both places, we were hosted by a North Carolina community college and the local Chamber of Commerce served as a key partner. One place is trying to find a way to restore or reimagine a manufacturing economy; the other is looking for ways to encourage participation in the advanced manufacturing opportunities that exist. Both are grappling with limited public transportation systems and affordable housing options that would ease the burden on families trying to make ends meet and get ahead.

In each community work session, we’ve asked people to share their mobility stories. We ask them to think about how their starting point affected where they ended up, and to consider what people or policies or simple serendipity cleared a path or propelled them to their current situation. The same elements showed up in Wilkes County and in Monroe (and nearly every other work session):

  • Adults—often educators—who “believed in me”
  • Personal drive
  • Military service and the GI bill
  • Education (and related scholarships, including athletic opportunities)
  • Public policies (like war bonds) that allowed people to save and transfer wealth

The headwinds faced were also similar, including public policies that were not available because of discriminatory practices. These shared experiences are a great example of how systems and aspirations intersect. In order to make the elements of an infrastructure of opportunity pervasive and available to more people across North Carolina, communities must find ways to cultivate aspirations and institutions that are launching pads for the enormous potential that exists in our residents. It may seem a daunting challenge, but as Jeff Cox, president of Wilkes Community College, said “we’re not afraid of a fight and we’re ready to move forward, ready to tackle the problems we have. We’re ready to get about the business of solving those problems. We need to look forward.”

Bootstraps vs. Blockades: Closing the Growing Racial Wealth Gap When Doing the “Right Thing” Doesn’t Work for Everyone

Conceptions of the American Dream often frame upward mobility as an ideal best accomplished through individual effort and perseverance. However, persistent racial disparities despite similar inputs demand a reconsideration of the story we tell ourselves about the degree to which success is available to everyone. A recent report using data from the Survey of Consumer Finances shows that, in 1983, white households held, on average, 5.3 times greater wealth than black households and 6.1 times greater wealth than Latino households. By 2013, those rates had increased to 7.7 and 6.7 times greater, respectively. This is a growth of 85 percent for white households, but only 27 percent for black households, and 69 percent for Latino households.

Source: CFED and Institute for Policy Studies. The Ever Growing Gap. August 2016

Source: CFED and Institute for Policy Studies. The Ever Growing Gap. August 2016

What is more striking, however, is that even if the wealth of black and Latino households had grown at the same rate as white households or even as drastically as those on the Forbes 400 list (a 736 percent increase in wealth between 1983 and 2013), their wealth would still not match the wealth held by white households. Black households would fall short by $181,000 and Latino households would fall short by $270,000. The report concludes that:

“If average Black family wealth continues to grow at the same pace it has over the past three decades, it would take Black families 228 years to amass the same amount of wealth White families have today. That’s just 17 years shorter than the 245-year span of slavery in this country.”

Catching Up: The Racial Wealth Gap is Unlikely to Narrow

In order to catch up to white families, black and Latino families would need to find a way to increase their wealth by over 700 percent. But traditional drivers of wealth creation do not produce as much value for people of color relative to their white counterparts (with the exception of Asians). For example, education has long been described as the great equalizer and, while there are significant economic returns to a college degree, there are large earnings and wealth gaps by race even among those who have earned postsecondary degrees. Similarly, homeownership is the largest expenditure for many families and represents a large portion of their total wealth, but non-whites are less likely to own their own home and, when they do, their property values are significantly lower. Given the extent to which homeownership is constrained by income and student loan debt (which is accumulated in larger amounts by non-white students), these racial disparities are not surprising.

Source: Georgetown University Center on Education and the Workforce. The College Payoff. 2011

Source: Georgetown University Center on Education and the Workforce. The College Payoff. 2011

 

Source: St. Louis Federal Reserve Bank. The Regional Economist. Unequal Degrees of Affluence: Racial and Ethnic Wealth Differences across Education Levels. October 2016.

Source: St. Louis Federal Reserve Bank. The Regional Economist. Unequal Degrees of Affluence: Racial and Ethnic Wealth Differences across Education Levels. October 2016.

Intergenerational transfers of wealth are another major contributor to wealth creation, but for black families, this strategy is much less successful. Black children born into moderately wealthy families (the middle wealth quintile), are more than twice as likely as white children to fall from the middle to the bottom quintile as adults (33 percent vs. 14 percent).

This trend is especially concerning in the South, with deep racial divides in economic opportunities and a long history of excluding racial minorities from sources of wealth accumulation. For example, the high degree of residential segregation found in the South further exacerbates the gap in wealth created by home ownership; neighborhoods with higher concentrations of non-white residents often have significantly lower property values. Coupled with lower rates of intergenerational income mobility, this suggests that an even greater challenge exists for black and Latino families hoping to build wealth and economic security.

New Outcomes Require New Systems

If black and Latino families are pursuing the same strategies for upward economic mobility as white families, why aren’t they reaping similar rewards? As we’ve written before, our history, particularly in the South, of economic dependence on forced and exploitative labor limited opportunities for wealth creation for those outside the economic elite, and particularly for people of color. Unequal investment in community resources that are beneficial to the entire population, like schools, transportation, and healthcare compounded these issues. This history and it’s continued legacy, apparent in current disparities, undermines a pillar of our proclaimed American ideal that upward economic mobility is available to all who are motivated, persistent, and hard-working. If we believe that closing the racial wealth gap is an issue best solved with strategies implemented at the individual level, what then, is a viable pathway for black and Latino families to catch up, if not through education, income, or homeownership? If we do not have a good answer to this question, we cannot continue to tell ourselves that the only thing standing between poverty and prosperity is a strong work ethic. Instead, we must commit to systemic changes at the institutional level, which focus on the racial disparities among major drivers of wealth creation and create an infrastructure of opportunity that is prosperous for everyone.

Redefining Collaboration: Communities in Eastern N.C. Come Together to Work Together

If you’ve been keeping up with us here on the State of the South blog, you probably know that we’ve been traveling across North Carolina since August facilitating community work sessions with the John M. Belk Endowment and local institutional partners. These work sessions were sparked by a report that MDC and the Belk Endowment released earlier this year titled North Carolina’s Economic Imperative: Building an Infrastructure of Opportunity, examining how North Carolina reflects recent research showing that the South has the lowest rates of economic mobility for young people in the nation.

To find out how these data play out in real places in North Carolina, we talked with leaders from eight communities in the state about how residents and institutions are confronting slim odds for upward mobility. Now we’re reconvening those same leaders and more to reflect on the data as a cross-sector group and to lay the groundwork for planning next steps.

#NCMobilityMatters to Lori Preast and Rachel Bridgers of Pitt Community College because equity is not the same as equality

Lori Preast and Rachel Bridgers (Pitt Community College) share why mobility matters to them.

In mid-November, two MDC staff members had the privilege of traveling to the eastern part of the state to hold two of these work sessions: one in Brunswick County, including leaders from New Hanover County; and one in Beaufort County, including leaders from Pitt and Martin counties, as well. Though distinct in geography and history, these regions in the southern and northern parts of the state have a lot in common—people in leadership who care about their community and are striving for deeper cross-sector coordination; a mixture of urban and rural areas, each with unique needs; and strong higher education institutions that are determined to expand access to all residents in their service areas.

Those of us at MDC who had the opportunity to speak with a variety of leaders in both communities couldn’t help but notice a similar challenge, followed by a similar proclamation, in both regions: Fragmented work makes for fragmented funding, which stalls strategic investment that could move a community forward as a collective group. Both sets of leaders bemoaned that all too often, groups of leaders get together, each say their bit about the work they’re doing, and then go back to their corners without having really changed much about their way of working. Even in communities where there is some cross-over, it can be difficult to create deep collaboration that reaches every system or institution at every level. In fact, a participant at the Brunswick County session raised an issue with the word “collaboration” itself: one definition of the word refers to how an enemy might gather information from their opposing side. Though malicious intent doesn’t apply, this sense of working on separate “teams” is all too common as communities strive in silos to achieve change and growth.

But both of these work sessions were different. Inspired by sobering data showing that nearly 70 percent of children born into poverty in both the southeast and northeast regions in North Carolina will stay at the very bottom or rise only one income quintile as adults, leaders from these eastern counties were ready to put their heads together to find a new way of pooling their resources. By aligning their efforts and working to fill gaps in resources as a community team, in which all players are working towards the same goal, these regions can start to build an infrastructure of opportunity in which the systems and factors that influence a person’s path to success are strengthened and aligned to make sure no one sees inequitable barriers to opportunity.

Big thanks to the caring and insightful leaders from New Hanover, Brunswick, Pitt, Martin, and Beaufort counties for two great conversations this November on why #NCMobilityMatters! It’s hard to believe we only have on more community work session to go—we’ll see you Dec. 13, Fayetteville!