This article is part of State of Health, a new series examining health disparities, how they affect Michigan's children and seniors, and the innovative solutions being developed to address them. It is made possible with funding from the Michigan Health Endowment Fund.

Imagine this: Your child has tested positive for lead poisoning, so you request a city inspection of your home. At the same time, you receive an eviction notice. You follow up with the city to find out when the lead inspection will occur so you can use it to fight your eviction notice, but the city has canceled the inspection because of your eviction. In the same week, you have your second child, who will grow up in transitional housing after your eviction.

It sounds like some sort of nightmare scenario, but it's the story of a very real Grand Rapids woman who Jeremy Moore met in his work as director of community health innovations at Spectrum Health. Moore uses the story to illustrate the concept of health equity, and the differences in the quality of health people may experience due to a host of factors known as social determinants.

For example, that Grand Rapids woman's first child was already at a health disadvantage due to the social determinant of an unsafe physical environment. Her second would face potential health disadvantages due to social determinants including income, housing, access to services, and stress. Here in Michigan, those determinants may cause dramatic differences in the quality of health and health care, especially for children and seniors.

Phyllis Meadows, senior fellow in the health program at the Kresge Foundation, says health equity comes from "creating the conditions that allow folks to have opportunities for good health."

She emphasizes that the key term is "equity," not "equality."

"The greatest inequality is doing the same thing for everybody, because some people need more or different things" to achieve good health, she says.

Looking further "upstream"

Meadows says many people focus on access to healthcare services when they're discussing health equity. But she wants people to "look upstream" and examine how social determinants affect people's health.

"It really takes healthcare out of the clinical into more social and environmental factors that might make it difficult for people to achieve good health," Meadows says.

She notes that physical environments, such as an old home full of lead or a home located near a pollution-heavy business, may have a major impact on health.

While pollution is a problem in urban areas, rural areas have many unique challenges of their own, including an opioid epidemic that is a problem largely among white men with less access to substance abuse help.

Lack of good mass transit also makes it difficult to move out of a rural area with few opportunities, Meadows says. It can also pose an especial challenge for seniors who have no transportation of their own and no way to reach a hospital or other healthcare services, which may be a considerable distance from some rural communities.

"Transit creates opportunities," Meadows says.

Rhonda Powell, director of the Macomb County Department of Health and Community Services, notes access to nutritious food as a key social determinant of health because it affects other factors, such as academic achievement.

"We know and have known for years that children who come into school and have had a nutritious breakfast have better educational outcomes, retain more, and learn at higher rates than children who do not have that access," Powell says.

Powell notes that the social determinants that have a big impact in a region can change over time. One growing challenge in Macomb County is language barriers. A 2017 study found that 116 different languages are being spoken in Macomb County schools.

"Over the past 10 years, there's been a growing immigrant and refugee population in Macomb, so language access and language barriers are newer areas that need to be addressed," Powell says. "We have to provide really culturally and linguistically appropriate services."

Moore says income and wealth disparity is a "huge" social determinant of health in Michigan. It only got worse after the loss of thousands of industrial jobs in the early 2000s and the economic downturn in 2008, which disproportionately affected poor people.

The roots of wealth inequality go back even further through decades of institutionalized racism that manifested in city ordinances dictating where people of color could buy property. That led to neighborhood segregation and, eventually, poorer health outcomes.

"Every measure of outcome disparity for people of color, of course, has everything to do with history," Moore says. "To reverse that takes some targeted investment and intentional work."

Collaborations are key

The good news when it comes to health equity in Michigan is that "there is a lot of great work going on in the state," Meadows says. She, Powell, and Moore all rattle off a variety of programs that are working to advance health equity in Michigan – and those are just the tip of the iceberg.

Moore gives the example of an older program in Kent County, Strong Beginnings, which focuses primarily on preventing infant mortality. About two decades ago, Kent County had such a huge racial disparity in this area that a black baby was six times more likely to die before age 1 than a white baby.

Major risk factors include preterm births and having two children within an 18-month period. After decades of interventions targeting these two risk factors, a black baby born in the Grand Rapids area today is two times more likely to die before age 1 than a white baby – a remarkable improvement, despite the still-staggering level of disparity.

Powell says one of the strongest strategies for dealing with health inequities is the power of "co-location," or situating a number of different services in one place.

"If we are all separated and spread out, and you have to get to this building for one service and that building for another, we're creating barriers for people who are more vulnerable," Powell says.

In response to that concern, Macomb County used the annual Distressed Communities Index to identify two ZIP codes, one in Warren and one in Mount Clemens, to target for intervention. In both communities, the county partnered with school districts to repurpose unused school buildings as Community Resource Centers.

These centers provide one stop where at-risk children, families, and seniors can find utility and weatherization assistance, diabetes prevention and nutrition classes, a food pantry, and many other services. Partnerships with local businesses also provide workshops where county residents can check their credit score, open savings accounts, and work with professionals to stabilize their finances.

Powell says a collaborative mentality, and a holistic approach to the factors that contribute to health, are the most effective ways to address health equity. She gives the example of someone with an addiction issue who then loses their transportation, leading to risking losing employment altogether.

"Then there's this spiral toward homelessness and having your kids turned in to child protective services," she says. "When parents are focused on addiction, they're not focused on nutrition, good health, and all that. We're trying to come together and look at the whole picture instead of picking apart individual parts of someone's story. We're listening to their story holistically and determining what services they need, and wrapping those services around them, so they can rebound as quickly as possible."

Meadows says attitudes are changing all over Michigan in regard to the factors that affect health. A recent study on health equity in local health departments conducted interviews with more than 40 of these departments, and 38 of them made mention of the concept of health equity, Meadows says.

"They've had to partner with other sectors in human services like mental health and housing to meet the needs of the people they're seeing," Meadows says. "It's very promising that the vast majority are stepping out of their comfort zone in public health and looking upstream at factors like housing and education. People kind of get it, but there's more work to do."

Sarah Rigg is a freelance writer and editor in southeast Michigan. You may reach her at sarahrigg1@gmail.com.

Rhonda Powell and Phyllis Meadows photos by Nick Hagen. Jeremy Moore photos by Adam Bird. All other photos courtesy of Spectrum Health Beat.