Every year I have the opportunity to provide the closing keynote address at the Minnesota Rural Health Conference. Not wanting to be repetitious, I continually look for new perspectives on rural health that might be helpful to conference attendees. As I began to prepare this year’s remarks, I was made aware of a book of essays by Wendell Berry, a poet, writer, and farmer from Henry County, Kentucky. Knowing that his writings deal with healthy rural communities, sustainable agriculture, appropriate use of technology, connection to place, and the interconnectedness of life, I thought he might provide some inspiration.
I wasn’t disappointed.
In his essay “Health is Membership” Berry wrote that “…the community in the fullest sense is the smallest unit of health…to speak of the health of an isolated individual is a contradiction in terms.” That statement both stunned and energized me. Public health is based on data and measurement of health and this statement challenges how we currently think about, define, and appraise health. Although we are learning how individual health is profoundly affected by the environment in which people live, work, and play, we struggle to find ways to measure and assess that influence and appropriately improve it. The question is why?
You don’t have to go further than the guiding mantra of today’s health care reform, the “Triple Aim,” to find the answer. The “Triple Aim of Health Care” is: better care for individuals, lower per capita costs, and better health for populations. The focus is entirely on individuals. Even the population health aim looks at populations as the summation of individually-focused data and interventions. There is no direct or implied acknowledgement of the importance of community, which reinforces the common narrative that health is due solely to high quality health care and good personal choices.
The “Triple Aim” reinforces an industrial model of health care that rewards efficiency and assumes bigger is better. It focuses on the care of each individual and assumes that a person can be healthy independent of outside factors. It strives for standardization and evidence-based, best practices although only certain kinds of evidence are acceptable. To best treat individuals with specific disease conditions, health care has become increasingly specialized and technology dependent. This model, effective as it is in providing excellent care to some individuals, discounts the importance of communities.
With that perspective, I had to conclude that the “Triple Aim of Health Care” is potentially detrimental to health – particularly rural health and health equity – and made that the premise of my speech. Knowing that my audience would be mostly health care providers, I made note to emphasize that health care is not detrimental to health rather it’s the health care systems put in place by the values represented by the “Triple Aim.” Health care is an important and necessary contributor to health but how it’s organized and funded is not necessarily best for the health of communities and health equity. In other words, what’s good for our health care system may not be good for communities or health equity.
The “Triple Aim” reinforces the notion that health is the responsibility of the health care system. It crowns our health care system as the benevolent dictator of health in our country. All of health is viewed through a health care lens further reinforcing the narrative that health is solely about health care. It allows the health care system to dictate where health investments are made. That’s why public health and social services are underfunded in the United States compared to other countries and why other sectors that influence health are also under-resourced due to the overly-resourced health care system.
Knowing that people would not want to leave the conference on a negative note, I decided to offer an alternative triple aim for consideration – the Triple Aim of Community Health and Health Equity:
- Expand our understanding about what creates health
- Implement a Health in All Policies approach with health equity as the goal
- Strengthen the capacity of communities to create their own healthy future
The value underlying these three components is community connectedness – the social capital and social cohesion that’s essential for individual and community health.
The Triple Aim of Community Health and Health Equity is built on a community health model, not an efficiency model. It recognizes that health is created in communities by the social, economic, and environmental conditions in which people live, work, and play. It acknowledges that every sector of the community (including health care) impacts the community’s health. Most importantly, it recognizes the need for communities to possess the power to address the conditions that impact their health.
To build healthy communities, the health care system should not be in charge of health nor should the public health system. The community needs to be in charge of health. Health care and public health are crucial to creating healthy communities but are only two of multiple partners who need to be at the program and policy tables where decisions are made about how to invest in health for current community members and for generations to come.
I made the above points in my speech and it was met with polite applause. No one commented or challenged me or even asked a question during the Q and A session so I was left wondering how the speech was received. That was partially answered when three different people approached me after the session and said, “We’ve been waiting for this speech for twenty years. Our present system isn’t working for rural communities. You explained why and you gave us a framework to change that.”
As a farmer, Wendell Berry knows that the seeds he plants determines the crop he harvests. The seed in his essay that “health is membership” blossomed into my understanding that health and health equity is community. Who knows what crop will spring from my speech? If something grows, I hope it’s a crop of social connectedness that shows us that community really is the smallest and most basic unit of health.