Brian D. Smedley
Joint Center for Political and Economic Studies

Michael P. Scott
Equity Matters, Inc., Chief Equity Officer /
Baltimore Place Matters Collaborative for Health Equity, Chair

Maryland ranks near the bottom third among states in health, in large part because of significant inequities among our state’s racial, ethnic, and socioeconomic groups. African Americans in Maryland, for example, face infant mortality rates that are nearly three times higher than white Maryland residents. Latinos are over four times more likely than whites to not have health insurance. And low-income residents of the state’s Western and Eastern Shore counties, as well as our urban communities, face higher rates of chronic disease but have less access to primary care and other health care services than residents of higher-income Maryland communities.

A growing body of research argues for a focus on neighborhoods and communities—the spaces and places where people are born, grow, live, work, and age—as a key factor in predicting health and health care access. Neighborhoods powerfully and negatively shape health directly through things like environmental degradation and the stress that comes from living in a high-crime area. They also indirectly influence health in that they shape behavior, such as diet and exercise, based on what’s bought and sold, and whether people feel safe outdoors.

As a result, policymakers are increasingly considering place-based strategies to improve health and reduce health inequities.

Recently, a bill was passedin the Maryland State Legislature that attempts to address some of these needs, which disproportionately hurt minority and low-income rural communities, but affect all Marylanders because they are unfair and dampen our economic recovery.

The Maryland Health Improvement and Disparities Reduction Act of 2012 seeks to reduce health inequities among Maryland’s racial and ethnic groups and low-income rural communities. It would establish a Health Enterprise Zones (HEZs) pilot program that will improve health care access and health outcomes in underserved communities. Such an effort would be vitally important to improve health care for those who need it most. But HEZs have the greatest potential to reduce health inequities and improve population health to the extent that they focus on community-level health promotion and disease prevention by reducing the concentration of health risk and improving access to health-enhancing resources.

Under this legislation, some of Maryland’s communities that have the poorest health status can receive special incentives and funds to create healthier neighborhoods. HEZs create an array of financial incentives for primary care providers and other health care resources to practice in underserved communities.

Beyond access to health care, HEZs have great potential to address the root causes of poor health, which are often found in neighborhood conditions. For example, too many low-income and minority Maryland communities lack access to healthy food because they don’t have grocery stores or other vendors selling fresh, low-cost produce. Incontrast, many are overrun with fast food, carryout, and convenience stores that sell inexpensive but high-fat, high-sodium products. HEZs can provide communities with tax incentives to attract healthy food vendors, and the tools to enact land use policies that limit unhealthy foods.

If structured properly, HEZs also have the potential to address other health risks that are more common in low-income and minority communities, such as unhealthy housing, transportation patterns that increase risk for accidents, and concentrated environmental health risks from sources such as polluting industries. For example, they can support funding more Health Impact Assessments, which are increasingly being used by jurisdictions across the country to estimate the health consequences of any new policy, program, or project in sectors such as education, criminal justice, and others not generally viewed as health-related. 

Another promising aspect of the bill lies in the use of technological innovation which could help expand in public health practice, the connection to an already large body of research that documents the relationships between the social determinants of health, well-being, and health equity outcomes. A small technology investment in the evaluation of intervention effectiveness would also greatly empower the role of communities by strengthening civil society’s contribution to policy-making and implementation via more effective and timely participation in public decision-making, as well as create greater potential leverage to attract outside of state resources.

In other US jurisdictions place-based strategies are being implemented that help people in communities that suffer from disinvestment develop the tools and strategies needed to make every neighborhood a healthy one. Perhaps the most famous is the Harlem Children’s Zone, which provides an array of services and community supports to help some of Upper Manhattan’s most vulnerable children survive and thrive. As a result, children and their families in this community have better educational outcomes and are able to harness the best of the community’s resources to help them achieve their educational goals. But the program has also demonstrated that it supports healthy development among children whose health risks at the community level are multiple and systemic.

It’s time Maryland asserted its leadership in addressing health inequities by establishing a strong focus on the places and spaces where Marylanders live. Doing so will make ours a fairer and more equitable state. But, given the significant share of the state’s population that doesn’t enjoy good health and can’t be productive as a result, it also makes us a smarter and more competitive state.