Advancing Health Equity through Empowered Place-Based Community Action

This special issue features the inexorable link between health and place. As Dr. Francis Collins, the former Director of the National Institutes of Health, once remarked, “If DNA is our biological blueprint, ZNA (zip code at birth) is the blueprint for behavioral and psychosocial makeup.”¹ While Dr. Collins was defining ZNA in terms of residential address at birth, place more broadly defined can refer to the settings where we attend school, work, purchase food, recreate, seek care, and live out our years. As the articles in this issue clearly illustrate, this broader concept of place is critical to the health of Delaware’s residents.

While likening ZNA to DNA provides a useful analogy, there are important distinctions to be made. Our DNA is a unique recombination of genetic information passed down from our parents—and ultimately the full human genetic pool. In other words, we inherit our genetic code through an “equal opportunity” process. One’s zip code at birth, by contrast, is largely predetermined by historical laws that have mandated the segregation of people by race and ethnicity over many generations – the de facto effects of which persist today.² Attempts to remedy these injustices, whether through the passage of the Fair Housing Act of 1968 or Supreme Court rulings such as Brown v. Board of Education, represented important strides in the cause to advance civil rights and, by extension, health equity. However, the promise of these legislative and judicial milestones was never fully realized. Our neighborhoods and schools remain segregated, with life and death consequences.^3,4 To paraphrase the words of Chief Justice Warren, separate is still not equal.

The cause to advance civil liberties is not merely unfulfilled; it is now in retreat. For one, dwindling supplies of affordable housing and concentrated poverty limit who gets to live in communities conducive to health. The impact falls disproportionately on racial/ethnic minorities and other marginalized groups, which stands to exacerbate preexisting place-based inequities.⁵ Given the way the housing market is currently structured, these trends are unlikely to improve absent government intervention.⁶

The Supreme Court, once a bulwark against the discriminatory laws and markets, now appears poised to take us back to an era that predated the civil rights movement. Case in point, quite literally, Justice Alito recently wrote for the majority in Dobbs v. Jackson Women’s Health Organization that the only unenumerated rights that should be protected by the Constitution are those “deeply rooted in this Nation’s history and tradition” (p. 2).⁷ Any honest reading of US history will find an unmistakable tradition of forcible segregation, even if certain states are now outlawing the teaching of that history to future generations.⁸ While we can only speculate about what opinions the Supreme Court will render next, it is probably safe to assume that the judiciary will not help to remedy place-based health inequities.

Where does that leave us? If we cannot count on Congress or the Supreme Court, then we must act locally. Scholars and academic institutions, health care organizations, public health officials, and not-for-profit organizations can join with marginalized communities to advance a bold, reinvigorated approach to advancing health equity across all of Delaware’s neighborhoods. To quote David Imbroscio, “…mobilized and democratically empowered local communities should employ a full range of public/community-controlled regulatory powers toward the construction of a robust affordable housing and anti-poverty/anti-inequality urban policy agenda (p.238).”⁹ May the examples of this approach described in this special issue be a springboard for empowered, place-based action to advance health equity in the First State.