In 1965, Jack Geiger, a doctor working in the Mississippi Delta, founded one of the first federally-funded community health centers in the U.S. There he treated many children who were seriously malnourished. He wrote “prescriptions” for meat, milk, vegetables, and fruit that were to be “filled” at nearby grocery stores. Grocery store owners then submitted bills to the community health center where Geiger used the pharmacy budget to pay the bills.
The federal agency that funded community health centers, then called the Office of Economic Opportunity (OEO), sent an official to tell Geiger that he cannot use health center funds for groceries called “prescriptions.” Geiger met with the federal official and said: “The last time I looked in my textbooks, the specific therapy for malnutrition was food.” End of OEO complaint in 1965. Community health centers have grown since 1965 to number 1100 and serve 19 million low-income people.
Geiger knew then that supplying the right food would cure malnutrition. He understood that malnourishment does not come from mothers’ refusal to give their babies food; it comes from the lack of the right food and money to get that food. In a word, poverty. He saw malnutrition as a public health problem located in socioeconomic and political structures that cause and sustain poverty. He saw that for the health of the poor community to improve, the center he directed had to do more than diagnose medical conditions and write prescriptions for pills and ointments. He did not draw a line between his community health center and the poverty that Mississippi Delta families experienced daily. He saw the connection between better health and a better life for malnourished children and did something about it.
Since the mid-1960s, he and thousands of medical professionals and policymakers in the U.S. and internationally have come to understand that “social determinants of health,” especially the impact of poverty, affect which babies live beyond infancy, who succeeds in schools, who has access to high quality health care, and when we die (Marmot-Social determinants of health inqualities ).
Can anyone deny that ill health affects success in school? The stark example of malnutrition makes the connection obvious. Researchers and policymakers today know well the strong correlations between health and level of education. Whether more schooling creates better health (less smoker-related diseases, less obesity-linked conditions, etc.) or better health generates higher levels of education can be debated endlessly. What is less debated and generally accepted internationally and within the U.S. is that early education from birth to four years of age is crucial to both good health and school success (see Can Education Policy be Health Policy? In short, there are “social determinants of school success.”
These “social determinants of school success,” of course, are at the heart of the current debate among school reformers. One crowd–the “no excuses” reformers (e.g., Michelle Rhee, Joel Klein, Bill Gates, Eli Broad)–argue that schools alone can erase the achievement test score gap and insure that all student go to college. They focus on recruiting, training, and rigorously evaluating teachers–the single most important in-school influence on children–as the road to school success. They say that effective teachers and schools can overcome the effects of poverty and other “social determinants.”
Another crowd–and I include myself among them–champion programs where schools not only prod and support low-income students to achieve academically in school but also provide ready access for students and their families to an array of social, medical, and mental health services from birth to adulthood. This crowd recognizes the importance of upgrading the teacher corps, having strong principals, and pushing students to achieve but also know that “social determinants” shape school success.
Surely, paying attention to “social determinants of school success” costs more money, funds that cannot be provided wholly by the private sector or foundations. Federal and state government episodically have provided such funds. Like community health centers in the 1960s, community schools that see the child and family as as part of a social system, schools can and have provided an array of services that help toddlers, children, and youth achieve and grow into healthy adults.
At a time in U.S. history when the role and size of government are being heatedly debated and, for now, has tilted toward reducing government-sponsored social safety nets and cutting back expenditures in the name of controlling national debt and deficit reduction, the reform ideology of “no excuses” has the virtue of being less expensive. In the short-term, at least. In the long-term, as Jack Geiger knew in 1965 and does today, the “social determinants of health” cannot be ignored if children are to grow into healthy adults. And so it is with the “social determinants of school success.”