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Building Healthy Communities

How understanding the healthcare system can lead to better outcomes for students
Tony Iton

As the senior vice president of Building Healthy Communities for The California Endowment, Tony Iton has built health initiatives that have reduced school suspensions, led to the reclassification of minor felonies, and insured 300,000 undocumented children. Overall, he has spent $1 billion — and not a single dollar has gone to what might traditionally be defined as “healthcare.”

“Our $3.7 trillion healthcare system is essentially managing the consequences of underinvestment in the social contract…. We’ve argued that this doesn’t just happen in health. You see the same manifestations in the education system — school absences, truancy, failure, and dropout,” Iton says. That’s why his work has focused on building up communities.

Speaking at the Education Redesign Lab’s recent By All Means convening, which emphasizes the work of children’s cabinets to bolster the assets of communities across the country, Iton addressed the ways in which the health industry should be understood, so that communities can come together to combat the root causes of inequality. His talk was cosponsored by the Harvard T.H. Chan School of Public Health.


  • Behavioral: We like to think that if people would just behave or make different choices, they’d be healthier. But what’s missing from this narrative is the fact that people can’t always afford or don’t always have access to better choices.
  • Transactional: We like to think health is about services and the more you see doctors, the healthier you are. But a doctor has no control over larger, systemic problems that influence health outcomes.
  • Genetic: We like to think if we’ve have good genes, we’ll live longer. However, this does not include external factors like trauma that research has linked to changes in genes.


  • Political with a small ‘p’: “It is a struggle and at the end of that struggle there is an allocation of certain health-protective resources … things as simple as a park or a grocery store in your neighborhood,” Iton said.
  • Community and individual agency: “If you want to improve health, you have to build power — social political and economic power matter,” Iton said.

“If you want to improve health, you have to build power — social political and economic power matter."

Where You Live Determines Life Expectancy

Looking at four pieces of data (age, race and ethnicity, place of residence, and cause of death) from death certificates in different cities across the country, Iton and his team of researchers found differences of 15–20 years in life expectancy across distances of less than five miles. Usually these differences appeared between racial and socioeconomic groups.

According to Iton, this was no coincidence. “This is [an] American pattern. This is how we layer opportunity in this society and we can predict it,” he said. “It’s not only what we do today, it’s also the legacy of what we did. These patterns are just imprinted into the very geography of the country and it has clear health manifestations you can measure.”

Health is an Investment in Partnerships to Support a Community

The United States has historically spent a tremendous amount on healthcare. However, 80% of what influences life expectancy has little to do with healthcare as we understand it. Access to grocery stores, public transportation, libraries, and public green spaces are also important factors in determining overall health. Indeed, research has shown that when healthcare spending is directed toward social services, rather than medical care, that money is incredibly effective.

Unfortunately, policy in the United States directs a relatively small amount of funds towards social services. So much so that over time, life expectancy in the U.S. has declined drastically for those born in the country.

“America is bad for your health,” Iton said. “The disadvantage [of living in the U.S. has been] getting worse for three decades, especially among women — not just uninsured or poor. Even advantaged Americans including insured, white, college-educated, or upper income are in worse health than similar individuals in other countries.”

Key Takeaways:

  • Consider the idea of a social compact — institutions like schools need to serve its constituents and promote a narrative of inclusivity.
  • Think “upstream.” Where do problems originate from? Are test scores declining because the curriculum isn’t working or is it because poverty rates are growing? Treat the cause, not the symptoms.
  • Health and education make a natural team. Look to build partnerships, not just for funding, but schools can provide valuable resources like time and space for community stakeholders.
  • Civic engagement can also help a community shape the health of its members. Schools can provide a place for parents and students to engage in civic dialogue.

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