When the only grocery store in Manchester, Mich., closed down in February 2019, longtime resident Ruth Vanbogelen found herself challenged to find healthy foods.
Vanbogelen recalls that accessing the simplest grocery staples was suddenly fraught with incredible obstacles. Occasionally, she had to purchase food from very limited options at the local Dollar General, or resign herself to steeply overpriced items available in nearby gas stations.
Describing the first several months without a grocery store as "a pretty desperate situation," Vanbogelen recalls that it became an inside joke for Manchester residents to figure out various delivery schedules if they even wanted a shot at securing a dozen eggs, milk, or bread.
"Our community had an essential need taken away from us and we had to come up with a solution," she says. "People were really experiencing a gap, and it was quite hard-hitting."
Recognizing that the lack of access to healthy foods would have a broader eventual effect on both residents' wallets and wellbeing, Vanbogelen became a leading force in creating the Acorn Market and Cafe. Open part-time since last November, the non-profit, community-driven market offers locally-sourced meat, healthy beverages, dairy products, produce, baked goods, and ready-to-eat fresh foods. Ruth Vanbogelen at Acorn Farmers Market and Cafe in Manchester.
"It's truly no small thing," says Amy Heydlauff, CEO of 5 Healthy Towns Foundation (5HF), an organization that promotes healthy communities in Chelsea, Dexter, Grass Lake, Manchester, and Stockbridge.
Like Vanbogelen, Heydlauff believes Acorn Market is just one key example of how social determinants of health can affect residents' wellbeing.
Often the first thing people think of when they hear the words "health care" is access to, and quality of, care. However, Heydlauff says those things actually account for just 20% of a person's overall health. The concept of social determinants of health revolves around evidence that somewhat less obvious economic and social conditions — such as education, income, employment, family and social support, community safety, access to healthy foods, and transportation — also play vital roles in health outcomes.
Identifying local needs
For a little over a year, 5HF has been working with Rethink Health, Washtenaw County Community Health, University of Michigan Family Medicine, and St. Joseph Mercy Chelsea Hospital to address health needs on the rural, western side of Washtenaw County.
Heydlauff says 5HF is taking particular interest in how the social determinant of social support affects some residents' health outcomes. One of her staff's biggest challenges is identifying and caring for people who are outside of the established community, more isolated, and perhaps lack Wi-Fi or social support. Amy Heydlauff.
"We have people who are on rural roads without lots of houses nearby," she says. "They have no close neighbors to see that they didn't fall down the stairs, no one to bring them a meal or check up on them."
5HF's service area includes about 45,000 people, nearly 3,000 of whom responded to a recent survey that asked, "How often do you get the social and emotional support you need?"
The results showed that the semi-rural communities (Chelsea and Dexter) responded "sometimes" or "rarely" less frequently, and "always" more often, than the more rural communities of Grass Lake, Manchester, and Stockbridge.
Heydlauff says decisions about how to approach this challenge must be made with the assumption that the situation is probably worse than reflected in the survey numbers. Residents who have fewer connections in the community, or who are in more rural areas without home internet access, were less likely to complete the survey.
"We're realizing more and more that resilient communities are communities where people are connected," she says. "Along with income and employment, research shows that family and social support have a high correlation to good physical and mental health."
Social support is just one key social determinant of health in one area of the county, however. Charles Wilson, the Washtenaw County Health Department's community health promotions supervisor, points to the residents of Whitmore Lake, who have no health service providers and must travel to Ann Arbor to get health services. Establishing a clinic in the area remains a high priority. Charles Wilson.
"Several community conversations found that access to health care services and a pharmacy are huge issues and barriers to health," Wilson says.
Adam Paberzs, a health equity analyst with the health department, adds that for various reasons, a number of Whitmore Lake residents won't — or can't — travel to get the health services they need.
Fortunately, Northfield Human Services, a Whitmore Lake-based nonprofit, has recently made a commitment to house an eventual health clinic in the community. The development is the result of several shared efforts between the health department, its Community Voices for Health Equity team, Whitmore Lake organizations, residents, and health care partners.
"Things are pretty much rolling and underway," Paberzs says. "We need more of that kind of cross-sector collaboration to bring equity to health care for all Washtenaw County residents."
Housing and food access in Ypsilanti
Wilson notes that different social determinants affect vulnerable populations across the county, in both rural and urban areas. Many examples of social determinants' impact in urban communities can be found in Ypsilanti. Access to healthy food is one of the key determinants affecting residents, particularly lower-income people and people of color, who lack a full-service grocery store in their community.
"You can imagine the problems you might face if you’re located in West Willow [in Ypsilanti Township], but you have to take a couple of buses to get groceries," Wilson says.
While social and economic barriers to health existed long before the current pandemic, Wilson says COVID-19 has exacerbated some issues.
"Things that we tend to not give second thoughts to, like going to get household cleaner or paper products, and bare grocery store shelves, become huge issues for our most vulnerable populations," Wilson says. "A person who already has transportation issues can't go to five different stores to get a roll of toilet paper."
"If I had a megaphone, I would tell everyone that Washtenaw County has a lot of resources," he continues. "But I would also also add that we have a number of residents for whom that is not their experience."
Alex Thomas says many strides must be taken to address the plethora of social determinants affecting West Willow, the place he has called home since early childhood, and which he represents on the Community Voices for Health Equity team.
Thomas says that while the residents in the area he represents are impacted by a number of social determinants — such as access to healthy foods and social isolation — housing insecurity is of particular concern to him currently.Alex Thomas.
"When I grew up, West Willow was 99% owner-occupied. Now the best numbers say it's 40% owner-occupied," he says. "Housing insecurity affects blood pressure, stress levels, and cognitive ability in children. Not knowing where they are going to be sleeping is a real problem for many people here."
He says removing barriers to health equity in West Willow is certainly complicated, but he and others in the community are relentlessly working to dismantle them and to raise government officials' awareness of them.
Thomas praises local grassroots organizations like Washtenaw County My Brother's Keeper and the Mutual Aid Network of Ypsilanti (MANY) that work to address issues like food insecurity and poverty relief. But he cautions that poverty relief efforts cannot address the foundation of the situation, and notes that they may create the false impression that structural change is happening.
Advancing policy is a priority
Paberzs says it's key to follow the lead of communities that are most directly impacted by inequities in social determinants of health.
"We need to do whatever we can to advance the policy solutions and innovative ideas that they have already created," he says. "People know best what they need and the challenges they are experiencing."Adam Paberzs.
Paberzs says Washtenaw County made huge strides earlier this year after both the county's board of health and board of commissioners declared racism a public health crisis. The statements spotlighted the fact that Washtenaw ranked 80th out of 83 Michigan counties for income inequality and that there is a 10-year difference in life expectancy between Black and white residents. Between Latino and white residents the difference is even wider, at 17 years. Also within the statements are key resolutions to pursue equitable health for all.
"We need to ask ourselves how we can go deeper to follow through on those commitments and confront ways that institutional racism shows up in our own departments and within local government," Paberzs says. He adds that looking at budgets and dedicating resources to protect those who are most marginalized is paramount.
Wilson shares similar sentiments about the need to dive deeply into both the needs of those affected and the effects of policy.
"Even though many of our residents may not be familiar with the concept of the social determinants of health, they live it," he says.
Jaishree Drepaul-Bruder is a freelance writer and editor currently based in Ann Arbor. She can be reached at firstname.lastname@example.org.
All photos by Doug Coombe.