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\begin{document}

\title{Working With Communities: Meeting the health needs of those living in
vulnerable communities when primary health care and universal health
coverage are not available}



\author[1]{Mark Dehaven}%
\author[2]{Nora  Gimpel}%
\author[3]{Heather  Kitzman-Carmichael}%
\affil[1]{University of North Carolina Charlotte College of Health and Human Services}%
\affil[2]{UT Southwestern Medical}%
\affil[3]{Baylor Scott and White Health}%


\vspace{-1em}



  
  \date{June 13, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Background: The health care delivery model in the United States does not
work; it perpetuates unequal access to care, favors treatment over
prevention, and contributes to persistent health disparities and lack of
insurance. The historical lack of support in the United States for
primary health care, universal health coverage, population health,
addressing the social determinants of health, and community empowerment,
creates opportunities for community health scientists to develop
innovative solutions for addressing community health needs. Methods: We
developed a model community health science approach combining
community-oriented primary care (COPC), community-based participatory
research (CBPR), asset-based community development, and service learning
principles. The approach defines health as a social outcome, resulting
from a combination of clinical science, collective responsibility, and
informed social action. Results: From 2000-2020, we established
partnerships with community organizations to reduce the risk of chronic
disease in vulnerable minority communities. Our programs have provided
structured community health science training for hundreds of physicians
and other health care workers in training. Conclusion: As the U.S.
begins to seek solutions to chronic health disparities and health
inequities, community health science provides useful lessons in how to
engage communities to address the deficits of the current system.
Perhaps the greatest error that U.S. health care systems could make in
trying to better address population health and the social determinants
of health, would be ignoring the important community initiatives already
underway in most local communities. Building partnerships based on local
resources and ongoing social determinants of health initiatives is the
key for medicine to meaningfully engage communities for reducing health
disparities. This has been the greatest lesson we have learned during
the past two decades, has provided the foundation for our community
health science approach, and accounts for whatever success we have
achieved.%
\end{abstract}%



\sloppy


\emph{ABSTRACT}

\emph{Background:} The health care delivery model in the United States
does not work; it perpetuates unequal access to care, favors treatment
over prevention, and contributes to persistent health disparities and
lack of insurance. The vast majority of those who suffer from
preventable diseases and health disparities, and who are at greatest
risk of not having insurance, are low-income minorities (Native
Americans, Hispanics, and African Americans) who live in high risk and
vulnerable communities. The historical lack of support in the United
States for primary health care, universal health coverage, population
health, addressing the social determinants of health, and community
empowerment, creates opportunities for community health scientists to
develop innovative solutions for addressing community health needs.

\emph{Methods:} We developed a model community health science approach
combining community-oriented primary care (COPC), community-based
participatory research (CBPR), asset-based community development, and
service learning principles. During the past two decades, our community
health science team has collaborated community members, leaders, and
organizations, to address the health needs of vulnerable patients. The
approach defines health as a social outcome, resulting from a
combination of clinical science, collective responsibility, and informed
social action.

\emph{Results:} From 2000-2020, we established partnerships with
community organizations and worked together to reduce the risk of
chronic disease in a vulnerable minority community by stimulating
lifestyle changes, increasing healthy behaviors and health knowledge,
and improving care seeking and patient self-management. Our programs
have also provided structured community health science training in
high-risk communities for hundreds of physicians and other health care
workers in training.

\emph{Conclusion:} Our community health science approach assumes that
the factors contributing to health can only be addressed by working
directly with and in affected communities to co-develop health care
solutions across the broad range of causal factors. As the U.S. begins
to seek solutions to chronic health disparities and health inequities,
community health science provides useful lessons in how to engage
communities to address the deficits of the current system. Perhaps the
greatest error that U.S. health care systems could make in trying to
better address population health and the social determinants of health,
would be ignoring the important community initiatives already underway
in most local communities. Building partnerships based on local
resources and ongoing social determinants of health initiatives is the
key for medicine to meaningfully engage communities for reducing health
disparities. This has been the greatest lesson we have learned during
the past two decades, has provided the foundation for our community
health science approach, and accounts for whatever success we have
achieved.

Introduction

\emph{``The present health care delivery model in the United States does
not work; it perpetuates unequal access to care, favors treatment over
prevention, and contributes to persistent health disparities and lack of
insurance. The vast majority of those who suffer from preventable
diseases and health disparities, and who are at greatest risk of not
having insurance, are minorities (Native Americans, Hispanics, and
African Americans) and those of lower socioeconomic status. Because the
nation's poor are most affected by built-in inequities in the health
care system and because they have little political power, policy makers
have been able to ignore their responsibility to this
group.\textsuperscript{1}}

When we wrote these words more than a decade ago, we had several
motives. First, we wanted to call attention to a health care system that
through its complacency and silence was providing tacit support to a
system of care that was inequitable and ineffective in meeting the needs
of minorities and the poor. Second, we were advocating for more emphasis
in primary care -- and especially the specialty of family medicine -- on
addressing the social determinants of health as the upstream causes of
disease. And, third, we proposed community health science as the vehicle
for addressing the needs of low-income patients and reducing health
disparities by linking together clinical practice, public health, and
community organizations.

The motivation for our research, training programs, and
community-engaged practice leading up to and since the publication of
the article, was to remediate a system of care in the United States
where primary care is not available to many and primary health care is
not practiced.\textsuperscript{2} Primary Care (PC) is familiar to most
Americans and refers to the care continuity care directed at the health
needs of individuals by physicians and other health care workers. It
includes diagnosis and treatment of acute and chronic illnesses, health
promotion and disease prevention, and patient education and counseling.
Primary Health Care (PHC) is a much broader concept and consists of
three components: 1) meeting people's health needs throughout their
lives; 2) addressing broader determinants of health through
multisectoral policy and action; and, 3) empowering individuals,
families and communities to take charge of their own
health.\textsuperscript{3-6} By providing care~\emph{in} ~the community
as well as care~\emph{through} ~the community, PHC addresses not only
individual and family health needs, but also the broader issue of public
health and the needs of populations.

Stronger integration between primary care and public health with a focus
on population health has enjoyed limited and sporadic periods of
popularity and success in the United States during the past 50
years.\textsuperscript{7} The Community-Oriented Primary Care (COPC)
model introduced in the 1970's provided a workable framework for
integrating public health into primary care practice, and in the late
1990's accountable care organizations brought renewed attention to the
role of medical systems in improving population
health.\textsuperscript{7-10} However, the need to address the social
determinants of population health in the U.S. has only very recently
emerged as a topic of importance in discussions about reforming U.S.
health care. \textsuperscript{11,12}And while primary care and public
health organizations have long recognized the potential benefits of
integration, significant longstanding barriers will need to be overcome
first before any meaningful progress can be
achieved.\textsuperscript{13}

The historical lack of support in the U.S. for population health,
medicine and public health integration, addressing the social
determinants of health, and community empowerment, has created a
situation where practitioners and researchers work independently in
their local communities to address these components. This often leads to
creating ``non-system'' approaches to meeting the health needs of
vulnerable populations in local communities.\textsuperscript{4,14,15}The
authors have worked together as a team during the past 20 years to
create innovative solutions to community health problems by combining
community-based participatory research (CBPR), community-based service
learning training experiences, and community-based practice. The purpose
of the present manuscript is to describe our community health science
approach and the ways we have worked in partnership with community
members to improve health outcomes. Our efforts have been focused in two
areas: 1) building community health capacity for testing program
interventions reducing and eliminating risk factors for chronic disease,
and, 2) training the next generation of physicians and other health
professionals how to address the health needs of vulnerable patients
when working in a system that eschews systemic approaches to addressing
the social drivers of health and disease.

The Community Health Science Approach

During the past 30 years we have developed and directed more than six
different academic units addressing health disparities located both
inside and outside the medical center. The community health science
approach we developed is based on these experiences and incorporates
principles derived from community-based participatory research,
asset-based community development, and community-oriented primary
care.\textsuperscript{8,16-19} The common element these approaches share
is their reliance on co-creating solutions through partnerships between
community members and leaders, local organizations, and health care
organizations. Our approach also draws on Dr. Kurt W. Deuschle's
community medicine approach, which combines clinical medicine,
population health, and social science.\textsuperscript{1} Therefore, our
community health science approach defines health as a social outcome
resulting from systematically combining clinical science, collective
responsibility, and informed social action.

We have described the community health science framework in detail
elsewhere.\textsuperscript{20} Essentially, the model posits that for
any community health issue -- whether chronic, acute, or infectious
diseases; or social determinants such violence, food scarcity, or
housing instability -- health promotion and disease prevention can only
be effective when clinical treatment, population health, and community
organization priorities and actions are
aligned.\textsuperscript{21}Consistent with asset-based community
development, the approach acknowledges that in most communities,
resources exist and activities are already underway for promoting health
on important community issues.\textsuperscript{22} Thus, the role of
community health science practitioners is to collaborate with those in
the community who are already working on any health issue at the
clinical, population, or community organization level, facilitate
communication and coordination across the different levels, and
contribute to partnership-building for creating sustainable solutions
for population health improvement.\textsuperscript{20}

(Figure 1 about here)

The Importance of Relationships and Collaboration

Strong and trusting relationships with community partners are the
foundation for effectively improving community health
outcomes.\textsuperscript{23,24} These relationships can only be
developed by inviting people to your table (the health center) and going
to their table (the community), working also with community leaders
inside and outside of health services organizations while demonstrating
genuine concern for their health and
wellbeing.\textsuperscript{16,25}The hundreds of organizations we have
worked with during the past 20 years include libraries, faith
organizations, neighborhood associations, local government, cultural
organizations, schools, colleges and universities, community clinics,
recreation centers, community centers, non-profit organizations,
hospitals, businesses, and civic organizations, among
others.\textsuperscript{26-28} The organizations all address one or more
aspects of the social determinants of health, including education,
access to health care, employment and job stability, housing, social
capital, and/or food security.\textsuperscript{29-31}

The activities reported here were focused in the South Dallas community
of Dallas, Texas. In 2005, South Dallas had a population of 35,000
residents, 68\% were African-American and 27\% Latino, 60\% of
households made less than \$25 000 annually, 80\% of births were to
single female-headed households, 52\% had less than a high school
education, and 57\% lacked health insurance. In South Dallas, death
rates from stroke and heart disease were more than double the county
rates, and premature mortality was extremely high - 45\% of deaths
occurring among residents aged 65 years or less.\textsuperscript{32} The
vast majority of individuals were renters working in low-wage low-skill
service occupations, and crime rates in the area were as much as two to
three times higher than in most other parts of the city.

Our location in South Dallas was by invitation resulting from a chance
encounter at a community meeting. In 2000, one of the authors (MJD)
expressed the opinion during a public forum that the priorities of
community residents deserved equal or more weight than governmental
priorities when addressing community development needs in low-income
areas. Although this opinion ran contrary to the preference of the local
government, the opinion was embraced by community leaders and based on
the science of asset based community
development.\textsuperscript{22}Based on these comments, the Executive
Director of the SouthFair Community Development Corporation (CDC),
invited the author to participate in the South Dallas Pastor's Weed and
Seed Coalition (Pastor's Coalition). This group was leading the U.S.
Justice Department's inner-city reclamation program, and the
relationships developed with the eighteen African-American faith leaders
in this group became the foundation of our 20 year
collaboration.\textsuperscript{33}

We also developed relationships with medical teams in other parts of the
world -- most notably Mexico in the early 2000's - in order to share
information and resources for better managing the health needs of
impoverished patients when resources are scarce. At that time, Mexico
was spending 5.6\% of its GDP on health care compared to about 15\% in
the U.S., but both systems were facing similar challenges in terms of
health care access inequities between rich and poor, concerns over
quality, rising costs, and limited resources.\textsuperscript{34-36} To
address these challenges, Mexico (unlike the U.S) developed a National
Health Program designed to diminish inequalities, ensure fair financing,
and improve responsiveness and health status. Mexico's close proximity
to Texas allowed us to develop a relationship with the government of
Chihuahua, Mexico, and the leaders of the The Programa de Desarrollo
Humano Oportunidades (Oportunidades) and we adapted the Oportunidades
approach for our use in South Dallas.\textsuperscript{37,38} We have
provided a more extensive description elsewhere of the Oportunidades
approach and how we adapted it to the South Dallas
community.\textsuperscript{20}

Health Promotion Interventions and Training Program Platforms

In 2000, we developed two projects that were subsequently funded in 2001
and became the foundation of our activities for two decades. The first
was a project with the Dallas Academy of Medicine - a component of the
Dallas County Medical Society -- which was beginning the initial stages
of developing a system of care for the uninsured ``working poor'' in the
City of Dallas, Texas. The project eventually became Project Access
Dallas (PAD), and provided our team the opportunity to develop an
expansive health promotion platform in South Dallas. The second was
funded by the U.S. Health Resources and Services Administration, for
creating the Community Health Fellowship Program (CHFP) for medical
students. The CHFP was designed to place medical students in community
organizations to complete community-mentored service-learning research
projects for improving health in ways identified by the community
organizations. \emph{These two programs illustrate the primary strategy
of the community health science approach -- developing and sustaining
activities beyond the academic health center designed to advocate for
and actively support community organizations addressing the social
determinants of health, rather than merely extending health center
programming out into the community.} This approach engages the AHC as
one partner among many in sustainable community change efforts, rather
than just building more AHC capacity with little or no regard for
existing community initiatives\emph{.}

\emph{Health Promotion Interventions - Reducing Emergency Room Use and
Cost Among the Uninsured}

Emergency departments (ED) in the U.S. are a vital source of care for
those without insurance who generally lack a source of primary care,
since they are required by law to treat patients regardless of their
ability to pay.\textsuperscript{39,40} Care delivered through the ED is
frequently for non-urgent problems, is substantially more costly than
comparable care delivered in the primary care setting, and can produce
significant financial charges for the uninsured and
hospitals.\textsuperscript{41-43} Our team worked with a group of
collaborators to improve access to continuity and preventive care for
the uninsured, reduce ED utilization and costs, provide better chronic
disease management, reduce health disparities, and increase quality of
life.\textsuperscript{44-46} Project Access Dallas (PAD) partners
included faith-based organizations, government agencies and social
service organizations, hospitals and the local medical society, several
universities and a medical school. It was a local community system that
provided access to existing nonprofit community health clinics,
volunteer primary and specialty care physicians, and local hospitals and
pharmacies.\textsuperscript{47}

The core of the PAD program was a Community Care Coordination system
(Care Coordination) using community health workers (CHWs) to provide
culturally competent case management when patients encounter social and
economic barriers while trying to access and navigate health-related
services. The CHWs were recruited from the local community and received
basic training in social services delivery, health care system
logistics, preventive care, and understanding physical and mental
health. Their role was to coordinate referrals and access to care for
patients, and provide support services and referral for social
determinants of health needs, translation services for non-English
speakers, health education, home visits, appointment compliance
reminders, and encouragement to follow health prescriptions.

Two key studies examined the effectiveness of the PAD program from the
perspective of patients using the system and the effect on reducing
costs in the local hospital system. In the first, patients were surveyed
to determine whether and how the CHWs effected their health and care
delivery. Findings indicated that the PAD Community Care Coordination
helped patients understand more about their health and how to navigate a
complex health care system, helped patients learn how to independently
manage their chronic health issues through self-care, guided patients
efficiently to appropriate care services, and provided emotional
support.\textsuperscript{48} The second study indicated that the PAD
system significantly reduced emergency department utilization and
related hospital costs among patients enrolled in the PAD
system.\textsuperscript{47,48} PAD patients had significantly fewer ED
visits and hospital days one year following their enrollment when
compared with patients not enrolled in PAD, and their direct and
indirect hospital costs were 60\% less and 50\% less,
respectively.\textsuperscript{47}

\emph{Reducing Heart Disease Risk}

Based on the lessons learned from PAD, and the partnerships with the
Pastor's Coalition and the Oportunidades Team in Mexico, we worked with
our community collaborators to develop an approach for reducing heart
disease risk in the South Dallas community. The South Dallas community
was almost 70\% African-American. Deaths from coronary heart disease
(CHD) and stroke are significantly higher among African-Americans
compared with other race groups. Greater percentages of Black women
(37.9\%) than White women (19.4\%) and Black men (61.5\%) compared with
White men (41.5\%) die from CHD before age 75. Similarly, death rates
from stroke before age 75 are substantially higher among Black women
(39.0\%) than White women (17.3\%) and among Black men (60.7\%) compared
with White men (31.1\%).\textsuperscript{49} African-American adults
have the highest rates of CVD mortality and prevalence of uncontrolled
cardiovascular risk factors.\textsuperscript{50} Death rates from heart
disease and stroke were 2-3 times higher in South Dallas when compared
to other parts of the city.\textsuperscript{32}

We obtained funding from the National Heart, Lung, and Blood Institute
(NHLBI) of the National Institutes of Health (NIH) to test a
community-based lifestyle intervention program, since modest but
sustained changes in physical inactivity and nutrition can reduce CVD
risk.\textsuperscript{50,51} Our program linked together the health
program activities of hospital-based planners, health center providers,
professional health educators, community health workers (CHWs), and
leaders in local African-American congregations.\textsuperscript{52} The
African-American church is an important and influential community
partner; it is the most important social institution in many
African-American communities, plays an important social role linking the
community to the larger society, is held in the highest esteem by most
African-Americans, and has a long history of engaging in community-based
health initiatives.\textsuperscript{53-55}

The core of our approach was to train CHWs in the churches, by expanding
and adapting the PAD training program to focus more on CVD prevention,
and then systematically connecting the CHWs to the medical community and
to other community-based organizations addressing the social
determinants of health. The objective was to develop the supportive
environments needed to produce lasting lifestyle changes in the
community-based setting.\textsuperscript{56} Outcomes have been reported
in detail elsewhere and demonstrated improvement in eating behavior but
not physical activity.\textsuperscript{20,57,58} However, when we
compared program participants with a general sample of African-American
adults from Dallas Heart Study on cardiovascular risk factors (CVRFs),
they had significantly higher rates of treatment and control of multiple
CVD risk factors including treated hyperlipidemia, controlled diabetes,
controlled hypertension, more physically active, and less likely to
smoke.\textsuperscript{49,59}

\emph{Testing the Diabetes Prevention Program (DPP) on Reducing Weight
(Heather Paper)}

Building on the relationships and progress in reducing heart disease
risk, our team continued to focus on reducing chronic disease risk by
focusing more on weight loss. With funding from the NIH National
Institute of Minority Health and Health Disparities (NIMHD), we modified
our approach by testing the Diabetes Prevention Program (DPP) in the
congregational setting. The DPP was a well-known program with global
reach, that is successful improving diet, increasing physical activity,
and reducing weight in order to lower chronic disease
risk.\textsuperscript{60} Our programs and a large body of research
demonstrate that African American women have disproportionately higher
rates of obesity, prediabetes, type 2 diabetes, and cardiovascular
disease compared to White women.\textsuperscript{61} African American
women tend to have less success than others in lifestyle interventions
and DPP translations in African Americans have been
suboptimal.\textsuperscript{62-65}

We continued using church-based community health workers to co-deliver
and support the program elements in the congregations. Consistent with
the findings from our heart disease risk reduction program, we combined
faith-based components - including active church leader support -- into
the standard DPP curriculum. Participants in the program who were
followed for 10 months had significant improvements in weight loss,
health behaviors, and biometrics.\textsuperscript{66} The study is very
important for several reasons. It demonstrated that participants in the
faith-based adaption of the DPP who received at least 15 sessions nearly
reached the DPP's original goal of 7\% weight loss and met the CDC's
goal of 5\% weight loss. Thus, a faith-based version of the DPP has the
potential to help African American women reach 5\% weight loss in a
community-setting outside of the AHC. Further, the program demonstrated
that female African-American congregation members can successfully
deliver the DPP providing a potential pathway for increasing reach and
adoption into high-risk communities.\textsuperscript{66}

\emph{Training Platforms}

As of 2015, 57 million people in the United States live in medically
underserved areas (MUA), or areas ``having too few primary care
providers, high infant mortality, high poverty, or a high elderly
population.'' While the number of MUAs in the U.S. is increasing, the
number of primary care physicians willing to work in these underserved
areas is decreasing.\textsuperscript{67} Although many reasons account
for the paucity of physicians practicing in MUA's, a primary factor is
an approach to medical education that does not embrace a wider
understanding of the role of medicine in promoting community health,
addressing the needs of populations, or the importance of the social
determinants of health.

Beginning in 2001, we created innovative elective service-learning and
mentored community based participatory research (CBPR) education
programs and experiences, initially funded through grants and eventually
institionalized at UT Southwestern Medical Center at Dallas. The
benefits of community-based service learning experiences for medical
students include increasing knowledge of diseases prevalent in the
community around them and enhanced ability to develop clinical practice
skills in community-based settings. Furthermore, students are better
able to address health disparities through service learning in
impoverished areas and are able to cultivate essential citizenship
skills that allow them to be adept at spearheading causes for medical
justice in community and global health.\textsuperscript{68}

Our training programs were designed to provide medical students and
residents with the skills needed to work together with communities to
reduce the disproportionate burden of chronic disease, and co-develop
appropriate and effective models of health improvement. The training
covers assessing the health needs of a specific population, implementing
and evaluating interventions to improve the health of that population,
and providing care for individual patients in the context of the
culture, health status, and health needs of the population. We prepare
trainees in community-oriented primary care, emphasize understanding and
addressing population-based health and interdisciplinary teamwork These
structured learning programs incorporate service learning activities,
community health interventions and scholarship under mentorship and
guidance from faculty members and community leaders familiar with the
social determinants of health, and include the following:

\textbf{Community Health Fellowship Program (CHFP} ): The Community
Health Fellowship Program (CHFP) introduces medical students to
community based and clinical research during the summer months between
their first and second year. A didactic curriculum introduces students
early in their training to population health, social determinants of
health, health disparities, and community based participatory research
(CBPR). Community organizations in low-income areas addressing the needs
of underserved communities, submit their health improvement needs to
program faculty, researchable projects are developed, and brief
proposals are presented to students. Students then select a specific
project of interest and collaborate with the community organization to
complete a mentored project to improve some aspect of the social
determinants of health. Community partner organizations include the
public health department, faith-based organizations, hospitals, local
nonprofit organizations, social service organizations, schools, and free
or reduced cost community clinics.\textsuperscript{69,70}

\textbf{Community Action Research Track (CART):} after developing the
CHFP program in 2001, we identified a need for a more longitudinal
experience directed at community health improvement. Using the CHFP as
the foundational experience, we collaborated with our community partners
to secure a training grant from the U.S. Health and Resources Services
Administration to create a four-year, longitudinal experience for
medical students that includes instruction in public health and
community-based participatory research (CBPR), annual service-learning
experiences in the community, and completing a community health elective
in the fourth year of medical school. The lectures and experiential
training focus on population medicine, health promotion and disease
prevention, and social determinants of health. The program focus on
community-based participatory research (CBPR) and service-learning train
medical students how to provide patient care from a population
perspective while partnering with community organizations to determine
how to best meet their needs by building on their strengths and
integrating knowledge to meet shared goals.\textsuperscript{71}

\textbf{Community Action Research Track (CARE):} The team also created a
training program in a family practice residency program with additional
support from the U.S. Health Services and Resources Administration.
Although family physicians are ideal candidates to improve access and
reduce health care disparities for individuals, many lack the knowledge
and skills to effectively impact community
health.\textsuperscript{72}We created a training model designed for
family medicine residents in community action research to equip them
with the knowledge, skills, and attitudes to care for the underserved
and reduce health disparities throughout the City of Dallas, and
stimulate their interest in practicing in community-based underserved
settings after graduation.\textsuperscript{73,74}

Although many of the training programs we created during the past 20
years were optional and elective, they have been extremely popular among
medical students and have had a profound effect on changing the culture
of UT Southwestern Medical School and increasing the number and depth of
community relationships. Medical students can now complete for credit, a
4-week community medicine elective or participate in a 12-week advanced
learning experience completing a community health project with a
community partner. The Albert Schweitzer Fellowship Program has been
created in partnership with a local university where fellows receive
mentorship, leadership training, and complete a long-term project with
the underserved in their community. Students can also participate in
Student Run Free Clinics (SRFCs) where they engage with the community in
special initiatives. And, the cumulative experiences provided through
combined community-engaged programs and research experiences, as of 2018
allows interested medical students to graduate with MD with Distinction
in Community Health. These physicians are equipped to assume leadership
roles for improving populations health, through engaging medicine in
partnerships with others throughout the community who are addressing the
social determinants of health.

Concluding Comments and Discussion

From 2000-2020, our team of health care professors, researchers,
clinicians, social scientists, and community members, developed and
tested means for improving health outcomes and providing training in
mostly low-income, underserved, minority communities. Our approach
combined community-based participatory research (CBPR), asset-based
community development, social determinants of health, and
community-based primary care (COPC) principles. Our model community
health science program combined clinical practice, population health,
and community organization components, with the goal of promoting health
equity and reducing health disparities. We also developed means for
training the next generation of physicians in this approach. In the
U.S., university faculty members who are motivated to offer
experiential, cross-sectoral, and interprofessional educational
opportunities with community partners to their students confront
significant barriers to acquiring the training necessary to provide
these opportunities. There are few faculty development opportunities for
obtaining the relevant competencies and skills, and few career pathways
and rewards from academic leadership. Our approach has been to integrate
training into medical student and resident curriculum from the outset,
as a means for overcoming these barriers.\textsuperscript{75-78}

Much of our work was and continues to be developed in response to the
deficiencies of the American health care system, which eschews primary
health care and universal health care. The U.S. health care system falls
far short of the World Health Organization standards for a
well-functioning health care system and is often considered a non-system
of health care.\textsuperscript{14,79} Despite spending more per capita
on health care than any other developed country, it consistently ranks
last in overall performance, access to quality care, administrative
efficiency, health equity, and health care
outcomes.\textsuperscript{80}During the last two decades, little has
changed regarding the U.S. approach to reducing health disparities or
initiating the types of reforms needed to produce a more equitable
system of care. Research consistently reveals significant differences in
chronic disease prevalence, levels of health and wellbeing, access to
quality care, average length of life, and rates of uninsurance and
untreated disease based on race, ethnicity, and
income.\textsuperscript{81-84} As Donald M. Berwick, President Emeritus
of the Institute for Healthcare Improvement observed recently, except
for a few clinical preventive services, most hospitals and physician
offices continue to be ``repair shops,'' trying to correct the damage
caused by the upstream social determinants of
health.\textsuperscript{85}

Our approach of advocating for and supporting community organizations
addressing the determinants of health and training the next generation
of physicians to understand the upstream causes of health, is only now
becoming understood in more mainstream areas of
medicine.\textsuperscript{86} A consensus is evolving in many parts of
medicine that we must take action to reduce health disparities by
addressing the full range of health
determinants.\textsuperscript{2,87}Researchers and clinicians in the
U.S. are beginning to understand that living in conditions of poverty
creates chronic disease, and that minorities are at greatest risk since
they are disproportionately represented in low-SES
communities.\textsuperscript{88-91} Poverty also helps explain why
research during the past 20 years focused on merely increasing access to
health care has not been successful, since health disparities result
from the conditions faced by residents in low-SES
communities.\textsuperscript{92}

Ten years ago appeals for medicine to more thoroughly engage the
community in order to reduce inequities were often met with puzzled
looks or indifference. However, today the evidence supporting the need
to reform health care in the United States is overwhelming; most in the
health professions recognize that the status quo is inequitable and does
little to curb epidemic levels of persistent chronic disease, especially
among those living in poverty.\textsuperscript{20} Survey data indicate
that hospital staff believe that clinical and administrative leaders are
becoming more committed to systematically addressing patients' social
needs as part of clinical care, and some hospitals are beginning to
partner with community organizations to address other health-related
needs. However, while these well-intentioned efforts no doubt reflect
movement in the right direction, these small steps are by no means
universal across health care systems and very little information exists
about their effectiveness.\textsuperscript{86}

Although we presented mostly our community-health related activities in
the present paper, the success of these activities has been promoted and
facilitated through our many longstanding partnerships with community
leaders in housing, education, food security, and economic
stability.\textsuperscript{20} Our approach assumes that the factors
contributing to health can only be addressed by working directly with
and in affected communities to co-develop health care solutions across
the broad range of causal factors. Perhaps the greatest error that U.S.
health care systems could make in trying to better address population
health and the social determinants of health, would be ignoring the
important community initiatives that are already underway in most local
communities. Understanding the value of combining the resources and
expertise of health professionals and community leaders been the
greatest lesson of our approach, has provided the foundation for our
community health science approach, and accounts for whatever success we
have achieved during these past two decades.

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