AMA Journal of Ethics^®

Social, environmental, and economic inequities are widely recognized as major drivers of health disparities.¹ As the US health care system shifts towards greater emphasis on these nonmedical determinants of health, a rethinking of relationships between clinicians, health care organizations, patients, and communities is essential to address existing and future challenges in achieving population health goals.² Increasingly, community development stakeholders have become active partners in the fields of clinical and public health.³

Community development is broadly defined as an “industry” that focuses on the revitalization of disenfranchised communities and the empowerment of community members.^3,4 It acts through a variety of public and private institutions and funding streams to improve economic opportunity, housing and public spaces, food access, and other sequelae of poverty.^3,4 Addressing the social determinants of health is integral to community development’s core functions. Although hospitals and other health care organizations ultimately respond to the manifestations of these root causes of ill health through direct patient care, the social determinants of health have not received sufficient attention by hospital systems and other health care organizations. What is less discussed is the level of responsibility health care organizations have in our health care system—particularly to their surrounding communities—and to society at large.

The Patient Protection and Affordable Care Act of 2010 specified tax exemption requirements for nonprofit hospitals—78% of US hospitals in 2014.⁵ They must perform a community health needs assessment (CHNA) every 3 years and invest in community benefit through uncompensated charity care, health improvement, or community building activities that can be justified as health improvement.^6-8 While not all hospitals are subject to these regulations, they provide a platform to consider the roles and actions of health care organizations across settings and structures. CHNA and community benefit investment are examples of how health care organizations can target nonmedical determinants of health and meaningfully engage in community development.^9-11 However, community benefit programs might not be fully leveraged in health promotion. In 2013, only half of nonprofit hospitals reported having community partnerships to develop CHNA implementation plans, suggesting a gap between community priorities and hospital action.¹² Additionally, a majority of hospital community benefit spending was cited as uncompensated care as opposed to direct investment in community health improvement or building activities.^5,13 Nevertheless, areas served by greater numbers of for-profit institutions, which have no regulatory mandate to invest in community benefit, had less per capita spending on community benefit.⁹

Socioeconomic contrasts between hospital campuses and adjacent neighborhoods have recently been highlighted, calling attention to increases in hospital revenue with simultaneous cuts in charity care and community investment,^14,15 and, ultimately, injustice in the distribution of benefits and burdens. Health care organizations, as major stakeholders in the health care system and recipients of large sums of federal funding, are well positioned to engage meaningfully in community development with the aim of eliminating health inequity. Guiding principles, frameworks, and policy recommendations for strengthening community benefit contributions and enhancing population health outcomes have been published, along with reports of success and suggestions for improvement.^{3,4,9,11,16,17} This issue of the AMA Journal of Ethics adds to a growing literature on the roles and conduct of health care organizations participating in community development within the communities they serve, highlighting successful applications, ethical dilemmas, and process challenges.

Three contributions discuss community benefit obligations and how to maximize community benefit to achieve health equity. Alex Myers, Aaron Cain, Berkeley Franz, and Daniel Skinner respond to a case in which a hospital administrator is faced with balancing the needs of patients and communities and the profitability of the emergency room by arguing that prioritizing emergency room revenue violates core legal and moral standards. Michael Rozier, Susan Goold, and Simone Singh explain the current state of community benefit regulations for nonprofit hospitals and provide recommendations for their better alignment with health equity. And Hannah R. Sullivan argues that community benefit can be increased not only through better regulation but also through innovative care delivery models.

Hospitals serve other functions beyond providing care, acting as major employers and contracting with local businesses. These economic and social impacts are sometimes so significant that hospitals are labeled “anchor institutions.”¹⁸ Numerous examples exist nationwide of the closure of entire hospitals or departments, all with lasting impacts on surrounding communities. In a case of a rural hospital closure, George Mark Holmes and Sharita R. Thomas examine the responsibilities of the health care network and clinicians in easing the transition to care in different locations, emphasizing how patients and the community might be supported.

Not all issues confronted by hospitals have clear health implications. For example, a common experience in refugee populations is isolation. Responding to a case of a resettled refugee with vitamin B₁₂ deficiency, Julie M. Aultman applies the capabilities framework to understand how adverse social determinants of health can prevent full human functioning and how physicians and health care organizations can leverage information and resources to improve refugee health related to social isolation and the social determinants of health.

Hospitals have changed greatly over the course of history—in mission, function, size, and influence, often catering to specific populations. Jeanne Kisacky provides a historical survey of the significance of building design and geographic setting in the delivery of care and in hospitals’ interactions with their surrounding communities, with a focus on New York City from the mid-19th to the mid-20th centuries. And Amber Dushman examines how the American Medical Association’s Physicians’ Placement Service encouraged communities to develop medical facilities that would attract physicians through one of its pamphlets containing descriptions and photographs of example facilities.

As the health care system continues to evolve, so, too, must medical education and the skill sets of new graduates. Christopher R. Davis and Jed D. Gonzalo explain a new pillar of medical education—health systems science—and the benefits and challenges of training systems “citizens” who have dynamic relationships with the health care system. As an example, Gabriela Aitken describes an interpreter certification program for medical students that aims to address an interpreter shortage while simultaneously providing culturally competent care.

Adequate financing and community representation remain significant challenges to public health and community development goals. Robin Hacke and Alyia Gaskins argue that health care institutions’ community investment supports not only health equity but also institutional mission and can generate a return on investment. They also discuss how clinicians can catalyze this process by leveraging data and generating demand for community development. Using Nationwide Children’s Hospital as an example, Skinner, Franz, and Kelly Kelleher describe a successful partnership with a faith-based development organization to improve both housing conditions in the surrounding community and best practices for hospital community engagement.

Lastly, 4 pieces have implications for our understanding of communities in health care. Sienna Moriarty examines research on high-risk human papillomavirus (HPV) genotypes that are not protected against in the 9vHPV vaccine and that occur with greater frequency among some Mexican populations. She also describes the University of Illinois Medical Center’s research on prevalence and distribution of HPV genotypes among Mexican-born immigrant women in Chicago with the aim of improving vaccine-based preventive care for this population. Doug Bradley and Omar Viswanath discuss the surprising health benefits of music and its value in helping Vietnam veterans heal from their war wounds. Anum Fasih’s image of 3 physicians illustrates the continuity of ethical standards over time, and Manpreet Kaur’s Bleary Image pictorially represents the personal sacrifice and fulfillment that upholding those standards entails for medical students.

This issue of the AMA Journal of Ethics aims to increase awareness of and dialogue about the achievable benefits and existing challenges of health care organizations’ engagement in community development. In turbulent political times with uncertainty about the current health care system, this discussion is not only relevant but also urgent as we continue national efforts aimed at achieving social, economic, and health equity.