How Should We Measure Human Flourishing?

This article originally appeared in Public Justice Review, a publication by the Center for Public Justice.

Human flourishing is a familiar phrase in Christian circles. And while the advancement of human flourishing is a sacred call which many of us take seriously, we often fail to clearly define what we mean by it or how we measure something as all-encompassing and elusive as human flourishing.

Anthony Bradley, in an article for World Magazine, provides an integrative vision of human flourishing. He writes: “An emphasis on human flourishing, ours and others’, becomes important because it is characterized by a holistic concern for the spiritual, moral, physical, economic, material, political, psychological, and social context necessary for human beings to live according to their design.” As Michelle Kirtley explained in the first article of this series, human flourishing is connected to the biblical notion of shalom, not just as a synonym for generic peace, but as a holistic vision for the interconnected well-being of individuals and communities.

Unfortunately, conversations about how to measure our well-being often begin and end with economics and are largely tied to the Gross Domestic Product (GDP). Yet the GDP comes up short in many ways. The state of Maryland’s website, for example, explains the limits of measuring human flourishing primarily through the GDP: “While it has long been realized that GDP is an insufficient measure of well-being, even its creator, Simon Kuznets, stated in 1934 that ‘The welfare of a nation can scarcely be inferred from a measurement of national income.’ However, that has not prevented GDP’s primacy as the measure of progress.” Maryland became the first state to adopt an alternative means of measuring human flourishing called the Genuine Progress Indicators (GPI). These indicators evaluate progress beyond economic productivity to include “non-market benefits” and measure social determinants of well-being.

The GPI has also been adopted by other states, such as Vermont, Hawaii, Minnesota, and Washington, as a means of identifying, measuring, and advancing holistic community health. Although GDP growth has long been seen as an indicator of a prosperous nation, states around the country are increasingly realizing that GDP growth fails to sufficiently account for social determinants of well-being, including health. This emphasis on economics to the exclusion of other factors incorporated into an integrative approach like the GPI distorts the health care reform debate so that it is essentially a rehashing of the debate about national economic policy, tax policy, and welfare policy.

In our divisive political climate, our conversations around health care are happening at such a granular level, with endless debates on what qualifies as essential health benefits or mechanisms for payment of medical care, that the notion of what constitutes health care itself has been co-opted by partisan wrangling. Expanding the notion of health may sound expensive, but changing the paradigm does not necessarily mean an increase in government spending. In fact, alternative approaches to measuring community well-being such as the GPI consider economic well-being in a more holistic way. For example, rather than simply putting the money spent on infrastructure or public transportation into one category, this model considers how spending in these areas could have positive economic and health impacts in other areas like medical health, business growth, and educational access.

We believe we need a bigger vision for what constitutes health care that is not just the reactive medical interventions necessary after someone gets sick.

We believe we need a bigger vision for what constitutes health care that is not just the reactive medical interventions necessary after someone gets sick. Moreover, we believe even a definition of health care that also includes preventive services as defined by the ACA is too narrow because it still is dealing only with the medical interventions of physical and mental health.

What if a definition of health care took into account social determinants of health such as housing, public transportation, strength of the family unit, and connectedness to civic and spiritual groups? All of these factors ought to be part of how we measure quality of life for individuals and communities. What does it look like if we think of health care in these more holistic and foundational terms?  

THE TRIPLE BOTTOM LINE

A public justice perspective considers what the right responsibilities and roles are for both government and other key institutions in society to promote human flourishing. Human flourishing is inextricably connected to the health of individuals and communities, but too often, we only discuss public policy solutions to health care concerns in terms of medical health care.

The Maryland Quality of Life Initiative is a collaboration between the state, businesses, nonprofits, and those in academia organized by Maryland Nonprofits to track and advance quality of life for all individuals and communities in the state. It represents a partnership between government and civil society that demonstrates how a public justice approach to the complex challenge of promoting individual and community health might look. The initiative develops resources to guide public officials in Maryland in their understanding of how alternative measures of quality of life can shape public policy. The Maryland Quality of Life Initiative webpage states: “Recognizing the GPI is just one indicator that measures quality of life, Maryland Nonprofits will develop a live ‘dashboard’ of key data that indicate the extent to which Maryland is making progress on improving the quality of life.”

In the 2016 inaugural State of Our State: Maryland’s Quality of Life, Heather Iliff underscored the indispensable role diverse nonprofits play in “bringing together community, businesses, and governmental leaders to transform local communities for the better.” Iliff describes the interdependence of community, environmental, and economic flourishing as the “triple bottom line” approach. Iliff gives the example of how the poor air quality in low-income neighborhoods increases the chances of children suffering from asthma and other chronic respiratory conditions. But the impact doesn’t stop there, Iliff noted: “[The children’s] concentration and education suffers…Parents often miss work to care for them and [their] job performance and income suffer.”

In short, our physical health is connected to many different spheres of life and creation; negative effects on the environment can impact our physical health, which can in turn impact our economic productivity. With this “triple bottom line” orientation towards holistic human flourishing, Iliff explains, “we can make decisions that improve our economic bottom line without threatening our communities and the environment.”

INTEGRATIVE APPROACHES TO HEALTH AND HUMAN FLOURISHING

Putting in place preventive policies that attend to the link between our physical health outcomes and other areas of our lives can be accomplished through government partnering with different faith-based and community-based nonprofit organizations. Government should take into account that we live in a pluralist society with great geographic, racial, religious, and socioeconomic diversity. Therefore, government should create the space needed in our diverse public square for equally diverse civil society organizations to thrive and make their distinctive impact on their communities.

Healthy People 2020 is an example of a governmental initiative to measure human health through an integrative approach. This initiative was launched by the Department of Health and Human Services in 2010 with four main goals: to achieve high quality, longer lives; to realize health equity across a diverse population; to create social and physical environments that promote health; and to promote quality of life and healthy development and behaviors.  It provides a framework for federal, state, and local governments, as well as a variety of private and public-sector partners, to prioritize and manage health issues. Healthy People 2020 was developed by the Federal Interagency Workgroup (FIW), with members from major agencies such as the Department of Education, the USDA, and HHS, among others.

According to the Healthy People 2020 website, “FIW meets monthly to steer the initiative, monitor changes and discuss progress, and guide implementation of Healthy People.” This initiative sets a framework to be used by multiple federal agencies, as well as local and state governments, when making policy and funding decisions that impact community health. For example, this initiative allows local communities to search an evidence-based resources database “to find interventions and resources to improve health in your community.” The initiative also provides examples of communities and local governments from across the country that are implementing Healthy People 2020.

Within this framework, multiple factors affect health, including an individual’s biology, behavior, social environment, physical environment, and available health services. These factors are further organized into forty-two topic areas, such as injury and violence, environmental health, and mental health. Each of these topics is measured by a variety of health indicators. For example, access to health services, a hotly debated topic since the Affordable Care Act was passed, is measured not just by persons with medical insurance, but also by persons who use a primary care provider. Mental health is measured by suicides and adolescents who experience major depressive episodes.

This framework has been successfully applied in diverse settings and communities throughout the United States, including in partnership with various faith-based organizations and churches. In North Carolina, for example, more than six million people are obese and at risk for obesity-related illnesses. African Americans were identified as being at higher risk than whites, especially in Wake County. With the support of a CDC Preventive Health and Health Services grant, Wake County Human Services partnered with forty-six African American churches to leverage their access and influence in the African American community.

Under the Eat Smart, Move More initiative, church leaders were educated on how they could use the social and spiritual capital of their faith community to increase healthy eating and exercise among their congregants. The Health Department offered health screenings, and churches built community gardens, family wellness centers, installed exercise equipment, and offered nutrition and exercise classes. The fact sheet summarizing the results of this program states: “Studies show that efforts to promote health in faith-based communities reach more people and have greater potential to reduce health disparities because of the power of churches to influence the behavior of their members.”

As well, hospitals, health clinics, and health providers need to be joined with other civil society institutions like churches, schools, families, fraternal organizations, neighborhood groups, urban gardens, gyms and sports clubs, and advocacy groups to support a more holistic approach to health upstream of the doctor. This is good for both healthy individuals and health care costs because such involvement in other civil society institutions can help prevent health crises.

Health providers need to be joined with other civil society institutions like churches, schools, families, fraternal organizations, neighborhood groups, urban gardens, gyms and sports clubs, and advocacy groups to support a more holistic approach to health upstream of the doctor

Among the White Mountain Apache Tribe, for example, the suicide rate had risen to four times the national suicide rate. In partnership with Johns Hopkins Center for American Indian Health, tribal leaders developed the Empowering Our Spirits initiative.  The coalition included tribal mental health, foster care, and justice agencies, as well as traditional healers and churches. The initiative resulted in a multipronged approach including a media campaign to raise awareness about the issues of suicide, multiple programs to empower elders in the community to help the youth, and two bilingual and culturally adapted evidence-based interventions. These included A New Hope, an emergency room educational and safety planning intervention for youth who had injured themselves or attempted suicide. The other, Re-Embracing Life, is a multi-session program that teaches coping, problem-solving, and conflict management skills to youth and their families.

Healthy People 2020 provides critical evidence of successful interventions that should dispel skepticism from some members of the public and public officials regarding whether government funding in these areas is effective and efficient. By providing both qualitative examples and quantitative studies backing the effectiveness of such distinctive community-based and faith-based interventions, Healthy People 2020 is supporting government investment in quality of life and a more integrative vision of health.

A HOPEFUL VISION

These examples present a hopeful vision of the implementation of a public justice framework to advance a holistic vision of health and human flourishing. This framework calls on collaborative, both/and solutions to supporting health and well-being. These examples demonstrate that government can most effectively uphold human flourishing in the context of health when it partners with diverse institutions that both respond to existing physical and mental health challenges and work upstream in different areas of life (housing, education, employment, environment) to prevent such health issues in the first place.

Policy experts and social researchers have barely scratched the surface when it comes to how civil society organizations and government can creatively collaborate to best serve the needs of the whole person and whole communities. Still, there is evidence that such soul-shaping institutional engagement could be transformational right now to socially, financially, and spiritually impoverished individuals and communities experiencing a deficit of health and well-being in different areas of their lives.

In the fall of 2016, the White House’s Office of Faith-Based and Neighborhood Partnerships’ Advisory Council released a report summarizing Recommendations to Address Poverty and Inequality. The report echoes the importance of something faith-based organizations know: that solutions must address the soul needs of a person in addition to the material needs. The reports state that government policies and partnerships with neighborhood organizations should take such a holistic approach into account to serve the physical and spiritual health of communities and individuals:

Government resources must therefore sow the seeds of community-based efforts to heal and unlock communities’ and individuals’ inner assets triggering and sustaining lasting external and internal transformations. We should remember that capital is not just financial; it is social, informational, experiential, spiritual, emotional, natural, and cultural.

Government resources must therefore sow the seeds of community-based efforts to heal and unlock communities’ and individuals’ inner assets triggering and sustaining lasting external and internal transformations.

We hope that taking a macro view of this issue demonstrates that public justice requires individuals, diverse faith-based and community-based civil society institutions, and government to think about health broadly as interconnected to every area of life. This approach may not produce the quick and clean solutions many are looking for, but it does, we believe, open the door for a more fruitful conversation about what human flourishing really means, as well as how we might measure our progress toward the advancement of health and human flourishing for all.

-Joshua Bombino, LGSW is the Manager of Community Support Services with Humanim, a human services agency in the Baltimore region. He recently completed his MSW from the University of Maryland.

-Chelsea Langston Bombino is Director of Strategic Engagement at the Institutional Religious Freedom Alliance, a division of the Center for Public Justice. She holds a JD from the University of Michigan and is a licensed attorney by the State Bar of Michigan.