The depth of poverty in America is rising and exceeds that of all other industrialized countries, with the largest overall level of inequities of modern societies.¹ The rate of American childhood poverty has been linked to poor population health and long-standing economic disparities.² The most recent US Census Bureau data found that children are the poorest age group, accounting for almost one-third of people living below poverty lines (https://www.census.gov/topics/income-poverty/poverty.html). This is defined as an annual income below approximately $25,485 for a family of four and extreme poverty below approximately $12,500.³ This is an urgent crisis to address because poverty in children is associated with broad deficits in physical and mental health, academic achievement gaps, and higher rates of social or behavioral dysfunction.⁴ Such gaps are even more pronounced in deep poverty, with families trapped for long periods from early childhood into adulthood. Children of color and ethnic minorities disproportionately make up nearly three-quarters of all poor children in the United States. Rigorous research has also found statistical relationships between children growing up in poverty to adult earnings, the propensity to commit crimes, and poor overall health.⁴ Aggregate costs to the US economy for childhood poverty is averaged at $500 billion/year, nearly 4% of the GDP.⁵ Multiple studies have demonstrated that poverty affects student achievement at all levels, and the US Department of Education found that poor students score below norms in all grades and that schools with high percentages of poor children have worse achievement scores in all subjects.⁶

Many negative health outcomes have been related to poverty. The rates of low-birth-weight and infant mortality are all significantly higher in children born into poverty in the United States.⁷ Even more striking is that one in eight US households report being food insecure (limited or uncertain availability of adequate food), and this affects infant feeding practices, toddler and childhood obesity, and depressive symptoms among parents.⁸ Children born into poverty are also more likely to experience injuries related to trauma and accidents, and neighborhood-level socioeconomic characteristics are associated with pediatric injuries.⁹ Recently connections between these and other health disparities have been closely related to neighborhoods with high rates of poverty and crime.¹⁰ For example, certain neighborhoods in Chicago, IL, with the highest rates of violent crime also have the highest rates of infant mortality.¹¹ Likewise, with the highest homicide rate in the Midwest, Cincinnati also carries the highest infant mortality rate in the state of Ohio. Violent crime and health disparities in birth weight, infant mortality, obesity, and asthma cluster to segregated poor neighborhoods. Recent research around health disparities has shifted to addressing differences in socioeconomic status and the links between poverty, neighborhood segregation, and health outcomes.¹²

The Harlem Children’s Zone Project is a successful national outreach model of a holistic approach to breaking the effects of generational poverty through innovative programming (https://hcz.org/). The goals of the program are to provide full support for children to and from college with education, family support, and health initiatives for 100 blocks of neighborhoods in central Harlem, NY. The ultimate goal of the program is for children to attain college graduation. The comprehensive project has made incredible progress toward neighborhood transformation with results that include 97% college acceptance rate across programs, 9000 youth across Harlem participating in health and fitness programs, keeping over 1000 families intact and avoiding foster care, and currently serving over 14,000 children and just as many adults. The program has received many accolades and has been described
as one of the most comprehensive and successful broad antipoverty efforts to date in the United States. The nonprofit organization raises approximately $4500 per person served from private and public charity; according to the organization’s CEO:

The success of the Harlem Children’s Zone Project led to the establishment of Promise Neighborhoods, which is the legislative authority of the Fund for Improvement of Education Program for nonprofit organizations, institutions of higher education, and Indian tribes to develop educational initiatives and strong systems of family. Promise Neighborhoods is aimed at poverty reduction and education reform that are based on and maintained by the collective strength of individuals in communities, philanthropy, and universities. Promise Neighborhoods illustrates the potential of strong collaborations and partnerships between institutions and community organizations to create impactful outreach.

The Project on Human Development in Chicago Neighborhoods was an interdisciplinary study on how child and adolescent development are affected by neighborhood and family structure (https://www.icpsr.umich.edu/icpsrweb/PHDCN/about.jsp). The project studied pathways to and from poverty that included crime, violence, substance abuse, social behaviors, and health. The authors provided insight into Chicago’s neighborhoods over time, following over 6000 children and the circumstances of their lives that might lead to antisocial behaviors.¹³ The findings were compelling in that nearly all health disparities in a modern city can be traced regionally to communities, socioeconomic status, and neighborhood well-being. Many such segregated neighborhoods and communities are home to vibrant and successful academic medical centers.¹³

Given this, meaningful outreach efforts on poverty reduction and neighborhood support can be viewed as a public health opportunity and responsibility of Academic Medicine.

Academic Health Centers (AHCs) have traditionally had a three-part mission of education of the future healthcare workforce, biomedical and clinical research, and high-quality clinical care.^14,15 Despite advances, the US population continues to struggle with shorter life expectancy and poorer health compared with other countries internationally.^16,17 Increasingly, research is demonstrating that “the conditions in which people are born, grow, work, live, and age” influence health outcomes far more than medical care.¹⁸ Despite the impact of these social determinants of health (SDOH) on individual and population outcomes, the US healthcare system continues to pour disproportionate resources into medicine rather than health.^18,19 The lack of a more organized approach to addressing the main driver of health status, SDOH, has led to underwhelming impacts on improvements in the US health system. Major determinants of health are 50% social and behavioral; 10% environmental; 15% genetic; and only 25% related to medical care received (Figure 14.1). Thus, the overwhelming preponderance
of U.S. health status is not related to medical care but rather to environmental and social determinants of health (SDOH).^15,20,21 Therefore, in order to make real progress in health improvements, it is time for AHCs to expand their mission to include addressing social determinants of health and health inequities through social accountability.¹⁴