I didn’t notice it at first – my second coffee of the morning probably hadn’t kicked in yet. Most mornings, I sort all of the mail that has come into Bread for the City for their representative payee clients. These are consumers who have been declared mentally unable to take care of their own finances by a judge or doctor. BFC is one of a few organizations around the city that manages the consumer’s money to pay their bills and give them a weekly allowance. Sorting this mail requires looking up the recipient’s name and categorizing them according to what “group” the recipient is labeled as. 

After I got about halfway through the pile, I realized a lot of them were going to various teams at Anchor Mental Health – the building in which I work for Catholic Charities on Wednesdays and Thursdays. Anchor is the headquarters for all of Catholic Charities’ mental health and psychiatric care – which is a lot. They have about a half-dozen teams responding to various groups’ needs, with school interventions, crisis response, and counseling. The biggest recipient of the mail I was sorting was the ACT team. ACT, or Assertive Community Treatment, is for people who have severe, untreated mental illness. 

Dozens of these mail recipients, who were clients of Bread, were also clients of Catholic Charities. I guess I should not have been surprised by this, because both organizations provide similar but complementary social services. There is a lot of overlap in the groups of people who seek out their services. 

If someone is severely mentally ill, chances are they have a hard time keeping a job. That affects their ability to pay bills or get food, which Bread helps with. It also affects their ability to function independently, which Catholic Charities would help with. I mentioned what I had noticed to Ms. Kesara, my supervisor, and she explained it much more succinctly: “We help with the money and the food, they [Catholic Charities and other nonprofits] help with the other stuff.” 

This realization got me thinking more about how various social determinants of health overlap and feed off of each other. In the public health sphere, social determinants of health, in a broad sense, are the various nonmedical factors that affect health. These are the environments and conditions in which one grows up and lives in. Access to nutritious food is a good example, as are water and air quality, safe housing and transportation, exposure to trauma and violence, and financial stability. And a lot of times, these overlap. A child born in poverty lives in a rough neighborhood near an industrial park. The pollution he grows up breathing, coupled with the fact that there are no safe parks nearby to run around in, means that he has a vastly greater chance of developing asthma or other health issues.

Just by sorting the mail, I was seeing some of these social determinants play out in real life. Financial struggles were connected to physical health struggles were connected to mental health struggles were connected to food struggles were connected to… you get it. 

Local nonprofit organizations are uniquely able to get to know their clients and work with them on specific issues. They’re generally best suited to address the needs of consumers for whom the social determinants of health have overlapped in difficult ways. Picture an archetypal homeless person. Probably influenced as much by stereotypes as by lived experience, this is probably a drinking, smoking, guy talking loudly to himself. You (and me, too) start mentally preparing to look straight ahead and give him a wide berth as soon as you hear him down the block. Bread for the City might help him pay his bills if he is unable to. Catholic Charities might help him with psychiatric care and substance abuse recovery. Another organization might assist with finding a job.

Local, specialized NGOs can understand the local environment and residents far better than a statewide, national, or even international effort can. But it also means that there are that many more opportunities for information – and people – to slip through the cracks. Here we find a very fine balance between specialization and complication. 

Global public health at large faces the same difficulties. This week, I have continued reading Ellen Idler’s Religion as a Social Determinant of Public Health. In his chapter, “Religion and Global Health,” Peter Brown writes that global health is “fragmented, complicated, and inadequately tracked.” A pretty condemning description! In this chapter, Brown writes about how nationally- or internationally-funded programs work best when enacted by local actors. Instead of outsiders entering a community and attempting to run (usually very well-intentioned) initiatives, these initiatives should be run by those who they would benefit. Community leaders better understand the culture, the issues affecting the residents, and what solutions might work best. 

However, these locally-run initiatives often struggle to communicate with each other and as a group. This damages both day-to-day logistics as well as prevents everyone from learning what works and what doesn’t. 

In our conversation last Friday, Dr. Holman and I discussed these issues of autonomy, locality, communication, and consistency of care. Ultimately, it comes down to a balance between effectiveness and efficiency. Balancing the scale requires both being fair to local needs and emphasizing quality assessment. Yes, public health initiatives should be locally-run as much as possible if (!) they are consistently assessed to be working. 

It’s difficult to measure the costs and benefits of this fragmented approach to holistic public health. How many bills were late because a Catholic Charities intern took too long to sort the mail forwarded to another organization? How many people had to rethink their whole schedule because Bread changed their food pantry hours? But also: how many mentally disabled people are able to lead more independent lives with fewer financial burdens? How many meals have been distributed to those who would have otherwise not eaten? 

These next two weeks, I will be reading Bread for the World by Arthur Simon and the chapter “Toward a Theology of Medicine,” in Hostility and Hospitality by Michael and Tracy Balboni, and am looking forward to finally getting to My Year of Rest and Relaxation (the book, but maybe it’ll also spark a very mellow next 365 days). 

This is one in a series of post by Elizabeth Rambo, on her 2024 PLT summer internship experience.

The Project on Lived Theology at the University of Virginia is a research initiative, whose mission is to study the social consequences of theological ideas for the sake of a more just and compassionate world.