This season of giving


Let’s try to connect the dots between a new book on public health policy, a promising new program at Martha’s Vineyard Hospital, and some numbers from a century-old Edgartown annual town report.

First, the book. In “The American Health Care Paradox,” by Dr. Elizabeth Bradley, director of the Global Health Leadership Institute at Yale University, investigates how the United States manages to spend more per person on health care than any other nation on earth, yet ranks back in the pack in measures of outcomes such as longevity and infant mortality. One reason for this apparent paradox, Dr. Bradley argues, is that we’ve defined health care far too narrowly.

When you look at human services more broadly — including things like public education, housing support, job training and unemployment benefits, daycare for children, pensions and other programs caring for the elderly — our poor outcomes in the United States line up very well with our poor patterns of public spending. We might not think of these non-medical services as health-related, but in fact unmet social needs have very direct impacts on public health.

Even in the field of medical care, where so much of our money is spent, the realization is growing that health outcomes improve when we expand our vision to include the social world in which patients live their lives. At the Martha’s Vineyard Hospital, a new program called Integrated Care Management was launched in April to reach into the Island community and support people whose cases involve chronic and medically complicated conditions. Since a great deal is actually known about how to manage chronic ailments such as heart disease and diabetes, an outreach program can support people in the good habits that prevent the sorts of costly medical train wrecks that happen when a condition, left unmanaged, repeatedly requires hospitalization.

The Vineyard hospital’s Integrated Care Management program is based on a pilot project developed at Massachusetts General Hospital that showed great promise in achieving the prized twin goals of modern day health care reform: better health in the community with lower costs of care. The guess here is that the Island’s version of this program will accomplish exactly the same things.

Next, a bit of history. Recently, reading in the Edgartown annual town reports of a century ago, I was surprised to see a large portion of the municipal budget being spent every year in a category labeled “Support of Poor.” In Edgartown in 1914, “Support of Poor” accounted for some $2,500, nearly 11 percent of the town’s operating budget.

Digging further, I discovered that the town, as the unit of government responsible for basic social services, is a New England tradition that goes back to English law, where the care of the needy was the duty of the local parish. Under Massachusetts law dating to the late 1700s, larger towns appointed overseers of the poor, while selectmen in smaller towns like ours also held that post as a second responsibility. In 1914, Edgartown paid Edwin Coffin, William C. Nevin, and Alfred A. Averill $170 each for their work as selectmen and overseers of the poor.

The town report’s itemization of expenses suggests the range of social services supported in this category. Fully half the money, more than a thousand dollars, went to rent subsidies. Money also went for groceries, winter fuel, clothing, medical care and other basic needs — including $15.20 to Silva Shoe Co. for shoes and $38 to Francis W. Pent for burial services.

Such basic human services haven’t been funded by property taxes around here for many years — and you could make an argument that in some ways, it’s a pity. Now we have huge federal and state programs ministering to some of the Island’s social needs, and a diverse, dedicated but always needy network of nonprofit agencies at work here. Too many of the state programs are headed with the label, “Cape-and-Islands,” code language for agencies headquartered on the mainland and better at requiring paperwork than at providing access to services for the people here who need them. Meanwhile, our nonprofits have their boots on the Island ground and a deep, nuanced understanding of local needs, though seldom the resources to address them fully.

I’d love to see our towns, in a tip of the hat to the way Islanders cared for each other a century ago, apply a property surtax of one or two percent each year and pass that along to the agencies on the front lines of social services here. But until that happens, we need to provide in our holiday giving for those Island organizations that labor every day on the social front lines, delivering the human services that hold this community together.