advancing health in new york city: channeling the...

Presentation Title Goes Here 1

Advancing Health in New York City:

Channeling the Tides to Lift All Boats

Marc N. Gourevitch, MD, MPH

Department of Population Health, NYU School of Medicine

Intersectoral Forum on Advancing Health and Equity in NYC

March 26, 2014

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Overview •  Net gains in NYC health over last 10-15 yrs are substantial

and must be preserved and extended

•  Unacceptable inequalities persist, some worsening

•  Further gains require specific efforts to ↓ inequalities, by: o  Sharpening focus on most disadvantaged communities o  Engaging other sectors that also produce health o  Optimizing impact of healthcare sector on health

Dowell & Farley, Lancet 2012

Current smoking, ≥18 years old, NYC 1993–2010

IHME, 2013

Change in life expectancy, Females, 1985-2010

Alcorn, Lancet 2012

Life expectancy, by Borough, 1985-2009

NYC DOHMH, Bureau of Vital Statistics, March 2013 7

NYC DOHMH, Bureau of Vital Statistics, March 2013 8

NYC DOHMH, 2014 9

11

What produces health?

NY Times, March 16, 2014 12

Median household income & life expectancy, US counties

Bradley, Elkins, Herrin, Elbel. BMHJ Qual Saf, 2011

13

↑ ratio of social : health expenditures in OECD countries → ↓infant mortality ↑ life expectancy ↓ potential life years lost

(after adjusting for level of health expenditures, GDP)

Spending on social programs vs. healthcare: impact on health

Mortality, USA – Yr 2000: Dx’d vs underlying causes

Diagnosed Causes N = 2.4 million

Heart Cancer Stroke Resp Injury Diabetes Flu/Pneu Other

Underlying Behavioral Causes

N = 1.2 million

Smoking Obes/inact Alcohol MVA Guns Unprot'd sex Drugs

Mokdad JAMA 2004

Galea, Tracy, Hoggatt, DiMaggio, Karpati, AJPH 2011

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Mortality, USA – Yr 2000: Social factor attribution

Furman Center Annual Report 2012 16

Education: Bachelor’s Degree & Higher, NYC, 2000 - 2012

0

10

20

30

40

50

60

2000 2012

White Black Hispanic Asian %

NY

C a

dults

Furman Center Annual Reports, 2006 and 2012 17

Poverty rate, NYC, 2000 - 2012

0

5

10

15

20

25

30

35

2000 2012

White Black Hispanic Asian

% h

ouse

hold

s <

pove

rty


Severe crowding: % of rental households, NYC, 2006 - 2012

(>1.5 household members/room)

0

1

2

3

4

5

6

7

8

9

2006 2012

White Black Hispanic Asian

NYC DOHMH, 2010 19

Inequalities in income: Gini coefficients* by borough

*measure of income dispersion in geographic area

Inequalties in health: which way forward?


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House lights and spotlights

•  City-wide approaches o  Public health and healthcare sectors

Ø  Regulatory initiatives, prevention: continued promise

o  Other sectors Ø  Downstream impact could be even greater

•  Community/neighborhood/population – grounded approaches

o  Fundamental to eliminating health inequalities

Complementary approaches: policy and community

2014 2024 2034

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↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑

A B C D E


2014 2024 2034

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↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑

A B C D E


2014 2024 2034

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↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑

A B C D E


2014 2024 2034

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A B C D E


2014 2024 2034

↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑

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↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑

A B C D E

Smoking rates – NYC, 2002 - 2012

0

5

10

15

20

25

30

2002 2012

White, M Black, M Hispanic, M Asian, M White, F Black, F Hispanic, F Asian, F

NYC DOHMH, EpiQuery 31

32

Strategies forward

1. City-wide health policy approaches •  Legislation •  Regulation •  Procurement

2. Bridge other sectors to tackle upstream determinants

•  Health in All Policies 3. Deepen focus on / partnership with highest need communities 4. Extend the population impact of healthcare

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City-wide health policy approaches

•  Legislation •  Regulation •  Procurement

•  Examples: o  Sugar-sweetened beverage portion size o  ↑ age of cigarette purchasing to 21

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Bridging other sectors to tackle upstream determinants

Health in all Policies (HIAP)

•  Transportation

•  Education

•  Housing

•  Built environment

L Brotman, 2014

•  4248 families in Boston, Baltimore, Chicago, LA, NYC

•  Randomly assigned (1994-97) to: 1.  housing voucher that could be used to move to a low poverty

(<10%) neighborhood 2.  housing voucher with no geographic restrictions 3.  control group

•  In 2002, one adult (98% female) from each family was

followed up by interview

Moving to Opportunity demonstration

Kling JR, Liebman JB, Katz LF. (http://www.ksg.harvard.edu/jeffreyliebman/MTOcomprehensivejune2005.pdf)

Obesity Outcomes in MTO

0 5

10 15 20 25 30 35 40 45 50

Low poverty Traditional Control

% O

besi

ty

P = .04

P = .09

Kling JR, Liebman JB, Katz LF. (http://www.ksg.harvard.edu/jeffreyliebman/MTOcomprehensivejune2005.pdf)

36.7

51.2

22.2

60.2

0

10

20

30

40

50

60

70

HBP Ever Currently taking BP Meds

Black White

Percentage of residents reporting high blood pressure ever and currently taking HTN medications by race (age-adjusted)

NYC Community Health Survey 2012

Deepening partnerships w/ communities at highest risk: Hypertension inequalities in NYC

Deepening partnerships w/ communities at highest risk: Health Ministry-based BP Dashboard

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Extending the population impact of healthcare delivery •  Healthcare system: a minor actor?

But: »  Resource-rich »  Concentrated focus on health »  Strong evidence behind preventive interventions

•  New opportunities »  Payment mechanisms favoring population-oriented

approach »  Primary care »  CHWs »  Community benefit

Total area popula+on

Pop’n for which delivery system at risk

Total area popula+on Pop’n for

which delivery system at risk

42 Jacobson & Teutsch, 2012

43 Jacobson & Teutsch, 2012

Delivery system?

2013 2014 2015 2016 2017 2018 2019 2020

Accountable partnership

organizations (APOs)

↑ Affordable housing

Univ pre-K

Minimum wage

Green carts ubiquitous; Safe, well-lit

stairwells

Narcan

Pre

mat

ure

Mor

talit

y 2020 look-back?

Community-grounded, sector-bridging

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Moving forward

•  Don’t dim the house lights

•  Intensify focus on and deepen partnerships with communities at greatest disadvantage

•  Broaden interface of healthcare and community health

•  Actively adopt health strategies in key health-producing sectors

•  Address income inequality –  Tax policy; affordable housing policy; new entry level jobs

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