Community Health and Health Disparities:A Shared Responsibility

Saint Louis University School of Public HealthGreater St. Louis Community Health Speaker Series

Thursday, January 14, 2010

Deborah Prothrow-Stith, MDConsultant, SpencerStuart

Adjunct Professor, Harvard School of Public Health

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There Are Many Indicators of Poor Health Outcomes Among U.S. Minorities

• Incidence rate of hypertension is 11 % higher for African Americans as for whites

• Black infant mortality is more than twice white infant mortality: 14 per 1,000 vs. 6 per 1,000 births

• Life expectancy for black men (67.8 yrs) is seven years less than that for white men (74.6)

• Blacks, Hispanics, and Asian Americans are also more likely to be uninsured

• Approximately 39% of blacks, 46% of Hispanics, compared with 26% of whites do not have a regular doctor

• Approximately 45% of Hispanics, 41% of Asians, 35% of blacks report difficulty paying for medical care, vs. 26% of whites

National Center for Health Statistics

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MLK Quote

“Of all the forms of inequality, injustice in health is the most shocking and the most inhuman.”

Martin Luther King Jr.

March 25, 1966

Chicago

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Effective Strategies for Community Health Require

I. Increasing the knowledge base

Example: race and racism

II. Eliminating turf wars

Example: Medicine and Public Health

III. Thinking outside the box

Example: CBPR

IV. Yielding decision-making power

Example: Boxing Out the Violence

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I. Increasing KnowledgeExample: Racism and Health

• “Race” is not a biological construct that reflects innate differences, but a social construct capturing the social classification of people in our race-conscious society.

• Race-associated differences in health outcomes may in fact be due to the impacts of racism.

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Census Irregularities

• 1790 to 1850, the only categories recorded were White and Black (Negro), with Black designated as free and slave.

• 1850 to 1870, 1890, 1910, and 1920, enumerators were instructed to identify Mulattoes (and Quadroons and Octoroons in 1890) among the Black population .

• 1860, with much of the West region of the United States being counted, American Indians (excluding those not taxed) and Chinese (in California only) were identified separately. Japanese were identified separately starting in 1870.

• 1910 -1940 census, Asian and Pacific Islander categories other than Chinese and Japanese were identified for the first time in decennial census reports, including, for example, Filipino, Hindu, and Korean.

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Census Irregularities

• 1930 census only, there was a separate race category for Mexican. The race category of Mexican was eliminated in 1940, and 1930 race data were revised to include the Mexican population with the White population.

• 1950, an attempt was made for the first time (and with limited success) to identify individuals of mixed American Indian, Black, and White ancestry living in certain communities in the eastern United States.

• 1950-1960 -Other individuals who were Asian and Pacific Islanders and individuals of mixed American Indian, Black, and White ancestry were grouped together as "Other race.“

• 1970 - Koreans were identified in tabulations for the conterminous United States and Hawaii, and Eskimos and Aleut were again identified only in Alaska.

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Three Levels of Racism

• Institutionalized: Differential access by race to goods, services, and opportunities of society. – inherited disadvantage

– material conditions, access to power

• Interpersonal or Personally mediated: Prejudice and discrimination.

• Internalized: Acceptance by members of stigmatized races of negative messages about our own abilities and intrinsic worth.

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TIME SPAN

CITIZENSHIP STATUS -YRS

 PERCENT U.S. EXPERIENCE

STATUS HEALTH & HEALTH SYSTEM EXPERIENCE

 1619-1865

 246

 63%

 Chattel slavery

Disparate/inequitable treatment; poor health status & outcomes. “Slave health deficit” & “Slave health sub-system” in effect

 1865-1965

 100

 26%

 Virtually no citizenship rights

Absent or inferior treatment and facilities. De jure segregation/ discrimination in South, de facto throughout most of health system. “Slave health deficit” uncorrected

 1965-2010

 45

 11%

 Most citizenship rights

Southern medical school desegregation [1948], Imhotep Hospital Integration Conferences [1957-1964], hospital desegregation in federal courts [1964]. Disparate health status, outcomes, and services with apartheid, discrimination, institutional racism and bias in effect.

 1619-2010

 391

 100.00%

The struggle continues

 HEALTH DISPARITIES/INEQUITIES

 AFRICAN AMERICAN CITIZENSHIP STATUS & HEALTH EXPERIENCEFROM 1619 TO 2010

Source: Byrd, WM, Clayton, LA. An American Health Dilemma, Volume 1, A Medical History of African Americans and the Problem of Race: Beginnings to 1900, New York, NY: Routledge. 2000.

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Anti-Racism Curriculum

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II. Eliminating the Turf Wars Example: Medicine and Public Health

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Medicine

Anatomy

Histology

Biochemistry

Physiology

Pathophysiology

Pharmacology

Establishing a Relationship

Building Trust

Taking a History

Patient Education

Developing a Rx plan

Receiving Feedback

Soliciting Cooperation

Excellence in clinical care requires merging the “art” and “science” medicine

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Public Health

Epidemiology

Biological Sciences

Biostatistics

Behavioral Science

Political Science

Economics

Environmental Science

Assessment Policy developmentAssuranceProgram Development

DesignImplementationManagementEvaluation

CommunicationLeadershipCultural competency

Excellence in public health practice requires merging of the “art” and “science” of public health

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Proposed Relationship Between Public Health and Medicine

Primary Prevention Secondary Prevention Tertiary Prevention

Education & Policy Risk Reduction Treatment

Medicine

Public Health

Type of Intervention

Deg

ree

of D

isci

plin

e In

volv

emen

t in

Int

erve

ntio

ns

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III. Thinking outside the boxExample: Community Based Participatory

ResearchCBPR is a collaborative approach to research that equitably involves all partners in the research process and recognizes the unique strengths that each brings. W. K. Kellogg Foundation

Community Health Scholars Program (2001)

“participatory research fundamentally is about who has the right to speak, to analyze, and to act.”

Budd Hall, 1992

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Similar Activities and Labels

• PR –Participatory Research• PAR Participatory Action Research• Collaborative Action Research• Action Research – now a more overarching term describing

participatory inquiry and PRACTICE• Mutual Inquiry• FPR –Feminist Participatory Research

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What Created the CBPR Movement

• 21st century’s problems (e.g.HIV, Homelessness, environmental injustice, violence) are too complex for a traditional “outside expert” approach.

• Greater community and political demands for accountability within the research arena.

• Considerable community and funder disappointment with traditional research paradigms.

• Scholars of color and feminist scholars paying attention to issues of race, class, culture as these influence research enterprises.

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Fundamental Characteristics of CBPR

• It is participatory (from beginning to end).

• It is cooperative, engaging community members and researchers in a joint process in which both contribute equally.

• It is a co-learning process.

• It involves systems development and local community capacity building.

• It is an empowering process through which participants can increase control over their lives.

• It achieves a balance between research and action (a shift in the power equation).

* Barbara Israel et al (1998)

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CBPR Guiding Principles

CBPR begins with a research topic of importance to the community with the aim of combining knowledge and action for social change to improve community health and eliminate health disparities.

Community Benefit

Mutual Benefit

Mutual Investment

Career Development

Can Research become an organizing theme for a social change movement in a community that has been abused by research in the past?

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IV: Yielding PowerExample: Boxing Out the Violence

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Optimism is a MUST

I. Increasing the knowledge base

Example: race and racism

II. Eliminating turf wars

Example: Medicine and Public Health

III. Thinking outside the box

Example: CBPR

IV. Yielding decision-making power

Example: Boxing Out the Violence

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