Eliminate Health Inequities

Are we serious ?

Linda Rae Murray M.D. MPH Institute for Faith &

Public Health Leadership April, 2012

Eliminating “Health Disparities”

•A goal of U.S. health for the past THREE Healthy People plans.

• Many governmental and private foundation grant efforts to address this issue.

• Not doing well.

•ONE EXCELLENT RESOURCE: Steve Whitman et al; Urban Health : Combating Disparities with Local Data. (Chicago Area)

Basic Readings

Why are some people healthy and others not?

Evolution of Healthy People

Target Year 1990 2000 2010 2020

Overarching Goals

• Decrease mortality: infants–adults

• Increase independence among older adults

• Increase span of healthy life

• Reduce health disparities

• Achieve access to preventive services for all

• Increase quality and years of healthy life

• Eliminate health disparities

• Attain high-quality, longer lives free of preventable disease

• Achieve health equity; eliminate disparities

• Create social and physical environments that promote good health

• Promote quality of life, healthy development, healthy behaviors across life stages

# Topic Areas 15 22 28 39*

# Objectives/ Measures 226/NA 312/NA 467/1,000 >580/1200

* With objectives

Social Justice & Health “Where justice is denied, where poverty is

enforced, where ignorance prevails, and where any one class is made to feel that

society is an organized conspiracy to oppress, rob and degrade them, neither

persons nor property will be safe.”

Frederick Douglass – (c.1817–1895), U.S. abolitionist Speech made on the 24th anniversary of Emancipation in the

District of Columbia, April 1886, Washington, DC.

World Health Organization’s

Definition of Health

Health is not simply the absence of

disease, but the presence of physical, social, and emotional well-being.

Everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or lack of livelihood in circumstances beyond his control.

United Nations

Universal Declaration of Human Rights

Article 25

What is health ? • “ Health is a social, economic and political issue,

and above all a fundamental human right. Inequality , poverty, exploitation, violence and injustice are at the root of ill-health and the deaths of poor and marginalized people. Health for all means that powerful interests have to be challenged, that globalization has to be opposed, and that political and economic priorities have to be drastically changed.” The People’s Charter for Health Preamble Dec. 2000

This matter of admitting the true nature of a problem before setting about rectifying it, or even pretending to, is of utmost importance.”

Lorraine Hansberry, Monthly Review, 1965

“

What are we talking about ????

Definition: Health Disparities

• Differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States. This definition includes health disparities related to socioeconomic status (National Institutes of Health)

Definition: Institute of Medicine: • Across virtually every therapeutic intervention,

ranging from high technology procedures to the most elementary forms of diagnostic and treatment interventions, minorities receive fewer procedures and poorer quality medical care than whites.

• These differences persist even after differences in health insurance, SES, stage and severity of disease, comobidity, and the type of medical facility are taken into account.

• Moreover, they persist in contexts such as Medicare and the VA Health System, where differences in economic status and insurance coverage are minimized.

Source: Institute of Medicine, 2002

Margaret Whitehead’s definition

• Health Inequities: differences in health which are not only unnecessary and avoidable but , in addition , are considered unfair and unjust.

What is the difference between

“Health Disparity”

and

“Health Inequity” ?

Rate A ≠ Rate B

Inequality (or Disparity) = a difference

Two quantities that are not equal

How should we measure health inequalities?

Issues to consider: 1. Relative vs. absolute difference

– Absolute measures retain information

about the number of excess events – Relative measures allow comparisons

• Between objectives • Over time

Your Representative wants to know which inequality should be given policy priority –

What will you advise? Heart Disease Nephritis ______________________________ 83 deaths – absolute difference – 18 deaths 30% - relative difference – 250%

0

50

100

150

200

250

300

350

400

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990

Infa

nt M

orta

lity

per 1

,000

0

0.5

1

1.5

2

2.5

3

Rela

tive D

isparity

Black – White Inequality in Infant Mortality

over the 20th Century, USA

Relative Inequality

White

Black

0

50

100

150

200

250

300

350

400

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990

Infant M

ortality per 1,000

0.020.040.060.080.0100.0120.0140.0160.0180.0200.0

Absolu

te D

isparity

Absolute Inequality

White

Black

Has the Black/white

Infant Mortality gone UP or

Down ?

Disparities in health are based on

observed differences

•Poor people die younger than rich people

• Low social class infants have lower birth weight

• Smokers get more lung cancer than non-smokers

• Women live longer than men

Inequities in health are based on ethical

judgments about those differences

•Should poor people die younger than rich people?

• Should low social class infants have lower birth weight?

• Should smokers get more lung cancer?

• Should women live longer than men?

1

3

5

7

9

0

20

40

60

80

100

Which age group has the SMALLEST disparity

between rich and poor?

RR

Which age group deserves policy attention to reduce health inequalities?

Poorest 20%

Richest 20% Mor

talit

y R

ate

per

10

00

Rate Ratio Relative Risk

Epidemiologists can measure health

inequality.

However, some process of socio-political

discourse is required to assess which

inequalities are an affront to social

justice and thus require

intervention

1.How do we rank health inequities in

terms of their importance in regard to

policy intervention?

2.What criteria do we use to decide that

one inequity is more “important” than

another and therefore more deserving of

policy attention?

Efforts to monitor and eliminate health inequalities assume

• A scientifically rigorous and transparent strategy for measuring health inequalities – Across multiple dimensions of the

population – Across multiple health indicators – Across time

• Data Sources

Social Production of Health & Illness

“ Do we not always find the disease of the populace traceable to defects in society ”

-Rudolf Virchow,

in a late 19th century speech

Ecological Model

What is the most important level ? Where should action start ?

Societal Community Family Relationship Individual

Ecological Model

What is the most important level ? Where should action start ?

Individual Family Relationship Community Societal

Ecological Model

What is the most important level ? Where should action start ?

The main determinants of health

Source: Dahlgren and Whitehead, 1991

Age, sex and constitutional

factors

Source: Krieger, AJPH 98: (2) p. 221

CSDH FRAMEWORK • Emphasizes socio-economic and political

context and the structural determinants of health inequity

• CONTEXT includes all social & political mechanisms that generate and configure social hierarchies – Including labor market, education system,

political institutions and other cultural & societal values

• Among the contextual factors that most powerfully affect health are the welfare state and its redistributive policies (or absence of such policies

CSDH FRAMEWORK • STRUCTURAL DETERMINANTS – generate

stratification & social class divisions and define individual socioeconomic position within hierarchies of power, prestige and access to resources. – Most important structural stratifiers are: income,

education, occupation, social class, gender, race/ethnicity

• Together the context & structural determinants constitute the SOCIAL DETERMINANTS OF HEALTH INEQUITIES.

CSDH FRAMEWORK • ? WHERE DO HEALTH EQUITIES COME

FROM ? – Where do health differences among social groups

originate, if we trace them back to their deepest roots ?

– The structural mechanisms that

shape social hierarchies according to these key stratifiers are the ROOT CAUSE of inequities in health.

CSDH Model

Social determinants of health as a window into living

conditions

What are SDOH? • Social determinants of health are the

economic and social conditions that influence the health of individuals, communities, and jurisdictions as a whole.

• Social determinants of health are about the quantity and quality of a variety of resources that a society makes available to its members.

Ottawa Charter’s Prerequisites of Health

• peace • shelter • education • food • income • a stable eco-system • sustainable resources • social justice • equity World Health Organization, 1986

Social Class • Social classes are groupings of

individuals based on their relationship to the economy.

• Class matters

“Socioeconomic status is a strong and consistent predictor of mortality

and morbidity. Individuals lower in the SES hierarchy suffer

disproportionately from almost every disease … This association is

found with each of the key components of SES: income, education and

occupational status.”

Adler, et. Al., JAMA (1993) p. 3140

The Standard View of Socioeconomic Health Disparities

“Throughout history SES has been linked to health. Individuals higher

in the socioeconomic hierarchy typically enjoy better health that do

those below; SES differences are found for rates of mortality and

morbidity from almost every disease and condition.”

Adler, et. al., Am Psychologist (1994) p. 15

What do we mean by “SES”?

• Socioeconomic status/position • Wealth-- and/or the associated power

and social standing/prestige – Income, accumulated economic assets

(wealth) – Education (prestige, wealth, power) – Occupation (power, prestige, wealth)

• Multidimensional construct -- yet health studies often use a single SES measure

Measures of Socioeconomic Status

• Economic Status – Income – Poverty – Wealth

• Occupational Status

– Occupational prestige

• Educational Status

Presenter

Presentation Notes

Figure D shows that the top 1 percent of wage and salary earners increased their inflation-adjusted average annual salaries by 144% from 1979 to 2006. The top one one-thousandth (0.1 percent) of earners enjoyed annual wages growth of 324 percent over that same period. In contrast, the bottom 90 percent of wage earners increased their annual salaries by about 15 percent from 1979 to 2006. Most of this growth occurred during the relatively brief period of tight labor markets that accompanied the late 1990s boom. Between 1979 and 1995, average annual wages for the lowest-earning 90 percent grew just 2.8 percent. And from 2000 and 2006, wages did not improve at all. Thus, nearly all of the wage and salary growth of the bottom 90 percent from 1979 to 2006 occurred from 1995 to 2000 when unemployment was falling and then remained low.2

Economic Status

• INCOME: (personal, family, household) – More unstable – Age dependent – Varies widely within occupations – Moderately related to education – Fail to include informal economy – Can easily be changed through policies

Economic Status

• WEALTH: accumulated value of all assets, including home equity, savings, retirement accounts, stocks & bonds, rental property, businesses and vehicles. (Net worth = wealth – liabilities) – More strongly linked to social class than

income – Difficult to measure

Federal Poverty Levels

• Established by Office of Management & Budget in 1963-64

• Created by Mollie Orshansky of Social Security Administration – Chose cheapest of four food plans of Dept

of Agriculture. – Economy food plan was “ designed for

temporary or emergency use when funds are low.”

Occupational Status

• Summarizes power, income and educational requirements associated with various positions in the occupational structure. – Environmental & working conditions – Decision making latitude – Psychological demands

• Rapid changes in technology – blue collar disappearing.. Service sector increasing

Educational Status • Advantages

– Fairly stable for adults – Practical – An indicator likely to capture aspects of lifestyle and

behavior • Disadvantages

– Varies by age cohort – Relative to income decreasing variability in years of

education – Individual measure not household – Economic return varies by race and gender

Cognitive Test Scores at Ages 22, 42, 60 and 120 months by Parents SEP and early score

High Scores

Low Scores

Feinstein (2003)

SES & Health

• SOCIAL CAUSATION – Exposure to low SES leads to worsening of

health status

• SOCIAL SELECTION – Poor health status leads to lower SES

Community SES LOW

Community SES HIGH

Individual SES LOW

Worst health

Poor health

Individual SES HIGH

Better health

Best health

Relationship between Social Context and Health

SES: A Key Determinant of Heath

• Socioeconomic Status (SES) usually measured by income, education, or occupation influences health in virtually every society.

• SES is one of the most powerful predictors of health, more powerful than genetics, exposure to carcinogens, and even smoking.

• The gap in mortality between high and low SES persons is larger than the gap between smokers and non-smokers.

• Americans who have not graduated from high school have a death rate two to three times higher than those who have graduated from college.

• Low SES adults have levels of illness in their 30s and 40s that are not seen in the highest SES group until after the ages of 65-75.

Causes of death and median income of Zip Code area of residence in the men screened for MRFIT: relative risk for $10,000 lower

income RR > 1.50 RR 1.21-1.50 RR 1.00-1.20 RR < 1.00 AIDS Infection Aortic aneurysm Blood disease Diabetes Coronary Heart Suicide Motor neurone Disease disease Rheumatic Stroke Nervous system Flying accidents Heart Disease disease Heart failure Cirrhosis Oesophageal Lymphoma cancer COPD Genitourinary Stomach cancer Hodgkin’s disease disease Pneumonia/ SR Symptoms Pancreatic cancer Melanoma Influenza Homicide Accidents Prostate cancer Bone/connective tissue cancer Lung cancer Bladder cancer Liver cancer Kidney cancer Colorectal cancer Brain cancer Myeloma Leukaemia

Davey Smith (1996)

The Role of Segregation

Brian Smedley

Historical Overview of African Americans 1619-2005

Slavery

1640 - 1863

Reconstruction & Jim Crow

1863 - 1965

Post-Civil Rights 1965 - 2005

244 yrs = 63.2%

102 yrs = 26.4%

40 yrs = 10.4%

Biological determinism

“The Negro races stand at the lowest point in the scale of human beings…It is clear they are incapable of self-government and that any attempt to improve their condition is warring against an immutable force of nature.”

Dr. Josiah C. Nott, 1851 Source: Krieger, IJHS, 1987

SES and Race

• African Americans, Latinos, American Indians, and some Asian groups have lower levels of education, income, professional status, and wealth than whites. These differences in SES are a major reason for racial/ethnic differences in health.

• Education and income are generally more strongly associated with health status than race.

• Racial differences in health status decrease substantially when blacks and whites are compared at similar levels of SES.

Williams

Life Expectancy at Age 25, U.S. Men Race and Income Differences

Source: NLMS: Lin et al., 2003

Race Diffs.

Black White Family Income (1980 dollars) All 50.1 45.7 4.4

Williams

Source: NLMS: Lin et al., 2003

Race Diffs.

Black White Income (1980 dollars)

$25,000 or more

$10,000-$24,999

Less than $10,000

8.6 7.9

50.2

47.4 50.2

41.6 45.0

All

SES Diffs.

50.1 45.7 4.4

52.9

Life Expectancy at Age 25, U.S. Men Race and Income Differences

Williams

Source: NLMS: Lin et al., 2003

Race Diffs.

Black White Income (1980 dollars)

$25,000 or more

$10,000-$24,999

Less than $10,000

8.6 7.9

2.7 50.2

2.8 47.4 50.2

3.4 41.6 45.0

All

SES Diffs.

50.1 45.7 4.4

52.9

Life Expectancy at Age 25, U.S. Men Race and Income Differences

Williams

Race/Ethnicity and SES

• Race and SES are two related but not interchangeable systems of inequality

• In national data, the highest SES group of

African American women have equivalent or higher rates of infant mortality, low birth-weight, hypertension and overweight than the lowest SES group of white women

Williams

Infant Mortality Rates by Education Infants of mother > 20 yrs

White > 13 yrs education White HS grad

White < 12 yrs education

Black < 12 yrs education

Black > 13 yrs education

Infant Death Rates by Mother’s Education, 1995

Education Black White B/W Ratio

< High School 17.3 9.9 1.7

High School 14.8 6.5 2.3

Some College 12.3 5.1 2.4

College grad. + 11.4 4.2 2.7

Source: Health United States 1998. Non-Hispanic Mothers = 20 years of age and older.

Williams

74 Whitman

AMERICAN APARTHEID

“This extreme racial isolation did not just happen; it was manufactured by whites through a series of self-conscious actions and purposeful institutional arrangements that continue today.” (p 2)

AMERICAN APARTHEID

“If the escalating violence still failed to produce the desired results, the last step was dramatic and guaranteed to attract attention, not only of the homeowner but the entire black community: bombing. During and after World War I, a wave of bombings followed the expansion of black residential areas in cities throughout the north. In Chicago, fifty-eight black homes were bombed between 1917 and 1921, one every twenty days.” (p 35)

Share of children who experience double jeopardy: Live in BOTH poor families and poor neighborhoods

Source: Acevedo-Garcia, Osypuk, McArdle & Williams, 2008

Note: Poor neighborhoods are those with poverty rates over 20%. Source: 2000 Census.

Black/Hispanic Students Attend Schools with Dramatically Different Racial Compositions Than

Those of White Students (Percent of Students Attending Schools by Black/Hispanic Share of Enrollment: 2006-07)

Black/Hispanic Share of Enrollment Source: National Center for Education Statistics, Common Core of Data, 2006-07.

Negative Effects of Segregation on Health and Human Development

• Racial segregation concentrates poverty and excludes and isolates communities of color from the mainstream resources needed for success. African Americans are more likely to reside in poorer neighborhoods regardless of income level.

• Segregation also restricts socio-economic

opportunity by channeling non-whites into neighborhoods with poorer public schools, fewer employment opportunities, and smaller returns on real estate. Brian Smedley

Negative Effects of Segregation on Health and Human Development (cont’d)

• African Americans are five times less likely than whites to live in census tracts with supermarkets, and are more likely to live in communities with a high percentage of fast-food outlets, liquor stores and convenience stores

• Black and Latino neighborhoods also have

fewer parks and green spaces than white neighborhoods, and fewer safe places to walk, jog, bike or play, including fewer gyms, recreational centers and swimming pools

Brian Smedley

Negative Effects of Segregation on Health and Human Development (cont’d)

• Low-income communities and communities of color are more likely to be exposed to environmental hazards. For example, 56% of residents in neighborhoods with commercial hazardous waste facilities are people of color even though they comprise less than 30% of the U.S. population

• The “Poverty Tax:” Residents of poor

communities pay more for the exact same consumer products than those in higher income neighborhoods-– more for auto loans, furniture, appliances, bank fees, and even groceries

Brian Smedley

Map is from Woodstock Institute Corrects for foreclosures per 1,000 properties with a mortgage. Years looked at matter Previous charts 1999 – 2006 Looking at 2005 on yields higher increases

FORECLOSURE CRISIS

The Pervasiveness of Racial Disparities

• Hispanics, American Indians and Asian Americans have lower death rates than whites for the three leading causes of death (60% of all deaths).

• Hispanics have higher death rates than whites for diabetes, liver cirrhosis and homicide.

• American Indians have higher death rates than whites for diabetes, liver cirrhosis, accidents and suicides.

• Between 1955 and 1993 the gap in health between American Indians served by the IHS and whites remained large for causes of death such as accidents, homicide, T.B. and alcoholism and increased for others such as diabetes, liver cirrhosis and suicide.

- NCHS

Race Still Matters

1. All indicators of SES are non-equivalent across race.

Compared to whites, blacks receive less income at the same levels of education, have less wealth at the equivalent income levels, and have less purchasing power (at a given level of income) because of higher costs of goods and services.

2. Health is affected not only by current SES but by exposure to social and economic adversity over the life course.

3. Personal experiences of discrimination and institutional racism is an added pathogenic factor that can affect the health of minority group members in multiple ways.

Why race matters after adjustment for SES

Williams

Conclusions • There are large and persistent racial/ethnic

differences in health • SES is a major contributor to racial disparities

in health • Race still matters for health when SES is

considered • SES is one of the strongest known

determinants of Health. • Efforts to improve health require addressing

the broad determinants of health that are embedded in living and working conditions.

Williams

The Bottom-Line

Policies to reduce inequalities in health must address

fundamental non-medical determinants.

Williams

Pittsburgh Post-Gazette, 1999

Diabetes rates by race and ethnicity

www.cdc.gov/diabetes

Whites

Hispanics (overall) Asian

Specific AN/AI Alaska Natives/American Indians Blacks

Specific Hispanic groups

Ethnicity and Analgesia A chart review of 139 patients with isolated long-bone fracture

at UCLA Emergency Department (ED): • All patients aged 15 to 55 years, had the injury within 6

hours of ER visit, had no alcohol intoxication. • 55% of Hispanics received no analgesic compared to 26%

of non-Hispanic whites. • With simultaneous adjustment for sex, primary language,

insurance status, occupational injury, time of presentation, total time in ED, fracture reduction and hospital admission, Hispanic ethnicity was the strongest predictor of no analgesia.

• After adjustment for all factors, Hispanics were 7.5 times more likely than non-Hispanic whites to receive no analgesia.

Todd, et al. 1993

Avoiding the Life-Style Trap • Lifestyle choices are heavily structured

by life circumstances • Lifestyle choices by themselves

account for modest proportions of health status

• Lifestyle choices are difficult to change without considering life contexts

• Lifestyle choice emphases can have unintended side-effects that work against health

Ten Tips For Better Health - Donaldson, 1999 1. Don't smoke. If you can, stop. If you can't, cut down. 2. Follow a balanced diet with plenty of fruit and vegetables. 3. Keep physically active. 4. Manage stress by, for example, talking things through

and making time to relax. 5. If you drink alcohol, do so in moderation. 6. Cover up in the sun, and protect children from sunburn. 7. Practice safer sex. 8. Take up cancer screening opportunities. 9. Be safe on the roads: follow the Highway Code. 10. Learn the First Aid ABC : airways, breathing,

circulation.

Ten Tips for Staying Healthy - Dave Gordon, 1999.

1. Don't be poor. If you can, stop. If you can't, try not to be poor for long.

2. Don't have poor parents. 3. Own a car. 4. Don't work in a stressful, low paid manual job. 5. Don't live in damp, low quality housing. 6. Be able to afford to go on a foreign holiday and sunbathe. 7. Practice not losing your job and don't become unemployed. 8. Take up all benefits you are entitled to, if you are

unemployed, retired or sick or disabled. 9. Don't live next to a busy major road or near a polluting factory. 10. Learn how to fill in the complex housing benefit/ asylum

application forms before you become homeless and destitute.

Cheap ingredients mean larger portion sizes & more calories

Source: Jackson, R. (2009) Jour Hunger & Environmental Nutrition vol 4 p. 393

Sustainable Food System Model

Source: 2007 ADA Primer on Sustainable Food: Healthy Land, Healthy People

How did we get in this mess ??? And what can we do about it ? 1. Where do health

differences among social groups originate, if we trace them back to their deepest roots ?

2. What pathways lead from root causes to the stark differences in health status observed at the population level ?

3. In the light of the answers to the first two questions, where and how should we intervene to reduce health inequities.

Questions from CSDH Framework 2007 version WHO

Key Tenets of Neo-liberalism • Markets are the most efficient allocators of

resources in production and distribution; • Societies are composed of autonomous

individuals (producers and consumers) motivated chiefly by material or economic considerations;

• Competition is the major market vehicle for innovations

Coburn, D. (2000), Social Science and Medicine.

What should we do ?

• A focus on prevention, particularly on the conditions in which people live, work, play, and study

• Multiple strategies across sectors

• Sustained investment and a long-term policy agenda

• Place-based Strategies: Investments in Communities

Overarching Principles • Improve daily living conditions

– The circumstances in which people are born, grow, live, work and age

• Tackle Inequitable Distribution of Power, Money and Resources – The structural drivers of those

conditions of daily life – globally, nationally, and locally

• Measure and understand the problem and assess the impact of action – Expand knowledge base, develop a

workforce trained in social determinants of health, raise public awareness about the social determinants of health

SDOH and their Public Policy Determinants

• early life – income supports, progressive family policy, availability of childcare, support services

• education – support for literacy, public spending, tuition policy

• employment and working conditions – active labour policy, support for collective bargaining, increasing worker control

• food security – income and poverty policy, food policy, housing policy

• health services – public spending, access issues, integration of services

SDOH and their Public Policy Determinants

• housing – income and housing policy, rent controls and supplements, provision of social housing

• income and income distribution – taxation policy, minimum wages, social assistance, social assistance levels, family supports

• social exclusion – anti-discrimination laws and enforcement, ESL and job training, approving foreign credentials, support of a variety of other health determinants

• social safety net – spending on a wide range of welfare state areas

• unemployment – active labour policy, replacement benefits, labour legislation

Reducing Inequalities Address Underlying Determinants of Health- I

• Improve living standards for poor persons and households

• Increase access to employment opportunities

• Increase education and training that provide basic skills for the unskilled and better job ladders for the least skilled

• Invest in improved educational quality in the early years and reduce educational failure

Williams

Reducing Inequalities Address Underlying Determinants of Health- II

• Improve conditions of work, re-design workplaces to reduce injuries and job stress

• Enrich the quality of neighborhood environments and increase economic development in poor areas

• Improve housing quality and the safety of neighborhood environments

Williams

Reducing Inequalities Health Care

• Improve access to care and the quality of care • Give emphasis to the prevention of illness • Provide effective treatment • Develop incentives to reduce inequalities

in the quality of care

Williams

Social Justice & Health

“ Rarely do we find men who are willing to engage in hard, solid thinking. There is an almost universal quest for easy answers and half baked solutions. Nothing pains some people more than having to think. “

Rev. Martin Luther King Jr.