health equity: the evolution of public health practice in the 21 st century december 4, 2013
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Health Equity: The Evolution of Public Health Practice in the 21 st Century December 4, 2013 Rex Archer, MD MPH Director of Health Kansas City, Missouri. Saving Lives, Protecting People from Health Threats, Saving Money through Prevention. - PowerPoint PPT PresentationTRANSCRIPT
Health Equity:The Evolution of Public Health
Practice in the 21st CenturyDecember 4, 2013
Rex Archer, MD MPH
Director of Health
Kansas City, Missouri
Saving Lives, Protecting People from Health Threats,
Saving Money through Prevention
“Public health is what we, as a society, do collectively through organized actions to assure the conditions in
which all people can be healthy.”
-Institute of Medicine (1988), Future of Public Health
“Show-Me” Health
Overall National Rank 2012: 422011 Rank: 40 1990 Rank 24
"The reason we have government is to solve
problems collectively that we can not solve
individually."Dr. Thomas Farley, NYC Health Commissioner (from
the HBO May, 2012 Documentary, "Weight of the Nation"
Saving Lives, Protecting People from Health Threats,
Saving Money through Prevention
Zip Code*
Life expectancy(years)
Zip Code*
Life expectancy(Years)
64158 85 64108 7664112 83 64110 7664113 83 64111 7664156 83 64131 7664157 83 64133 7664151 82 64124 7564152 81 64134 7564153 81 64129 7464154 81 64123 7364114 79 64145 7364117 79 64106 7164118 79 64127 7164155 79 64109 7064116 78 64128 7064119 78 64132 7064137 78 64130 6964138 78
Life Expectancy by Zip Code, Kansas City, MO, 2008-2009
*Zip codes with population >5,000 people.
10-16 years difference
Life expectancy by zip code, Kansas City, MO 2008-2009
Life expectancy Nonwhite
Below poverty,
Median household
(year) % % income ($)81-85 years 14.1 7.3 76,92873-79 years 35.1 20.5 46,24169-71 years 83.5 39.0 23,363
Life expectancy
81-85 years
73-79 years
69-71 years
Too small pop.*
*Too small population to calculate life expectancy
64153 64154 64156
64163
64155
6411964151
64134
64129
64120
64157
64161
64132
64138
64149
64116
64130
64137
64117
64118
64160
64164
64139
64127
64165
64133
64108
64133
64128
64147
64118
6413164114
64146
64136
64145
64133
64110
64111
64113
6415864152
64109
64126
64079
64106
64166
64112
6412464123
64125
64012
64152
6410564101
64102
64167
64030
64079
64081
64079
64152
Longest and Shortest Life Expectancy Area by Zip Code, KCMOLongest and Shortest Life Expectancy Area by Zip Code, KCMO
Longest life expectancy
Shortest life expectancy
4zipcodes area has 55,846 residents5zipcodes area has 46,162 residentsKansas city, MO has 459,787 residents
64153
64163
64154 6415664155
64119
64134
64151
64129
64157
64120
64161
64132
64149
6413864131
64116
64130
64117 64160
64137
64136
64118
64164
64139
64127
64147
64165
64133
64108
64133
64128
64158
64118
64114
6414664145
64133
64110
64111
64113
64152
64109
64126
64106
64112
64166
6412364124 6412564105
64152
6410164102
64167
Leading Causes Crude Mortality Rates in Two Areas, CMO 2005-2009
4zipcodes include zip code 64109, 64128, 64130, 64132, which are the shortest life expectancy; 5zipcodes include zip code 64112, 64113, 64156, 64157, and 64158, which are the longest life expectancy.
1. INTERRUPT TRANSMISSION
How Are Epidemics Reversed?
3. CHANGE COMMUNITY NORMS
2. BEHAVIOR CHANGE
The Cure Violence / Aim4Peace The Cure Violence / Aim4Peace Model to Stop Shootings and Model to Stop Shootings and KillingsKillings
Identification and Detection
Change Behaviors and
Norms
Interruption, Intervention and Risk Reduction
Data and Monitoring
Image: Neil SladeImage: Neil Slade
Interrupt Transmission: Interrupt Transmission: AngerAnger
Prepared by: T.ColePrepared by: T.Cole
Exhibit AEPD Sector 330 – Yellow EPD Sectors 320 & 340 - Grey
Prepared by: T.ColePrepared by: T.Cole
Aim4Peace is not a silver bullet… We are focused on prevention of gun-related violence that is primarily related to arguments and retaliation in targeted areas of East Patrol, but we seek to expand to the entire Kansas and
Missouri Region.
A4P Current Target Zone: Kansas City Police Sector 330 (Beat 324 is of keen interest. We monitor, without proper staffing level.)
2010 (Jan-Dec)
2011 (Jan-Dec)
2012 (Jan-Dec)
diff % change 2013 (Jan-Dec 1, 2013)
diff % change
331 0 4 3 -1 -25% 2 -1 -33%332 6 3 7 4 133% 1 -6 -86%333 0 5 2 -3 -60% 0 -2 -100%334 8 3 4 1 33% 3 -1 -25%
14 15 16 1 7% 6 -10 -63%
324 4 7 4 -3 -100% 1 -3 -75%
January – October 2013 January – October 2013 ResultsResults
Prepared by: T.ColePrepared by: T.Cole
Conflict Mediations by KCPD Sector
Sector 110 1
Sector 140 1
Sector 210 1
Sector 320 7
Sector 330 31
Other 6
A4P Current Target Zone: Kansas City Police Sector 330
Provide Alternatives to violence:• 47 Conflicts mediated• 34 Dispute intakes (calls for service)
Annualized infant mortality rates by zip code median family income, KCMo, 2003-2007
Saving Lives, Protecting People from Health Threats,
Saving Money through Prevention
Kansas City’s Geography of Health Inequity
16
Source: Map produced by and data derived from the Kansas City Health Department,
2010 Community Health Assessment
Saving Lives, Protecting People from Health Threats,
Saving Money through Prevention
Fam
ily
&
C
ult
ure
Fam
ily
&
C
ult
ure
Health Inequities
Health Disparities
Fam
ily
&
C
ult
ure
PlacePolicyNarrative
POWER
Health System Dynamics
Safer,Healthier
Population
VulnerablePopulation
Becomingvulnerable
Becoming nolonger vulnerable
Afflictedwithout
ComplicationsBecomingafflicted
Afflicted withComplications
Developingcomplications
Dying fromComplications
Presented by: Jeanne F. Ayers, Minnesota Department of Health - Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Syndemics Prevention Network, Centers for Disease Control and Prevention; April 15, 2008. Available at: http://www.cdc.gov/syndemics/monograph/index.htm
Safer,Healthier
Population BecomingVulnerable
Becoming nolonger vulnerable
VulnerablePopulation Becoming
Afflicted
Afflictedwithout
Complications DevelopingComplications
Afflicted withComplications
Targetedprotection
Primaryprevention
Secondaryprevention
Dying fromComplications
Tertiaryprevention
Society's HealthResponse
Generalprotection
Adverse LivingConditions
World of Providing…
• Education• Screening• Disease management • Pharmaceuticals• Clinical services• Physical and financial access• Etc…
Medical and Public Health Policy
DISEASE AND RISK MANAGEMENT
World of Transforming…
• Deprivation• Dependency• Violence• Disconnection• Environmental decay• Stress• Insecurity• Etc…
By Strengthening…
• Leaders and institutions• Foresight and precaution• The meaning of work• Mutual accountability• Plurality• Democracy• Freedom• Etc…
Healthy Public Policy & Public Work
DEMOCRATIC SELF-GOVERNANCE
Presented by: Jeanne F. Ayers, Minnesota Department of Health - Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Syndemics Prevention Network, Centers for Disease Control and Prevention; April 15, 2008. Available at: http://www.cdc.gov/syndemics/monograph/index.htm
Areas of Emphasis
Refocusing Upstream
Seeing a Wider Set of Relationships
Health
LivingConditions
Capacity toAct
Centers for Disease Control and Prevention, Bobby Milstein
Power
• Ability to act or produce an effect
Arena’s of Power
• Directly impacting decision makers
• Developing deeper relationships and aligning interests
• Consciously shifting the narrative
Latinos/Hispanics in Kansas City, Missouri2001-2010
Hispanic Population, 2000 and 2010Distribution of Hispanic population, by age, Kansas City, Missouri, 2000 and 2010
2000 2010
Age (Years) HispanicPercent Hispanic
All Races HispanicPercent Hispanic
All Races
0-4 3,615 11.4% 31,755 6,009 17.4% 34,557
5-9 3,015 9.5% 31,829 5,969 19.3% 30,874
10-14 2,447 8.0% 30,770 4,700 16.5% 28,566
15-19 2,465 8.5% 29,053 3,948 13.6% 28,931
20-24 3,237 10.2% 31,590 3,556 10.4% 34,043
25-34 6,092 8.4% 72,393 8,975 11.9% 75,490
35-44 4,226 5.9% 71,309 6,731 11.0% 60,956
45-54 2,549 4.5% 56,492 5,386 8.3% 64,947
55-64 1,326 3.8% 34,662 2,330 4.6% 50,717
65-74 1,001 3.7% 27,163 1,364 5.1% 26,701
75+ 631 2.6% 24,529 832 3.5% 24,005
Total 30,604 6.9% 441,545 49,800 10.8% 459,787
Hispanic Males, 2000 and 2010Distribution of Hispanic men, by age, Kansas City, Missouri, 2000 and 2010
2000 2010
Age (Years) HispanicPercent Hispanic
All Races HispanicPercent Hispanic
All Races
0-4 1,876 11.6% 16,105 3,333 19.0% 17,570
5-9 1,550 9.6% 16,219 3,109 19.8% 15,703
10-14 1,280 8.1% 15,807 2,454 16.9% 14,525
15-19 1,370 9.4% 14,578 2384 16.5% 14,420
20-24 1,859 12.2% 15,284 1,549 9.5% 16,277
25-34 3,435 9.5% 36,079 4,445 12.0% 37,191
35-44 2,358 6.6% 35,498 3,359 11.0% 30,564
45-54 1,368 5.0% 27,154 2,946 9.2% 32,073
55-64 652 4.0% 16,185 1,324 5.5% 23,997
65-74 449 3.8% 11,671 863 7.2% 11,943
75+ 257 3.0% 8,561 280 3.1% 8,920
Total 16,454 7.7% 213,141 26,046 11.7% 223,183
Hispanic Females, 2000 and 2010Distribution of Hispanic women, by age, Kansas City, Missouri, 2000 and 2010
2000 2010
Age (Years) HispanicPercent Hispanic
All Races HispanicPercent Hispanic
All Races
0-4 1,739 11.1% 15,650 2,676 15.8% 16,987
5-9 1,465 9.4% 15,610 2,860 18.9% 15,171
10-14 1,167 7.8% 14,963 2,246 16.0% 14,041
15-19 1,095 7.6% 14,475 1564 10.8% 14,511
20-24 1,378 8.5% 16,306 2,007 11.3% 17,766
25-34 2,657 7.3% 36,314 4530 11.8% 38,299
35-44 1,868 5.2% 35,811 3,372 11.1% 30,392
45-54 1,181 4.0% 29,338 2,440 7.4% 32,874
55-64 674 3.6% 18,477 1,006 3.8% 26,720
65-74 552 3.6% 15,492 501 3.4% 14,758
75+ 374 2.3% 15,968 552 3.7% 15,085
Total 14,150 6.2% 228,404 23,754 10.0% 236,604
BirthsHispanic births, Kansas City, Missouri, 2001-2010
Year Hispanic Percent Hispanic All Ethnicities2001 997 13.6% 7,3452002 1,015 13.8% 7,3572003 1,152 15.7% 7,3452004 1,282 17.2% 7,4422005 1,271 16.8% 7,5822006 1,258 16.0% 7,8662007 1,324 16.5% 8,0232008 1,231 15.7% 7,8502009 1,092 14.1% 7,7582010 1,032 13.9% 7,429Total 11,654 15.3% 75,997
DeathsHispanic deaths, Kansas City, Missouri, 2001-2010
Year Hispanic Percent Hispanic All Ethnicities2001 100 2.6% 3,8962002 112 2.9% 3,8402003 117 3.1% 3,7422004 123 3.3% 3,7452005 113 3.0% 3,7842006 112 2.9% 3,8092007 128 3.4% 3,7212008 103 2.6% 3,9032009 82 2.3% 3,6092010 103 2.8% 3,643Total 1,093 2.9% 37,692
Poverty and incomePoverty and income, by race and ethnicity, 2007-2011, Kansas City, Missouri, American Community Survey
Families living in poverty (n (%))
Households receiving food stamps (n(%))
Mean per capita income (in
dollars)
White 5,664 7.64% 10,059 35.92% $30,033
Black or African American 8,547 35.43% 15,051 53.74% $21,258
American Indian and Alaska Native
79 189 0.67% $15,999
Asian 347 15.77% 496 1.77% $ 24,707
Native Hawaiian and Other Pacific Islander
66 98 0.35% $11,024
Hispanic or Latino origin (of any race)
2,357 31.21% 2,618 9.35% $20,151
White alone, not Hispanic or Latino
4,558 6.52% 8,745 31.22% $31,048
LanguageLanguages spoken at home, Kansas City, Missouri, 2007-2011, American Community Survey
Number Percent
Population 5 years and over
511,606 92.77
English only 456,566 89.24
Language other than English
55,041 10.76
Speak English less than "very well"
23,836 43.31
Spanish 32,479 6.35
Speak English less than "very well"
15,185 46.75
Expansion of Medicaid coverage reduces mortality among adults
Benjamin D. Sommers DB et al. Mortality and Access to Care among Adults after State Medicaid Expansions. N Engl J Med 2012; 367:1025-1034
176 insured to prevent one death per year
For every 10M more insured, ~57,000 lives saved per year
For every 300,000additional Missouriansinsured by Medicaid
~1,700 lives saved per year
~150 KCMO lives Saved per year
Questions?
Your Nationally Accredited
Kansas City, Mo., Health Department
Improving Service.Protecting People. Saving Lives.
POPULATION APPROACH VS. INDIVIDUAL APPROACH
Public Health As A Social Justice Enterprise
JUSTICE = TRUTH + POWER
Public Health Practice Research + Data
Community Organizing
=
Of all the forms of inequality, injustice in health is the
most shocking and inhumane.-- Martin Luther King, Jr.
Presentation at: The Second National Convention of the Medical Committee for Human Rights;
March 25, 1966; Chicago, IL.
In U.S., Latinos outlive In U.S., Latinos outlive whites by 2 1/2 years whites by 2 1/2 years
CDC's report on life CDC's report on life expectancy yields expectancy yields surprising resultssurprising results
--Associated Press 10-13-10Associated Press 10-13-10
January – October 2013 January – October 2013 ResultsResults
Prepared by: T.ColePrepared by: T.Cole
A4P Current Target Zone: Kansas City Police Sector 330
Indicator Quarterly Data
Quarterly Data
May June July Q1 (May-July)
August September October Q2 (Aug - Oct)
Aim4Peace (street conflict) mediations 5 2 6 13 2 1 4 7
Number of community changes in intermediary measures to assess how Aim4Peace Program is contributing to overall change in the zone
3 1 2 6 3 2 1 7
Number of participants and pre-participants who received case management services through the Aim4Peace Program
87 65 68 220 55 51 53 159
Number of contacts with participants and pre-participants (target is 4 contacts per participant) 117 301 332 750 294 172 214 680
Percent of participants who are high risk 100% 93% 87% 93.3% 84% (26/31) 84% (27/32) 84%
(27/32)84%
(26.7/31.7)
ExamplesCondoms, eat healthy, be physically active
Rx for high blood pressure, high cholesterol
Poverty, education, housing, inequality
Immunizations, brief intervention, cessation treatment, colonoscopy
Fluoridation, 0g trans fat, iodization, smoke-free laws, tobacco tax
Religious, moral teachings, beliefs
LargestImpact
SmallestImpact
Contributory (Social) Justice
Changing the Contextto make individuals’ default
decisions healthy
Long-lasting Protective Interventions
ClinicalInterventions
Counseling & Education
Socioeconomic Factors
Factors that Affect Health
Frieden, Archer
Population and EmploymentPopulation and employment by race/ethnicity, Kansas City, Missouri, 2007-2011, American Community Survey
Population (n (%)) Adults in labor force (n (%)) Unemployed (n (%))
Total population 551,464
One race 534,651 96.95%
White 357,905 64.90% 205,826 57.51% 18,399 10.94%
Black or African American
142,617 25.86% 69,840 48.98% 19,539 32.10%
American Indian and Alaska Native
2,265 0.41% 1,267 55.94% 183 18.90%
Asian 13,005 2.36% 7,247 55.73% 639 10.82%
Native Hawaiian and Other Pacific Islander
1,074 0.19% 435 40.50% 14 3.99%
Hispanic or Latino origin (of any race)
48,866 8.86% 23,480 48.05% 3,978 18.40%
White alone, not Hispanic or Latino
331,709 60.15% 192,997 58.18% 16,702 10.67%