public health in philadelphia: economics, health and ... health in philadelphia: economics, health...

Public Health in Public Health in Philadelphia:Philadelphia:Economics, Health and Economics, Health and

DisparitiesDisparitiesDonald F. Schwarz, MD, MPHDonald F. Schwarz, MD, MPHDeputy Mayor for Health and Deputy Mayor for Health and

Opportunity and Health CommissionerOpportunity and Health CommissionerCity of PhiladelphiaCity of Philadelphia

OverviewOverview

Interlocking cycles of disadvantage Interlocking cycles of disadvantage Education and opportunityEducation and opportunityHealth and disparitiesHealth and disparitiesProgress Progress Economic crisisEconomic crisisWhere to go from here Where to go from here

Interlocking Cycles of Disadvantage

Interlocking Cycles of DisadvantageInterlocking Cycles of Disadvantage

Unemployment

Poverty

Population Loss

Health

Education

Crime

Manufacturing Workers -1980

Unemployment Rate - 1980

U.S. EmploymentU.S. EmploymentNonNon--farm, average monthly changefarm, average monthly change

9000-35000

-51000-4000

-40000-16000

3000-3000

-17000-27000

25000-17000

60009000

-60000 -40000 -20000 0 20000 40000

Government

Other services

Leisure and hospitality

EDUCATION AND HEALTH SERVICES

Professional and business services

Financial activities

Information

Utilities

Transportation and warehousing

Retail trade

Wholesale trade

Manufacturing

Construction

Natural resources and mining

Source: Bureau of Labor Statistics, Current Employment Statistics Survey, Oct 3, 2008.

Annual Unemployment Rate 1990-2008

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

Perc

enta

ge in

Pov

erty

National Rate PA Rate Philadelphia Rate

ClintonBushBush

Source: US Bureau of the Census, Annual Population Survey, 2008.

Top 10 Most Populous CitiesTop 10 Most Populous CitiesUnemployment, 2007Unemployment, 2007

0

1

2

3

4

5

6

Percent Unemployed

City

PhoenixSan AntonioHoustonDallasSan DiegoNew YorkSan JoseChicagoLos AngelesPhiladelphia

U.S. Bureau of the Census, Annual Population Survey, 2008.

Health Care EmploymentHealth Care EmploymentMonthlyMonthly Change in Growth Rates, 2007 Change in Growth Rates, 2007 vsvs 20082008

-1900

-1200

-1600

-1300

-7700

-4200

-10000 -8000 -6000 -4000 -2000 0

Nursing and Residential Care

Hospitals

Home Health Care Services

Outpatient Care Centers

Offices of Physicians

Ambulatory Health Care Services

Source: Bureau of Labor Statistics, Current Employment Statistics Survey, Oct 3, 2008.

Health Care as a Percent of GNPHealth Care as a Percent of GNP

% Population in Poverty - 1980

U.S. vs. Philadelphia Poverty RateU.S. vs. Philadelphia Poverty Rate

25.123.8

20.2

0.0

5.0

10.0

15.0

20.0

25.0

30.0

1969

1973

1977

1981

1985

1989

1993

1997

2001

2005

Perc

en

tag

e

PhiladelphiaPoverty RateNational PovertyRate

Top 10 CitiesTop 10 Cities’’ Poverty RatePoverty Rate

0

5

10

15

20

25

Percent in poverty

City

San JoseSan DiegoPhoenixSan AntonioNew YorkChicagoLos AngelesHoustonDallasPhiladelphia

U.S. Bureau of the Census, Annual Population Survey, 2008.


Unemployment

Poverty

Population Loss

Health

Education

Crime

Rate of Population Change: 1980 - 1990

-10

-5

0

5

10

15

20

25

30

35

40

1970-1980 1980-1990 1990-2000

Perc

enta

ge C

hang

e

Native-Born Black Native-Born White Foreign Born

Philadelphia: Impact of ImmigrationPhiladelphia: Impact of Immigration

Source: Katz M, Philadelphia Migration Project; from U.S. Census, 2000.

-30

-20

-10

0

10

20

30

40

50

1970-1980 1980-1990 1990-2000Perc

enta

ge C

hang

e

Foreign Born Native-Born

Philadelphia: Impact of ImmigrationPhiladelphia: Impact of ImmigrationAge 20Age 20--30 Years30 Years

Source: Katz M, Philadelphia Migration Project; from U.S. Census, 2000.

Philadelphia BirthsPhiladelphia BirthsRace/EthnicityRace/Ethnicity

0

2000

4000

6000

8000

10000

12000

14000

1996 1998 2000 2002 2004 2006

WhiteBlackAsianHispanic

10 Largest U.S. Cities10 Largest U.S. CitiesRankRank 19601960 2007200711 New York CityNew York City New York CityNew York City22 ChicagoChicago Los AngelesLos Angeles33 Los AngelesLos Angeles ChicagoChicago44 PhiladelphiaPhiladelphia HoustonHouston55 DetroitDetroit PhoenixPhoenix66 BaltimoreBaltimore PhiladelphiaPhiladelphia77 HoustonHouston San AntonioSan Antonio88 ClevelandCleveland San DiegoSan Diego99 Washington, DCWashington, DC DallasDallas1010 St. LouisSt. Louis San JoseSan Jose

Philadelphia BirthsPhiladelphia Births19601960--20062006

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

50000

1960

1962

1964

1966

1968

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

Births

0

5

10

15

20

25 Births Per 1,000

Births Birth Rate

Source: City of Philadelphia, Vital Statistics Reports

PhiladelphiaPhiladelphiaInfant Mortality RateInfant Mortality Rate

0

5

10

15

20

25

30

35

1960

1963

1966

1969

1972

1975

1978

1981

1984

1987

1990

1993

1996

1999

2002

2005

2008

Dea

ths

per 1

,000

live

birt

hs


Philadelphia Child PopulationPhiladelphia Child Population

020,00040,00060,00080,000

100,000120,000140,000160,000

1981 1986 1991 1996 2001 2006

0-4 years 5-9 years 10-14 years 15-19 years

Philadelphia Philadelphia Elder:ChildElder:Child RatioRatio

0

0.1

0.2

0.3

0.4

0.5

0.6

1981 1986 1991 1996 2001 2006

Pers

ons

65+/

Birt

h-19

yea

rs

Education and Opportunity


Unemployment

Poverty

Population Loss

Health

Education

Crime

Philadelphia Reading AchievementPhiladelphia Reading AchievementThird GradersThird Graders

0%10%20%30%40%50%60%70%80%90%

100%

2005 2006 2007 2008

Perc

enta

ge

Advanced or Proficient Basic Below Basic

51.6%

48.4%

Source: School District of Philadelphia, 2008.

Philadelphia Reading AchievementPhiladelphia Reading AchievementEleventh GradersEleventh Graders

0%10%20%30%40%50%60%70%80%90%

100%

2002 2003 2004 2005 2006 2007 2008

Perc

enta

ge

Advanced or Proficient Basic Below Basic

62.6%

37.4%


Household Income by Educational AttainmentHousehold Income by Educational AttainmentPhiladelphia, 2007Philadelphia, 2007

$19,172$25,647

$32,067

$41,859

$53,826

$31,056

$0

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

Hou

seho

ld E

arni

ng <HSHS Grad/GEDSome Coll/AssocBachelorsGraduate DegreeAll

U.S. Census Bureau, American Community Survey, 2007.

Unemployment by Educational AttainmentUnemployment by Educational AttainmentPhiladelphia, 2007Philadelphia, 2007

14%

10%

8%

4%

8%

0%

2%

4%

6%

8%

10%

12%

14%

Perc

ent U

nem

ploy

ed

<HSHS Grad/GEDSome Coll/AssocBachelorsAll


Poverty Rate by Educational AttainmentPoverty Rate by Educational AttainmentPhiladelphia, 2007Philadelphia, 2007

33%

18%

14%

8% 7%

0%

5%

10%

15%

20%

25%

30%

35%

Perc

ent P

oor <HS

HS Grad/GEDSome Coll/AssocBachelorsGraduate Degree


Philadelphia Reading ProficiencyPhiladelphia Reading ProficiencyAll GradesAll Grades

0%10%20%30%40%50%60%70%80%90%

100%

White Black Latino Asian

Basis/Below BasicAdvanced/Proficient

60% 62%


Health and Disparities

Infant MortalityInfant MortalityDeaths before 1 year per 1,000 live birthsDeaths before 1 year per 1,000 live births

0

5

10

15

20

25

30

1986 1991 1996 2001 2006U.S.PA

PhilaW. Phila

Source: City of Philadelphia, Vital Statistics Reports: Centers for Disease Control, Vital Statistics.

U.S. Infant Mortality Rates by CityU.S. Infant Mortality Rates by City

02468

10121416

Detroit

Baltim

ore DCNOLA

Philadelp

hiaChica

goHousto

nNYC LA

1996-19992000-2004

Philadelphia, 1961Philadelphia, 1961--20062006Infant Mortality RateInfant Mortality Rate

05

101520253035404550

1961 1966 1971 1976 1981 1986 1991 1996 2001 2006

WHITEBLACK

Inadequate Prenatal CareInadequate Prenatal CarePercent of births with third trimester or no carePercent of births with third trimester or no care

0

5

10

15

20

1986 1991 1996 2001 2006U.S.PennsylvaniaPhiladelphiaWest Phila

Source: City of Philadelphia, Vital Statistics Reports: Centers for Disease Control, Vital Statistics

Philadelphia BirthsPhiladelphia BirthsPoor Prenatal Care and Low Poor Prenatal Care and Low

BirthweightBirthweight

02468

1012141618

1960

1963

1966

1969

1972

1975

1978

1981

1984

1987

1990

1993

1996

1999

2002

2005

2008

Perc

enta

ge o

f Birt

hs

Low Birthweight Late or No Prenatal Care


Homicide RatesHomicide RatesDeaths per 100,000 PopulationDeaths per 100,000 Population

05

10152025303540

1986 1991 1996 2001 2006U.S.PA

PhilaW. Phila


Philadelphia, 1961Philadelphia, 1961--20062006Homicide, 15Homicide, 15--19 Year Old Males19 Year Old Males

050

100150200250300350400

1961 1966 1971 1976 1981 1986 1991 1996 2001 2006

WHITE NON-WHITE

Gonorrhea RatesGonorrhea RatesReported cases per 100,000 populationReported cases per 100,000 population

0200400600800

100012001400

1986 1991 1996 2001 2006U.S.PA

PhilaW. Phila


Syphilis RatesSyphilis RatesReported Cases per 100,000 populationReported Cases per 100,000 population

050

100150200250300350400450

1986 1991 1996 2001 2006U.S.PA

PhilaW. Phila


Malignant Malignant NeoplasmsNeoplasmsDeaths per 100,000 PopulationDeaths per 100,000 Population

0

50

100

150

200

250

300

1986 1991 1996 2001 2006U.S.PA

PhilaW. Phila


Philadelphia, 1961Philadelphia, 1961--20062006Child Mortality, Ages 5Child Mortality, Ages 5--9 Years9 Years

0

10

20

30

40

50

60

1961 1966 1971 1976 1981 1986 1991 1996 2001 2006

WHITEBLACK

Progress

PhiladelphiaPhiladelphiaLead PoisoningLead Poisoning

0

5

10

15

20

25

30

35

40

45

50

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Percent venous lead >10 ug/dl

0

100

200

300

400

500

600

700Properties Abated


Completed Early Childhood ImmunizationCompleted Early Childhood ImmunizationU.S. Cities and States, 2007U.S. Cities and States, 2007

0

10

20

30

40

50

60

70

80

4:3:1:3:3:1:4

New YorkLost AngelesChicagoHoustonPhiladelphiaDallas3-D Column 7TexasCaliforniaArizona

Source: Centers for Disease Control, US National Immunization Survey

Infant/Toddler Early InterventionInfant/Toddler Early Intervention

0500

1,0001,5002,0002,5003,0003,5004,0004,5005,000

Number

FY2003 FY2004 FY2005 FY2006 FY2007

ReferralsActive

Source: Office of Mental Retardation Services, Philadelphia, 2008.

Economic Crisis

U.S. Average Income Over the Past Century

Differential Spending on ChildrenDifferential Spending on Children

Source: Pati S, Keren R, Alessandrini EA, Schwarz DF, Generational Differences In U.S. Public Spending, 1980-2000, Health Affairs, Vol 23, Issue 5, 131-141.Copyright ©2004 by Project HOPE, all rights reserved.

Source: Pati S, Keren R, Alessandrini EA, Schwarz DF, Generational Differences In U.S. Public Spending, 1980-2000, Health Affairs, Vol 23, Issue 5, 131-141.

Differential Spending on ChildrenDifferential Spending on Children

Copyright ©2004 by Project HOPE, all rights reserved.

Worldwide Stock Market DeclinesWorldwide Stock Market DeclinesAugust 1 August 1 –– October 24, 2008October 24, 2008

-60%-50%-40%-30%-20%-10%

0%

Percent Loss

Buenos Aires Hong Kong Tokyo ParisZurich Cairo Tel Aviv New York

-28%

Philadelphia Financial ProjectionsPhiladelphia Financial ProjectionsOctober, 2008October, 2008

($900,000)($800,000)($700,000)($600,000)($500,000)($400,000)($300,000)($200,000)($100,000)

$0$100,000$200,000

City Fund Balance

FY08 FY09 FY10 FY11 FY12 FY 13

Health and Opportunity BudgetsHealth and Opportunity BudgetsCouncilCouncil--Approved, General Fund, FY09Approved, General Fund, FY09

$16$39

$40

$40$61

$122

$14

Behavioral Health Fairmount Park RecreationFree Library Supportive Housing Human ServicesPublic Health

Total General Fund: $332 Million

$ Million

Source: City of Philadelphia, Budget, FY 2009.

Health and Opportunity BudgetsHealth and Opportunity BudgetsCouncilCouncil--Approved, Grants and Contracts,FY09Approved, Grants and Contracts,FY09

$49

$572

$80$8$58

$16

$1,40

0

Behavioral Health Fairmount Park Free LibraryHuman Services Public Health RecreationSupportive Housing

Total grants andcontracts: $2.183 Billion

$ Million


Health and Opportunity BudgetsHealth and Opportunity BudgetsGeneral Fund vs. State/Federal, FY09General Fund vs. State/Federal, FY09

$16

$39 $40$40

$61

$122

$49

$8 $16$58

$572

$80

$14

$1,400

0%10%20%30%40%50%60%70%80%90%

100%

Behav

ioral H

ealth

Fairmount P

ark

Recrea

tion

Free Librar

ySuppo

rtive

Hou

sing

Human Serv

ices

Public H

ealth

General Fund State/Federal

$ Million


J. J. Heckman Science 312, 1900 -1902 (2006)

Department of Public HealthDepartment of Public Health

Access to health care for allAccess to health care for all•• Medical homeMedical home•• Prescription servicesPrescription services•• Prenatal carePrenatal care•• Behavioral health care Behavioral health care •• Health insuranceHealth insurance•• Health information availabilityHealth information availability

Healthy homes/neighborhoodsHealthy homes/neighborhoods•• Animal controlAnimal control•• Vector controlVector control•• Maternal, child, family healthMaternal, child, family health•• Chronic disease preventionChronic disease prevention

Death investigationDeath investigation•• CoCo--sleepingsleeping•• Fatality reviewsFatality reviews

Nutrition and food planNutrition and food plan•• Food safetyFood safety•• Smoking banSmoking ban•• TransTrans--fat banfat ban•• Nutrition labeling Nutrition labeling •• Obesity and food securityObesity and food security

Disease ControlDisease Control

HIV Prevention and CareHIV Prevention and Care

Air qualityAir quality

Health planningHealth planning

PNH/RiverviewPNH/Riverview

Board of HealthBoard of Health

Continuum of PreventionContinuum of PreventionPrimary Prevention for all

Secondary Prevention for those at risk

Tertiary Prevention for those affected

•Immunization•Food quality •Air quality management•Ambulatory health

•Lead poisoning prevention•STD screeningTargeted home visitingAmbulatory health

•TB control•Philadelphia Nursing Home•Vector Control •Ambulatory health

Health and OpportunityHealth and OpportunityOperating PrinciplesOperating Principles

Service delivery in a context of Service delivery in a context of preventionpreventionFamilyFamily--focused interventions to promote focused interventions to promote child and community wellchild and community well--beingbeingBestBest--practicespracticesCommunityCommunity--partneredpartneredEmphasis on costEmphasis on cost--effective programmingeffective programmingCrossCross--agency collaborationagency collaborationLive within a budgetLive within a budget

Key OutcomesKey Outcomes

Every child will enter kindergarten Every child will enter kindergarten ready to learn through investment in ready to learn through investment in familiesfamilies

Every 18 yearEvery 18 year--old will graduate from old will graduate from high schoolhigh school

Every senior will feel safe at home Every senior will feel safe at home

Every Philadelphian will have a homeEvery Philadelphian will have a home

public health in philadelphia: economics, health and ... health in philadelphia: economics, health...

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