4/27/2012
Creating Health Equity:
More
M
Than
Th an Apple
A l a
Day and a Walk in the
Park
Adewale Troutman, MD, MPH, MA, CPH
University of Florida
March 21, 2012
The Troutman Group
A case presentation
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Vital Statistics:
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What If We Had Eliminated Disparities in the
Last Century?
Fewer Black Deaths…
In 2000
 85,000 overall
 24,000 from heart disease
 7,000 from HIV / AIDS
 4,700 infant deaths
 22,000 from diabetes
 2000 fewer Black women from breast cancer
More Health Insurance Coverage…

2.5 million Blacks, including 620,000 children
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In a recent study, individual
behaviors such as cigarette smoking,
alcohol use and physical activity
explained
l i d less
l
than
h 20% off the
h
difference in death rates among
income groups
How you frame an issue
 The questions you ask
 Determines your analysis of the issue
 Determines how
h
you prioritize it
 Determines your policy choices
 Determines resource allocation
 Can determine your allies and your enemies
 Can define when an issue has been resolved
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Evolution of a concept
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Health Equity
 “Health equity is the realization by ALL people of
the highest attainable level of health. Achieving
health equity requires valuing all individuals and
populations equally
equally, and entails focused and
ongoing societal efforts to address avoidable
inequalities by assuring the conditions for optimal
health for all groups, particularly for those who
have experienced historical or contemporary
injustices or socioeconomic disadvantage.”
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Health Inequities
 Systemic, avoidable, unfair and unjust differences in
health status and mortality rates and in the
distribution of disease and illness across population
groups.
groups They are sustained over time and
generations and beyond the control of individuals
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Justice
 The quality of fairness
 The principle of moral rightness; equity
 Conformity
to morall rightness
in action or attitude
C f
h
d
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Social Justice
 The application of principles of justice to the
broadest definition of society
 Implies
p
 Equity
 Equal access to societal power, goods and services
 Universal respect for human and civil rights
Rights: Claims or
entitlements that are
recognized by legal or
moral principles
Human Rights (Summary)
 Universal
Universal,, the birthright of every human being;
 Aimed at safeguarding the inherent dignity and equal
worth of everyone;
 Inalienable (they cannot be waived or taken away);
 Interdependent and interrelated (every human right is
closely related to and often dependent upon the
realization of other human rights);
 Articulated as entitlements of individuals ((and
and groups)
groups)
generating obligations of action and omission
omission,,
particularly on States;
 Internationally guaranteed and legally protected
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Universal Declaration of
Human Rights
December 10, 1948
 Article 1: “All human beings are born free and equal
in dignity and rights.”
 Article 24: “Everyone has the right to a standard of
living adequate for the health and well being of him
self and is family including food, clothing, housing
and medical care.”
The Right to Health
 Preamble to the constitution of the WHO states “ The
enjoyment of the highest standard of health is one of the
fundamental rights of every human being without
distinction of race, religion, political belief, economic or
social condition
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The right to health or the right to
health care is recognized in at
least 115 constitutions.
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Constitution of Ecuador
(1998)
 Chapter IV: Economic, Social and Cultural
Rights, art. 42: “The State guarantees the
right to health, its promotion and protection,
through the development of food security,
the provision of drinking water and basic
sanitation, the promotion of a healthy
family, work and community environment,
and the possibility of permanent and
uninterrupted access to health services, in
conformity with the principles of equity,
universality, solidarity, quality and
efficiency.”
Health equity as a development outcome
The development of society can be judged by:
populations’’ health
• the quality of its populations
• the fairness in distribution of health, and
• the degree of protection provided from
disadvantage due to illill-health
Marmot 2006 Harveian Oration
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A New Direction; Social
Determinants of Health
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Looking
upstream,
finding the
causes of he
causes.
“The web of
causation”
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Social Determinants
Socioeconomic Status
 Occupation
 Education
 Income
 Income gaps
 Racism & discrimination
 Housing
 Political power
WHO
•
Early Life
•
Social Exclusion
•
Work
k
•
Unemployment
•
Social Support
•
Addiction
•
Food
•
Transport
•
The Social Gradient
•
Stress
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Healthy People 2020
Overarching Goals
 Attain high quality, longer lives free of preventable,
disability, injury and premature death
Q
,
 ACHIEVE HEALTH EQUITY,ELIMINATE
HEALTH DISPARITIES AND IMPROVE THE
HEALTH OF ALL GROUPS
 Create social and physical environments that
promote good health for all
 Promote quality of life, healthy development and
healthy behaviors across all life stages
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Healthy People 2020 – Phase II
New Topic Areas
 Adolescent Health
 Quality of Life
 Early and Middle
 Social Determinants
of Health
Childhood
 Blood Disorders and
Blood Safety
 Older Adults
 Genomics
 Healthcare
Associated Infections
 Global Health
The Social Gradient
Stress
 Continuing existence of anxiety, insecurity, low self
esteem and social isolation
 Lack of control over home and work life
 Profound effect on health
 Cumulative
 “When the bough breaks”
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Place Matters and the
p
power of GIS
Life Expectancy: Louisville
Metro
80
79
77
78
75
76
73
74
72
69
70
68
66
64
District 16
Nat. Ave.
District 24
District 21
District 5
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Environmental Stre ssors
Number of Premature Deaths
African-American Males
All C ancers
1991 - 1995
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And with the food environment
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The role of residential
segregation;
“The metropolitan areas with
the highest segregation levels
have the most unequal
geographies of opportunity”
Delores Acevedo
Acevedo--Garcia et al
Opportunity
Neighborhoods
 Sustainable employment
 High performing schools
 Access to high
h h quality
l h
healthcare
lh
 Adequate transportation
 High quality childcare
 Neighborhood safety
 Institutions that facilitate civic engagement
Housing
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Housing and Health
 Lead
 Indoor air quality
 Unsafe environments
 Obesity
 Asthma
 Stress
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 Place and Environment
Education
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In El Salvador, if mothers had no education
their babies have 100 chances in 1000 of dying
in their first year of life; if mothers have at
least secondary education the infant death
rate is a quarter of that (World Bank 2006)
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Food Justice
 Individual choice vs. structure and systems
 Food access, transportation and quality
 Decreased
d access to healthy
h l h foods,
f d increased
d access
to unhealthy foods ( food deserts )
 Economic development and community health
The Troutman Group
 Healthy Food Access
• In MS, NC, MD, MN neighborhoods:
 3x fewer places to consume
alcoholic beverages in the
wealthiest neighborhoods
 4x more supermarkets in white
neighborhoods
 Unequal access a variety of
healthy food choices available to
non-minority and wealthy
communities
Morland K et al. Neighborhood characteristics associated with the location
of food stores and food service places. Am J Prev Med 2002;22:23-29.
Strategy 3: Expand access to and distribution of healthy food.
The Troutman Group
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The
importance of
leadership
Increased Neighborhood
Access
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Racism
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What is racism?
A system of structuring opportunity and assigning
value based on the social interpretation of how one
looks (“race”)
 Unfairly disadvantages some individuals and
communities
 Unfairly advantages other individuals and
communities
 Saps the strength of the whole society through the
waste of human resources
The Troutman Group
Source: Jones CP, Phylon 2003
Joy – a feeling
That can last a moment
Even a day or a week
Hurt – also a feeling that
Can last generations…
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Rivera
Center for Health Equity
(CHE)
CHE works to
eliminate social and
economic barriers to
good health, reshape
the public health
landscape, and serve as
a catalyst for capacity
building, policy
change and
evidenced-based
initiatives.
The role of residential
segregation;
“The metropolitan areas with
the highest segregation levels
have the most unequal
geographies of opportunity”
opportunity”
Delores Acevedo
Acevedo--Garcia et al
The Troutman Group
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Opportunity
Neighborhoods
 Sustainable employment
 High performing schools
 Access to high
h h quality
l h
healthcare
lh
 Adequate transportation
 High quality childcare
 Neighborhood safety
 Institutions that facilitate civic engagement
The Troutman Group
Health Policy
y Is
Social Policy
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Some New Tools
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Photo Voice
 Youth empowerment through engagement
 Community health and barriers
 Youth
h as creators, producers,
d
interpreters
 Raise awareness about the policy process
 Presentation to policy makers ( Mayor Metro
Council, Board of Health, Business Community
The Troutman Group
If my community were healthy it would look like, no people littering, people riding bikes, no people dealing drugs, kids playing at the park, no gunshots, parents and kids walking their dogs, no people smoking, parents taking their baby’s in a stroller to the park to walk them around The Troutman Group
the park. Denzel: age 10
My neighborhood
has many train
tracks and a
really big factory
that does
something,
thi
I
don’t know what.
There is a church,
a community
center but there is
no store close to
where I live.
The Troutman Groupage 10
D’coreyan:
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Every day I go to the community center on the side of it, they
are selling drugs or showing off their guns and sometimes I
am scared to walk pass because I think they will shoot me.
Michael: age 10
The Troutman Group
Health in All Policies addresses the effects on health
across all policies such as agriculture, education, the
environment, fiscal policies, housing, and transport.
transport. It seeks to
improve health and at the same time contribute to the well
well-being and the wealth of the nations through structures,
mechanisms and actions planned and managed mainly by
sectors other than health. Thus HiAP is not confined to the
health sector and to the public health community, but is a
complementary strategy with a high potential towards
improving a population
population’’s health, with health determinants as
the bridge between policies and health outcomes.
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Health Impact Assessment
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Health Impact Assessment (HIA)
A combination of procedures, methods, and
tools by which a policy, program, or project
may be judged as to its potential effects on
the health of a population,
population and the
distribution of those effects within the
population (Gothenburg consensus
statement, 1999)
Social justice is a
matter of life and
death. It affects the
way people live,
their consequent
chance of illness,
and their risk of
premature death…
The Troutman Group
www.who.int/social_determinants
CSDH three overarching
recommendations:
1. Improve daily living conditions
2. Tackle the unequal distribution of power, money and resources
d
3. Measure and understand the problem and assess the impact of action
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Remember
 Health is more than health care
 Health
l h Inequities are neither
h naturall nor inevitable
bl
 The choices we make are shaped by the choices we
have
 Racism imposes and additional health burden
What to do
 Reframe
Reframe--See the problem differently
 Social Determinants research
 Multidisciplinary program development and
implementation & curriculum change
 Invitation for self evaluation
 Engaging nontraditional partners
 Think globally act locally
 Get involved
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Building a Social Movement; A
Common Vision of Hope
The Power of One
One”
“The
The Troutman Group
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The Troutman Group
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To laugh is to risk appearing a fool. To weep
is to risk appearing sentimental. To reach out
for another is to risk involvement. To expose
your feelings is to risk exposing your true self.
T place
To
l
your ideas,
id
your d
dreams b
before
f
th
the
crowd is to risk there loss. To love is to risk
not being loved in returned. To live is to risk
dying. To hope is to risk despair. To try is to
risk failure.
.
But risks must be taken because the
greatest hazard in life is to risk nothing.
The person who risks nothing, does
nothing, has nothing, and is nothing. He
id suffering
ff i and
d sorrow, b
may avoid
butt h
he
can't simply learn, feel, change, grow,
love or live. Chained by his certitude, he
is a slave, he has forfeited his freedom.
ONLY A PERSON WHO RISKS IS FREE
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Adewale Troutman, MD, MPH, MA, CPH
The Troutman Group
www.denzibell@aol.com
College of Public Health
University of South Florida
311 Fletcher Ave, MDC 100
atroutm1@health.usf.edu
813--974
813
974--9302
What Do I Do?
 Recommit to Health Equity and the belief that IM
and community health is a social justice issue
 Expand your organizational and personal contacts
t non ttraditional
to
diti
l partners
t
( unions,
i
civil
i il rights
i ht
groups, jobs for justice advocates, the faith
community in a new way, urban planners and
zoning experts, economic development agencies,
youth HIP HOP groups etc.)
 Strengthen or begin a relationship with local, state
and congressional delegations
What?
 See the problems differently ( Community
Empowerment vs Medical model )
 This is a women’s health, child health and men’s
health issue
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Healthy People 2020:
The Process Revealed
Office of Disease Prevention and Health Promotion
US Department of Health and Human Services
Adewale Troutman, M.D., M.A., M.P.H.
September 29, 2008
Advisory Committee Workgroups
• Five subcommittees to allow in
in--depth discussion
• Members were both internal and external (subject experts)
 Subcommittee on Health Equity and Disparities
 Subcommittee on Priorities
 Subcommittee on Environment and Determinants
 Subcommittee on Life Stages and Developmental stages
 Subcommittee on User Questions and Needs
• Two AdAd-hoc groups to address special topics
 Health IT
 Graphic model for Healthy People 2020
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Black women are at increased risk
for adverse birth outcomes
 Ectopic pregnancy
p
abortion
 Spontaneous
 Cesarean delivery


Preterm birth

Low birth weight

Birth defects

Infant death
Maternal death from pregnancy-related
complications
Reveiwed by: S. Gennaro, Am J Obstet Gyneco 192, S3–10, 2005
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 “Focusing
on prenatal care in our public
health policy prescription for infant
mortality disparities ignores the
socioeconomic context in which women
live, medicalizes a problem that is socially
and historically complex, and thus
contributes to the illusion that there is a
‘medical policy bullet’ that can provide a
comprehensive and efficacious solution”
Frisch & Lantz 1999
 Disparities in health, education, employment,
and wealth, along with persistent residential
segregation, are vestiges of a long history of
oppression and denial of fundamental human
rights. The legacy of racial injustice shadows this
nation
ti and
d Af
African
i
American
A
i
Communities
C
iti in
i
the form of persistent infant mortality
disparities. True healing must emerge through
acknowledgement, reconciliation, and
amelioration of the inequalities that continue to
disproportionately burden African Americans
and other people of color
Christopher, 2005
Accomplishments of the Healthy
Start Program, 2001
2001--2005
 Zero infant mortality to Healthy Start
participants over 4 years
 Significant reduction in low birth
birth--weight
bi h
births
 Increase in the women receiving prenatal
care during the first trimester
 Increase in the women receiving
preventive care services after delivery
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 Secretary’s Advisory Committee on
Infant Mortality 2011
 Workgroups
 Recommendations
Living and working conditions include
social, natural and physical environments;
racial segregation, employment status
and occupational factors and available
social services and health care services.
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