Making Health Equity a Reality:
Approaches to Transforming Public
Health Practice
Nicolas Freudenberg
ACHIEVE Action Institute
April 24, 2012

Nicholas Freudenberg
Distinguished Professor of Public Health
City University of New York School of Public Health
CDC ACHIEVE Meeting
24 April 2012
2

1. What is health equity and why is it important?
2. What are the obstacles to health equity?
3. What strategies can public health staff, health advocates and local policy makers use to advance health equity?
4. What are the assets local health departments, community organizations and local elected officials can leverage to promote health equity?
5. How can we get started in making equity a priority in our work?
3

Health equity is achieved when every person has the opportunity to achieve their full potential for health.
Amartya Sen
4

In an equitable society, everyone has opportunity to
Complete education needed to support themselves and families
Find food that sustains health
Live in safe housing
Breathe clean air and drink clean water
Participate in making decisions that affect well-being
What else?
5

Some Examples of Health Inequalities
• Mortality rate for infants of mothers with less than 12 years of education was 1.5 times higher than for those of mothers with 13
+ years of education.
• Native Hawaiians or other Pacific Islanders, American
Indians/Alaska Natives, African Americans, Hispanics/Latinos all significantly more likely to have been diagnosed with diabetes compared to White counterparts.
• More than twice as many children (2–5 years) from poor families experienced a greater number of untreated dental caries than children from non-poor families
• 25 year old with less than 9 years of school had average life expectancy 8 years shorter than those who had finished high school, and 12 years shorter than those who had finished at least a year of college.
6

• Increasing poverty and unemployment rates
• Cuts in safety net programs for children, poor people and others
• Decline of US manufacturing jobs that provided road out of poverty
• Shift of health care costs from employer to employee
• Reductions in state and local support for education, health care, and child care
7

Changes in Income Equality
8

Racial/Ethnic Differences in School Completion
9

Changes in Incarceration Rates by Race/Ethnicity
Source
: http://filipspagnoli.wordpress.com/stats-on-human-rights/statistics-on-freedom/statistics-on-prisoner-population-rates
/ 10

1. Improve the living conditions that are fundamental determinants of health
2. Protect populations against disease promoting forces
3. Support policies that create health promoting communities
4. Bring evidence to those who have the power to change policy
11

1. Improve the living conditions that are fundamental determinants of health.
12

13

Deaths Attributable to Social Circumstances,
US, 2000
• 245,000 adult deaths attributable to low education, defined as lack of a high school degree;
• 176,000 to racial segregation,
• 162,000 death to low social support, not being connected to people can support health,
• 133,000 to individual-level poverty, defined as an income of less than $10,000,
• 119,000 deaths to income inequality, and
• 39,000 to area-level poverty.
•
Source: Galea S, Tracy M, Hoggatt KJ, Dimaggio C, Karpati AAm J Public Health. 2011 ;101(8):1456-65 .
14

Better lifetime health
Improved school achievement
Better health
Improved school achievement
15

More education contributes to:
• Higher incomes (and the purchase of better food and housing, more health care, etc.)
• More skills, knowledge and resources to protect health
• More social support and stronger social networks
• Lower rates of unhealthy behavior
Having family members, peers or neighbors with more education also associated with better health
16

• Teen pregnancy
• Chronic illnesses such as asthma and diabetes
• Vision and hearing problems
• Learning disorders
• Psychological and emotional problems
• Substance use
• Family health problems
• Violence and bullying
• Hunger and obesity
• Social isolation
17

• School based health center with primary care, mental health and reproductive health services
• Comprehensive health and sexuality education
• Substance abuse prevention and treatment
• Healthy school environment
• Safety and violence prevention programs
• Family health services
• Food services and access to healthy food
• Physical activity program
18

• Educate public and policy makers on education and health virtuous circle
• Develop and advocate for health and other policies and programs that reduce health-related school drop out
• Participate in multi-issue coalitions to improve public schools
• Create an evidence base that can guide policy
What else?
19

Other areas where evidence shows improved living conditions can reduce inequalities
• Support paid sick leave and living wage campaigns
• End foreclosures and make affordable housing a policy priority
• Reduce institutional racism and the residential segregation that worsens education, employment and food inequalities
20

21

US Deaths Related to Products of Key Industries
Industry
Alcohol
Automobiles
Firearms
Health outcomes related to products
Accidents, homicides, liver cancer, cirrhosis
Respiratory diseases including lung cancer, heart disease, injuries; obesity and its associated conditions
Homicide, suicide, injuries
Estimated Annual Deaths US
100,000
43,000
35,000
Food and Beverages
Pharmaceuticals
Obesity, diabetes, heart disease, cancer
Over and under medication
365,000
(includes deaths attributed to inactivity)
100,000
Tobacco Heart disease, lung and other cancers, respiratory diseases
435,000
22

23

Increase opportunities for safe physical activity
Increase access to healthy foods
Decrease promotion of unhealthy food
Use public space to promote democratic participation
24

those who have power to change policy
27
26

• Who are the constituencies in your community who can support your efforts to change conditions that allow health inequality to persist?
• What are the messages that will bring these groups together ?
• What are the strategies that will mobilize communities to act to reduce health inequalities?
27

• Scientific and health evidence
• History of successful efforts
• Social Movements and community organizations
• America’s Second Language
• Capacity for critical self-reflection
28

• Look for deeper causes
• Focus on equity
• Find your partners
• Just do it
29

Nicholas Freudenberg nfreuden@hunter.cuny.edu
CUNY School of Public Health www.cuny.edu/sph
CUNY Doctor of Public Health Program http://web.gc.cuny.edu/publichealth
Corporations and Health Watch www.corporationsandhealth.org
30