Introduction (344 Words)
My name is Richard Lichtenstein and from the University of Michigan school of Public health and the
topic today is health inequalities in the United States so I show you a couple of neighborhoods that kids
might walk through to get to school is the first one is the second and then here’s the third I also wanted
to show you a scene from Southwest Detroit is a neighborhood in Detroit that faces out on this view kids
and adults look at this when they look at their window. So the question that I want to think about is how
was living in each of those different settings affect your health because besides these obvious
differences that I’m showing here in terms of income and if you think about quality of the streets in the
schools and the fire department and other things we know those differences exist in those different
communities but those communities also have a pretty big impact on people’s health and so what we’re
to talk about today is how factors like race and income and education and then something we call the
social determinants affect people’s health. And I think you’ll see that will we talk about health disparities
there are very big and really unconscionable differences in health status between people who are of
different races of different incomes different educational status and who live in different types of
communities so we’re really talking about all the root causes of these health disparities but were to start
with just an overview of some of the data on health disparities as they exist by race ethnicity income
education network and accountability to some models over how does where you live or your social
environment affect your health. Introduce concept of upstream and downstream risk factors and I will
talk about how the effects of cumulative stress affect one’s health and then in the third section were
going to talk about two different communities right side by side and how health is very different
depending on where you live feeling.
Topic One (1260 Words)
I be talking about disparities that exist in populations that differ by income and education and race and
since those are not all the same thing I just wanted to explain why were to do that so there is an
enduring relationship in the United States between race and educational level and income level so I just
wanted to show you that certain populations like blacks and Hispanics have a lot more poverty and a lot
less education than white populations and Asian populations so sometimes. I’ll be talking about blacks
versus whites but sometimes I’ll be talking to people with low income and some people with low
education versus higher education I wanted to clear not all black people are poor not all white people
are rich these are correlations but I just wanted to show you the reason why work and show the data
this way one measure of health status that is often use internationally as if immortality and if mortality
is defined as the number of babies who die before their first birthday per thousand live births so it’s the
number not the percentage the number of babies who die before their first birthday per 1000 live births
in this chart arrays whole bunch of countries in terms of their mortality rate and those here on the right
side are very low these have the lowest if mortality there less than 2.0 and then on on the backside in
this path we have some of the highest infant mortality rates in the world and you can see the US is
pretty much onto the left side the info mortality rate for US 6.05 and you can see that were nowhere
near the level that is achieved by some of countries like Japan and Sweden and Finland and Luxembourg
who are way down there so why is our mortality so much worse in the United States that’s one of the
questions will answer now if you can’t look at specific racial or ethnic groups you see some of the
dramatic differences that exist in the United States for the report offers that the US in the white rate
which is a good rate and the Asian rate in the United States is still a lot higher than has been achieved in
other countries so no one in the US uniform is doing well but really the key thing I want to show you is
that the black if mortality rates in the American Indian if mortality rate two and three times as bad in the
US as the white or Asian rate so something is going on that leads to poor health in these communities if
mortality is often thought of as a proxy measure for the overall health of the population so where you
have very poor if mortality rates you usually can see poor health of the whole population so we can look
at a number of different measures so I them is called life expectancy it’s the kind of a measure based on
past history how long will someone born today be likely to live their experiences like the previous
generations and it shows you that the white rate is a lot higher with this is the female rate much lower
life expectancy for white women there for black women the same holds true for males blackmails live a
shorter life expectancy than white males and then you can also see that in this measure Hispanics seem
to be doing quite well and there are a variety of theories about why that is and what we we don’t have
time talk about that but it could be a data problem it could be that blacks have different social situations
and then restarting with so there are a lot of theories about why this is true some people even question
whether the data are reliable but I think the point is that there are pretty big differences in in in life
expectancy at birth over these populations so here’s another chart that shows mortality rates from the
major killers cancer heart disease stroke and then specifically breast cancer and if you just look these
over you could see that blacks do worse on all of these than whites to you can also see the Hispanics
seem to be doing pretty well on these measures and again this is a paradox based on other factors that
we know now it’s not just that there’s a difference between people who are totally impoverished and
people who are affluent those are not the only reasons for disparities in a very famous they call the
Whitehall study done in England what the people in the British civil service if all them for 10 years there
is a pretty strong gradation of ranks in the British state civil service and the highest level are the
administrators and then the next levels are professionals there actually six different levels but these are
both people at the bottom here are the lowest prestige lowest pay people like people who work in the
kitchens and some of the cafeterias or people who drive trucks so not very well educated not earning a
lot of money and status in a dramatic difference just between the people at the lowest end of pay and
highest and you can see there’s this thing called the gradient all the way through just to reinforce one
point everyone in this study was working so none of them were in poverty and all of them had access to
healthcare through the British national health service so what is going on at your position in this
hierarchy or your place in society really has a big impact on your mortality now your income your
education to have an impact on illnesses that you might have and so rather look at mortality these
charts are showing the incidence of diseases like high blood pressure or asthma or diabetes and you can
see again at the low end of the spectrum very low income we have the highest rates of all three of these
chronic diseases and then at the highest income level or at the lowest level so again you have another
gradient for all of these diseases and the question is what is it about society and income that’s changing
people’s health status affecting the health status here we have another type of measure where we ask
people is your health excellent good fair poor and were looking just at the people who said fair or poor
or looking at people who are unable to do their usual activities so they can go to school or they can play
golf after work or whatever it might be you usually would do something and he couldn’t because of your
health you get added to these charts so again just like we saw with income the lower your education is a
less than high school is a college graduates again giant decrease in health status based on your
education how does your educational level affect your health so as a conclusion of this part I just
wanted to show you that there exist very dramatic differences in health status and quality of life along
racial ethnic income educational lines where your position as a society what race you are all these
factors seem to be related to your health and your health could be your mortality mortality but it also
could be your morbidity and also in the quality of your life
Section 2 (2387 words)
now in the second section of this presentation were to talk about the root causes of health problems
and so were to talk about what we call the social determinants of health now we look at slide that look
at race in common education previously but now working at this other factor and so it’s conditions of
your community conditions of your job what your family is like all these things have an impact on one’s
health and one metaphor that’s often used in public health are upstream and downstream factors I
wanted you to have a good understanding of this so let’s just say that there is a river running through
her beautiful part of the country and you’re having a picnic on the side and you suddenly hear someone
is drowning in the river and so you call 911 yet semi-jump out try to save the person the rescue
helicopter shows up a save the person and we’ve prevented a death in a person so that’s a nice thing
but what happens if a few minutes later another body is seen in the river and we have to go out and call
the helicopter back and rescue that person we could do that but we want to do that but the question is
what’s going on upstream that’s causing all these people to wind up in the river drowning and so we
need to look upstream and if you did you might see something like this in this metaphor this is a bridge
that collapsed in Minneapolis and people got thrown into the river and the point of this and for the
metaphor is that there’s something structurally wrong with this bridge because it’s collapsed and there
are characteristics that are structurally wrong in neighborhoods and communities that lead to worse
health so the left side is the upstream factors that tenant constant conditions in which people grow up
and live and work and the right side is more the downstream things of things that we can do right now
to try to help people who are in trouble here is a model of those determinants so we start with the
upstream factors things like education income where you work play all these things these are kind of the
conditions in which you have for the duration of your life so those are the upstream determinants and
they lead to the downstream determinants and those might be things like getting ability to get medical
care whether you live in a polluted community today where the smoke some of your other health
behaviors and then both of those sets of factors lead to whether your healthy or not we have to add and
that certainly biological factor like your genetic structure your age or sex all these things impact on
what’s can happen to your health and what I mean nearby genes are for example if you come from a
family where everyone has lived to be 90 your likely get a little pretty long time whereas if your family is
all die when they were in their 40s then you have some issues and those are not related to the
environment those are innate issues in your biology so the point here is that based on these and the
upstream and downstream factors your health could be adversely affected by the upstream factors the
downstream factors your biology or things that you’re exposed to today so the point is that we can’t just
look at your health today we have to look at what went on before to try to understand how we can
impact on health disparities and this is a sort of famous type of chart in in public health and eight,
displays what we call the ecological model and you can see there are various layers of society that
extend out in concentric circles and the point of this is that your health is not only determinant in the
center center place there where it says people but rather it’s affected by all the levels of society and
therefore if you really want to impact on people’s health especially population health you can’t just give
medical care to people inside that little circle in the middle but rather you have to think about a
multipronged effort at different levels on these concentric circles to affect both the downstream effects
impact to affect both the downstream factors and the upstream factors so it’s not a medical model
where you just treat sick people or give curative care to Oregon preventive care to so it’s not just the
medical model where you’re providing either preventive or curative services to people in the doctor’s
office over talking about is going out into communities and into society itself in trying to remediate
some of the upstream factors that may lead ultimately to a population having poor health now when
people have tried to figure out you know why is it that some people have early deaths systematically
some populations like think about the life expectancy of blacks first went much lower in blacks why is it
that blacks die in an earlier age well it try to partition those causes into these factors and here are some
of the numbers that come out these are not perfect scientifically determine numbers but they’re saying
the behavior you know eating wearing a helmet when you ride a motorcycle or your bicycle or having
enough sleep at night all these things affect your health and that might lead to 40% of the explanation
of why certain populations die early and you can see the rest of these but I want to point out that
medical care is only 10% of the explanation now this is not saying that medical care doesn’t work or that
we don’t want to have good medical care available to people as we do once somebody has a stroke we
want to have terrific specialists and hospital materials available to them that’s not the point’s point is
looking at a population over the lifetime why did this population had such a high incidence of strokes
and this will explain the because of their social circumstances or their environment or their behavior or
their genetics so it saying that there are certain social determinants of health rather than just biological
how we design our neighborhoods has impact on health and where we live certainly has an impact on
health so you can think about living in a community that has playgrounds like this in a beautiful
mountain region or even a community has rapid transit so that you can take the subway to work which
both of which were probably lead people to have healthier lives or you could think of a city that looks
like this pollution smog In hell that air every day or the city auto tuning in looks like it’s in Asia but look
at that traffic jam would you want to endure the stress associated with sitting in your car every single
morning and every evening on the way home in a in a jam that looks like that and and also what about
the people who live on the side of these roads that have to inhale all the fumes are coming from all
these cars not a very pretty sight so stressors happen in the water time or more usually they happen
multiple stresses at a time and to come up with a term for the totality of all the stressors that one is
enduring we come up with this term allostatic load so the definition is that it’s a cumulative
physiological burden that’s cut of laid onto a person over their lifetime and we’ve laid out a bunch of
stressors that could happen to individuals and if you go into low-income communities asked people
what stresses them they will name a bunch of these things in the point is that I think middle-class people
would really be upset if any of these things happened if they felt that so if if any of me me me me on
and is okay so if you look at these different stressors few asked middle-class or affluent person know
how they feel if they were having to live with inadequate social support the taking care of the kids is no
family around to help them they might say that’s pretty stressful but think about someone who’s got
low income and experiences all of these stressors at the same time and they do often happen all of
these things to the same families that would be called having a high allostatic load and so we have
evidence that people who live under conditions where they have a very high allostatic load don’t do as
well in terms of health is people who have us a small health” and so she and his kick it out so people
who live with a high allostatic load have much poorer health than people who have little stress or just
minor stressors in their lives and this is an article those in the New York Times by Helen Epstein talks
about ghetto miasma just there’s something about living in certain communities of bed for your help
and she shows some of these results and an urban studies correlating higher allostatic load with a higher
risk for death and further declines in cognitive and physical functioning and then I just added here what
might be found to be a physiological connection between stress and health which has to do with
something called telomeres which are at Kennedy and On chromosomes and as the genes is starting so
and then here’s another explanation that may be shown to be true but which connects physiological
functioning and stress so these are things called telomeres which happen at the genetic level every time
Jean has to replicate the end of it gets a little bit shorter so we know that older people have shorter
telomeres than younger people and there been some studies and one recently was by a Nobel Prize
winner Elizabeth Batt Blackburn who looked at the telomer wings of women who had very sick children
who would been taking care of the children for years and then moms who had helped the children were
taking care those children the telomeres of the stressed-out moms were shorter than the telomeres of
the less stressed mom and dad could be an indicator that people are going to get sick because of all that
stress so living under a high allostatic load is bad for your health now that there are other studies which
have tried to look at the social determinants of health and in one study by Santo DeLay and his
colleagues they looked at just the third of the deaths that could be identified in a year that seemed to
have some correlation sought social environmental factors case so in that study they portions the type
of social factor that had might have been associated with that death and this shows you for example
that 20% of those deaths were due to racial segregation that 28% were due to low education and so
does this again is not no perfect science that social these are exactly the numbers but again these social
factors seem to lead to deaths and in the population and finally I just wanted to show you a set of policy
objectives that were laid out by something called the Marmont committee the Marmite review which
looked at how can we illuminate or reduce dramatically these health disparities and what you see listed
here is not that we need more ICU beds in every community or more specialists on every block rather
their current things that just say we need to give everyone a very good family life they have to live in a
good community they need to have all the advantages of education and employment and a healthy
standard of living and those are the kind of things that lead to good health is not medical care its social
conditions that we really are trying to do only the very last point here is anything do with healthcare and
that feeling with doing health prevention which might be at the level of the physician or might be at the
level of public health so the conclusion to this part is basically that social determinants are really
important factor in looking at the health of the population that there are both upstream and
downstream factors that are related to the disparities in health that we seen that these disparities are
not just individually determined by people’s genetics or their lifestyle rather there created or associated
with community factors population statistic that we solely to start that again the last part so these
disparities are not really based on individual behavior or individual biology but rather they has to do
with the social conditions in which populations live and work and play and to the extent that we can
improve those social conditions within a create a lot more health than we can to medical care and in the
next section within basically just look at two ZIP Code areas to communities are right next to each other
that really have dramatically different social environments and also have very dramatically different
health status and they lead to the question that was raised by Tony I who is a physician who now works
at a foundation in California and does a lot of health disparities work PS the question does your ZIP Code
matter more than your genetic code in other words the phrase is often used place matters you want to
know why one population is sick and another was healthy it’s not their genes it’s their neighborhood so,
blogger so I is a religious do it then don’t I hope me to spend one second to scroll through the second
the next section is going to be a small case study on health inequalities and it deals with a couple of
factors what is that we know that there are big disparities in health status among certain groups and
they are enduring disparities that seem to be the most disease is so sectional
Three (1249 words)
The next section is going to be a case study about health inequalities and just as an introduction to this
section we know that there are major disparities and that those disparities have persisted for very long
time in the United States and their predictable by the age or the and their predictable by the income or
education or race or ethnicity of a population so we want us also reinforce that social inequalities
medical care are the factors that really lead to population inequalities in health outcomes so it’s not the
absence of medical care that’s causing certain popular the missions that much work. It’s the conditions
in which people live their social factors that do the and so in this case study I just want to try to address
the question does your ZIP Code matter more than your genetic code concept that was raised by Tony
Eitan from the foundation California so this is a case study that kind of shows health and social structure
into communities in Southeast Michigan so Oakland County borders Wayne County and the borders
right there and on this site is Detroit and on this site are some of the more affluent suburbs and this
street right here is the famous 8 mile and that’s the boundary between Detroit and the suburbs to work
in a compare the social conditions and the health status of the population in Oakland County versus
what happens in Detroit so I present is here some sociodemographic characteristics of Detroit and then
open County and just for comparison sake the average for the entire United States so it’s pretty stark
really dramatic Detroit does more poorly does worse on all these measures terms of income the
percentage of people in poverty the percentage of high school graduates the percentage of AfricanAmericans and the percentage of single-parent households so again, to say that they’re bad if you buy
me love you guys realize that did that to us in try to explain it right so this is a table that contrasts a
certain done sociodemographic characteristics in the city of Detroit versus open County and then it
compares it with the overall average for the United States and so if you look at something like income
Detroit much lower income on average than Oakland County the percentage below the poverty level
much higher percentage of high school graduates most lower and then another factor Detroit is
extremely segregated fact it’s been shown to be the most segregated area in the United States so about
83% of the people live in Detroit are African-American and 14% are African-American Oakland County
compared to 13% for the US now that we are not trying to say here that being black makes you sick but
it’s all the things associated with the African-American population which is that they’re more likely to
report their less likely to continue through high school graduation college the jobs opportunities are
inferior so all these things together plufacs the neighborhoods they live in plus discrimination all those
things together suggest that this population will have worse health than a population that’s more
integrated over this largely white and then a measure that so very significant percentage of families that
have single-parent households they didn’t have enough to measure in Oakland County but that’s pretty
dramatically different than 10% for the United States so just that based on the enduring relationships all
these characteristics we would assume that the social factors would be related to poor health status in
Detroit compared to open County and if you look at the actual numbers here so these are all mortality
rates and mortality heart disease mortality violence and unintentional injury and then lung cancer and
incidence and mortality Detroit does a lot worse on all of these measures than Oakland County dollars
and much worse than the national average so you can see heart disease really that long cancer really
bad compared to some of these others and then some measures of different and finally some other
measures of health status so another way of measuring mortality is not count each death is it one but to
think about how many years of life were lost under age 75 and then to aggregated to population level
socially die when you’re 50 lost 25 years of potential life and so will we do that you can see dramatic
differences between these population implying that Detroiters diet a much younger age than people in
Oakland County and then hospitalizations for asthma and for diabetes these are sometimes called
ambulatory care sensitive hospitalizations with the norm being that if you get good healthcare shouldn’t
ever need to be in the hospital overnight and yet you can see much higher in Detroit than in Oakland
County so big differences between these two relatively close areas in terms of both social characteristics
and in terms of their health status now I showed you something about cancer lung cancer more more
debt mortality so I just want you to recall that we looked at this issue of lung cancer incidence and lung
cancer mortality in these two communities both of these are higher in Detroit than they are in Oakland
County will initially a picture this is a picture that was taken in 2010 so not very long ago and this is a
place called Long Island it’s in the Detroit River in Southwest Detroit and these steel mills and other
factories look just like this looks like the 1860s but they’re still going on and so think about living right
next to this which is what Detroit is and then look at this dramatic difference in carcinogenic matter
that’s discharge into the air so nonetheless bar here we have 11,000 pounds per year of carcinogenic
discharge into the air and in Detroit 54,690 pounds of carcinogenic discharge so if you’re living in Detroit
in this and the prevailing winds go from Zion East and Oakland County is north of that they don’t get this
air I you can imagine how this environment would negatively impact people living in Detroit and not just
an cancer but also heart disease asthma lots of other diseases well so again in summary ZIP Codes can
be more important indicators of your health outcomes then your genetic code living in a community
that looks like that one will have a pretty important impact on your health status regardless of all the
other factors that might go into health so the conclusion so if we want to understand health inequalities
and root causes here is a couple things that we can say first of all that there are pretty persistent
dramatic differences in health status among predictable populations low income versus high income low
education higher education and then some of the discriminated against populations of color that seem
to do worse and help them in white population so there are social factors that are related to health and
there are both upstream and downstream attributes that could impact of population’s health and that
lead to the disparities that we’ve is described and finally that disparities are much bigger than just how
an individual views in terms of their health behavior in terms of their lifestyle it’s much more related to
your community factors and the environment in which you live and that healthcare is not the way to
eliminate health disparities healthcare matters when people are sick of sucks.
Conclusion (322 words)
I think that session should show you that there are a lot more factors leading to health disparities in the
United States and just medical care and talk about the data shown there are always to help based on
income education race all sectors that there are social factors you talk a lot about the community
factors social structure built environment and those social trends have open upstream and downstream
set backs so the public health approaches to address these disparities not downstream where it is
solving problems but upstream where were preventing workplace and other important thing to wear
this is that disparities transcend lifestyle factors that is not just how individual person does with their
health but it’s what are the social components to that and what kind of community living water off the
other actors that might be impinging on finally question raised by Tony Eitan does your ZIP Code matter
more and genetic code because a lot of evidence that says yes it does and do you show me where the
players and within reason I can tell you more about their health status that it would be outside the
venue. Either she structured so morbidity and mortality are much more than just access to healthcare
era upstream and downstream social determinants that contribute to health status of the upstream
downstream and scheduling for certain biological factors and then finally that stress is one of the big
concerns in terms of long-term health and that the built environment in the house that will have major
implications for population finally the solutions to help disparities are not that difficult to understand
the seem to be hard for searching for everyone but they’re sort of basic things that one for everyone
good family a good job house and some preventive healthcare as well but these are not difficult to
achieve we just need to help the will to get there
Notes
Intro
Topic one
Topic two
Topic Three
Conclusion