Title: CONFRONTING THE SOCIAL DETERMINANTS OF HEALTH INEQUITIES: RETHINKING PUBLIC HEALTH
1CONFRONTING THE SOCIAL DETERMINANTS OF HEALTH
INEQUITIES RETHINKING PUBLIC HEALTH
- Bob Prentice, PhD
- Director
- Bay Area Regional Health Inequities Initiative
(BARHII) - University of New Mexico
- February 26, 2009
2OVERVIEW
- BRIEF HISTORY OF BARHII
- A CONCEPTUAL FRAMEWORK FOR RE-THINKING PUBLIC
HEALTH - MOVING HEALTH EQUITY FROM THE PERIPHERY TO THE
CENTER OF PUBLIC HEALTH - REFLECTIONS ON SOME CONTRIBUTIONS OF THE SOCIAL
SCIENCES TO PUBLIC HEALTH
3BRIEF HISTORY OF BARHII
4PROLOGUE1998-2005
- INFORMAL CONVERSATIONS
- TWO STEPS FORWARD, ONE STEP BACK
- EXPANSION AND SUPPORT
- FROM TOP DOWN TO BROADLY PARTICIPATORY
- FORMAL BEGINNINGS OCTOBER, 2005
5BARHII MISSION STATEMENT
- . . . TO TRANSFORM PUBLIC HEALTH PRACTICE FOR
THE PURPOSE OF ELIMINATING HEALTH INEQUITIES
USING A BROAD SPECTRUM OF APPROACHES THAT CREATE
HEALTHY COMMUNITIES.
6HEALTH DISPARITIES vs. HEALTH INEQUITIES
- UNITED STATES
- ELIMINATING HEALTH DISPARITIES ONE OF TWO
OVERARCHING GOALS OF HEALTHY PEOPLE 2010 - CENTERS FOR DISEASE CONTROL PREVENTIONS RACIAL
AND ETHNIC APPROACHES TO COMMUNITY HEALTH (REACH) - CENTERS OF EXCELLENCE FOR ELIMINATING DISPARITIES
(CEEDS) FOCUS ON A DISEASE AND A POPULATION
7Health Inequities
- Health inequities are differences in health
status and mortality rates across population
groups that are systemic, avoidable, unfair, and
unjust. -
- Margaret Whitehead
- World Health Organization
8WORLD HEALTH ORGANIZATION EXECUTIVE BOARD
RECOMMENDATIONSFebruary 4, 2009
".........Confirming the importance of addressing
the wider determinantsof health and considering
the actions and recommendations set out in
theseries of international health promotion
conferences, from the OttawaCharter on Health
Promotion to the Bangkok Charter for Health
Promotionin a Globalized World making the
promotion of health central to theglobal
development agenda as a core responsibility of
all governments(resolution WHA60.24)"........U
RGES Member States(1) to develop and implement
goals and strategies to improve publichealth
with a focus on health inequities(2) to take
into account health equity in all national
policies thataddress social determinants of
health and to ensure equitable access tohealth
promotion, disease prevention and health
care(3) to ensure dialogue and cooperation
among relevant sectors with theaim of
integrating a consideration of health into
relevant publicpolicies
9(4) to increase awareness among public and
private health providers onhow to take account
of social determinants when delivering care to
theirpatients(5) to contribute to the
improvement of the daily living
conditionscontributing to health and social
well-being across the lifespan byinvolving all
relevant partners, including civil society and
the privatesector(6) to contribute to the
empowerment of individuals and groups,especially
those who are marginalized, and take steps to
improve thesocietal conditions that affect their
health(7) to generate new, or make use of
existing, methods and evidence,tailored to
national contexts in order to address the
socialdeterminants and social gradients of
health and health inequities(8) to develop,
make use of, and if necessary, improve
healthinformation systems in order to monitor
and measure the health ofnational populations,
with data disaggregated according to the
majorsocial determinants in each context (such
as age, gender, ethnicity,education, employment
and socioeconomic status) so that
healthinequities can be detected and the impact
of policies monitored in orderto devise
appropriate policy interventions to minimize
health inequities........"
10A CONCEPTUAL FRAMEWORK FOR RE-THINKING PUBLIC
HEALTH
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13Infant mortality
Mortality
Life expectancy
14PUBLIC HEALTH AS GOTH THE USES OF DEATH AS A
MEASURE OF POPULATION HEALTH
- INFANT MORTALITY
- MORTALITY RATES
- LIFE EXPECTANCY
- GLOBAL RANKINGS
- YEARS OF POTENTIAL LIFE LOST
15Chronic disease
Infectious disease
Injury (intentional and unintentional)
Mortality
Disease and Injury
16DISEASE AS THE CAUSE OF DEATH Ten Leading
Causes of Death Source Healthy People 2010
1767
18BURDEN OF DISEASEDISABILITY ADJUSTED LIFE YEARS
(DALYs)LOS ANGELES COUNTY(SOURCE JONATHON
FIELDING, MD, MPH, MBA, DIRECTOR AND HEALTH
OFFICER, LOS ANGELES COUNTY DEPARTMENT OF PUBLIC
HEALTH)
19EXAMPLES OF DISEASE-FOCUSED PROGRAMS IN
CALIFORNIA HEALTH DEPARTMENTS
- COMMUNICABLE DISEASE
- TB, STDs, HIV/AIDS, OTHER COMMUNICABLE DISEASES
- CHRONIC DISEASE INJURY
- ASTHMA, DIABETES
- INJURY PREVENTION
20Smoking
Nutrition
Physical activity
Disease and Injury
Mortality
Risk Factors
Alcohol Drugs Violence
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22Public Health Practice
Disease and Injury
Mortality
Risk Factors
23BRIEF INTERLUDE 1 TOBACCO vs. NUTRITION AS
EXAMPLES OF PUBLIC HEALTH PRACTICE
Disease and Injury
Risk Factors
Neighbor- hood Conditions
Institutional Power
Mortality
Social Inequalities
24BRIEF INTERLUDE 2 ASTHMA AS AN EXAMPLE OF A
CENTER OF EXCELLENCE FOR ELIMINATING DISPARITIES
(CEED)
Disease and Injury
Risk Factors
Neighbor- hood Conditions
Institutional Power
Mortality
Social Inequalities
25Physical environment
Disease and Injury
Risk Behaviors
Mortality
Neighbor- hood Conditions
Social Environment
26INSTITUTE OF MEDICINETHE FUTURE OF PUBLIC HEALTH
(1988)
- IT IS THE MISSION OF PUBLIC HEALTH TO . .
.ASSUR(E) THE CONDITIONS IN WHICH PEOPLE CAN BE
HEALTHY
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29EXAMPLES OF DIFFERENCES IN LIFE EXPECTANCY BY
NEIGHBORHOOD
- Bayview/Hunters Point lt14 years compared with
Russian Hill (City and County of San Francisco) - Bay Point lt11 years compared with Orinda (Contra
Costa County) - West Oakland lt14 years compared with the hills
(Alameda County)
30ALAMEDA COUNTY
31High school grads 90 Unemployment 4 Poverty
7 Home ownership 64 Non-White 49 (World
rank 15)
32High school grads 81 Unemployment 6 Poverty
10 Home ownership 52 Non-White 59
33High school grads 65 Unemployment 12 Poverty
25 Home ownership 38 Non-White 89 (World
rank 88)
34Corporations and businesses
Disease and Injury
Risk Factors
Neighbor- hood Conditions
Mortality
Institutional Power
Government agencies
Schools
35(PHOTO OF PORT OF OAKLAND)
36EXAMPLES OF INSTITUTIONAL POWERS THAT INFLUENCE
NEIGHBORHOOD CONDITIONS
- BUILT ENVIRONMENT
- LAND USE PLANNING
- TRANSPORTATION
- ECONOMIC DEVELOPMENT
- REDEVELOPMENT
- PORT
- NATURAL ENVIRONMENT
- AIR, WATER, SOIL
- SOCIAL ENVIRONMENT
- ECONOMIC INVESTMENT, EMPLOYMENT
- CLASS, RACIAL/ETHNIC COMPOSITION
- SCHOOLS
37Class
Gender
Disease and Injury
Risk Factors
Neighbor- hood Conditions
Institutional Power
Mortality
Social Inequalities
Race/ethnicity
Immigration status
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41WHAT DOES TRANSFORMING PUBLIC HEALTH PRACTICE
MEAN?
- BARHII COMMITTEES
- DATA
- COMMUNITY
- BUILT ENVIRONMENT
- SOCIAL DETERMINANTS OF HEALTH
- INTERNAL CAPACITY
42DATA
- PROVIDE EVIDENCE BASE TO SUPPORT EXPANDED PUBLIC
HEALTH PRACTICE - FROM PASSIVE (SURVEILLANCE, TRACKING, MONITORING)
TO ACTIVE - MEASURES OF NEIGHBORHOOD CONDITIONS THAT
INFLUENCE HEALTH (PREVENTION) - HEALTH IMPACT ASSESSMENTS HIAs OF POLICIES
THAT HAVE HEALTH CONSEQUENCES - SAN FRANCISCOS HEALTHY DEVELOPMENT MEASUREMENT
TOOL (www.thehdmt.org)
43COMMUNITY
- FROM ADVISORY COUNCILS AND CBO CONTRACTS
ORGANIZED AROUND DISEASES AND POPULATIONS TO
COMMUNITY ORGANIZING - COMMUNITY ENGAGEMENT AND CAPACITY BUILDING
44BUILT ENVIRONMENT
- LAND USE (SMART GROWTH, NEW URBANISM, etc.)
- EXPANDED PLATFORM TO INCLUDE TRANSPORTATION,
ECONOMIC DEVELOPMENT AND REDEVELOPMENT - EXPLICIT FOCUS ON HEALTH EQUITY
45SOCIAL DETERMINANTS OF HEALTH
- A PHRASE THAT IS INCREASINGLY USED BUT POORLY
UNDERSTOOD - INITIAL RESEARCH PROJECT TO GATHER WORK THAT IS
BEING DONE - MacARTHUR FOUNDATION RESEARCH NETWORK ON SES AND
HEALTH - RWJ COMMISSION FOR A HEALTHIER AMERICA
- CONNECTICUT HEALTH DIRECTORS SOCIAL DETERMINANTS
OF HEALTH EQUITY INDEX - COMMISSIONED PAPERS
- OTHER
- HOW TO TRANSLATE IT INTO PUBLIC HEALTH PRACTICE
46INTERNAL CAPACITY
- TRAININGS ON SOCIAL INEQUALITIES AND HEALTH
- ORGANIZATIONAL SELF-ASSESSMENT TOOLKIT
- RECONSIDERING THE FINANCING, WORKFORCE AND
ORGANIZATION OF LOCAL HEALTH DEPARTMENTS
47MOVING HEALTH EQUITY FROM THE PERIPHERY TO THE
CENTER OF PUBLIC HEALTH
48SOME FORCES SHAPING THE CONTOURS OF PUBLIC HEALTH
- ON THE ONE HAND . . .
- PUBLIC HEALTH FINANCING, WORKFORCE AND
ORGANIZATION STILL LARGELY REFLECT 19th, EARLY
20th CENTURY ORIGINS - ACCREDITATION AND CREDENTIALING
- CDC FOCUS ON HEALTH DISPARITIES AS DISEASES AND
POPULATIONS
49BURDEN OF DISEASE DISABILITY ADJUSTED LIFE
YEARS (DALYs) LOS ANGELES COUNTY(SOURCE
JONATHON FIELDING, MD, MPH, MBA, DIRECTOR AND
HEALTH OFFICER, LOS ANGELES COUNTY DEPARTMENT OF
PUBLIC HEALTH)
50ACCREDITATION DRAFT STANDARDS
- DOMAIN 1 CONDUCT ASSESSMENT ACTIVITIES FOCUSED
ON POPULATION HEALTH STATUS AND HEALTH ISSUES
FACING THE COMMUNITY - DOMAIN 2 INVESTIGATE HEATLH PROBLEMS AND
ENVIRONMENTAL PUBLIC HEALTH HAZARDS TO PROTECT
THE COMMUNITY - DOMAIN 3 INFORM AND EDUCATE ABOUT PUBLIC HEALTH
ISSUES AND FUNCTIONS - DOMAIN 4 ENGAGE WITH THE COMMUNITY TO IDENTIFY
AND SOLVE HEALTH PROBLEMS - DOMAIN 5 DEVELOP PUBLIC HEALTH POLICIES AND
PLANS - DOMAIN 6 ENFORCE PUBLIC HEALTH LAWS AND
REGULATIONS - DOMAIN 7 PROMOTE STRATEGIES TO IMPROVE ACCESS TO
HEALTH CARE SERVICES - DOMAIN 8 MAINTAIN A COMPETENT PUBLIC HEALTH
WORKFORCE - DOMAIN 9 EVALUATE AND CONTINUOUSLY IMPROVE
PROCESSES, PROGRAMS AND INTERVENTIONS - DOMAIN 10 CONTRIBUTE TO AND APPLY THE EVIDENCE
BASE OF PUBLIC HEALTH
51SOME FORCES SHAPING THE CONTOURS OF PUBLIC HEALTH
(CONTD)
- . . . ON THE OTHER
- REGIONAL STRATEGY
- CALIFORNIA
- CHRONIC DISEASE ORGANIZING CAMPAIGN
- CALIFORNIA/HAWAII LEADERSHIP INSTITUTE
- BARHII, LA, SHASTA
- NACCHO HEALTH EQUITY SOCIAL JUSTICE STRATEGIC
DIRECTION TEAM - PILOT SITES
- NATIONAL COALITION
- UNNATURAL CAUSES IS INEQUALITY MAKING US SICK?
- CDC INTEREST IN SOCIAL DETERMINANTS OF HEALTH
HEALTH EQUITY NEW ADMINISTRATION - RWJ COMMISSION FOR A HEALTHIER AMERICA
- WHO DECLARATIONS
52REFLECTIONS ON SOME CONTRIBUTIONS OF THE SOCIAL
SCIENCES TO PUBLIC HEALTH
53THEORETICAL FRAMEWORK
- WE NEED AN EQUIVALENT OF THE GERM THEORY OF
DISEASE TO HELP US UNDERSTAND THE SOCIAL ETIOLOGY
OF DISEASE - SOCIAL DETERMINANTS OF HEALTH IS A PHRASE THAT
OFFERS LITTLE CONCEPTUAL GUIDANCE - THEORY BY DEFAULT SOCIAL CAPITAL AND THE
DURKHEIMIAN INFLUENCE
54HEALTH EQUITY REQUIRES AN UNDERSTANDING OF SOCIAL
POWER AND HOW IT SHAPES THE WORLD WE LIVE IN
- HOW DO SOCIAL INEQUALITIES GUIDE THE EXERCISE OF
INSTITUTIONAL POWER? - HOW DO INCOME AND WEALTH GET CREATED AND
DISTRIBUTED, AND HOW ARE THEY AFFECTED BY PUBLIC
(e.g., TAX) POLICIES? - HOW DO INEQUALITIES BY RACE, GENDER GET
REFLECTED IN FORMS OF SOCIAL AND ECONOMIC POWER? - WHAT ARE THE HEALTH CONSEQUENCS OF HOW WEALTH AND
POWER ARE DISTRIBUTED, AND WHAT ROLE CAN PUBLIC
HEALTH PLAY?
55METHODS
- LIMITS OF EPIDEMIOLOGY
- POSES QUESTIONS IT CANNOT ANSWER
56EXAMPLE 1 LATINO PARADOX
57EXAMPLE 2 VIOLENCE AS A PUBLIC HEALTH ISSUE
- EPIDEMIOLOGICAL EVIDENCE SHOWS THAT THE BURDEN OF
HOMICIDE FALLS DISPROPORTIONATELY ON AFRICAN
AMERICAN AND LATINO YOUTH - PUBLIC HEALTH AND LAW ENFORCEMENT
- CeaseFire IN CHICAGO
- EVIDENCE-BASED PUBLIC HEALTH APPROACH
- INFECTIOUS DISEASE FRAMEWORK
- CONTAINING OUTBREAKS BY PREVENTING TRANSMISSIONS
58VIOLENCE (CONTD)
- PRIMARY PREVENTION MEANS DEALING WITH THE CAUSE,
NOT THE CONSEQUENCE - WHO IS KILLING AFRICAN AMERICAN AND LATINO YOUTH,
AND WHY? - PSYCHOLOGY OF RAGE AS A RESPONSE TO RACISM AND
OPPRESSION - FRANTZ FANON, WRETCHED OF THE EARTH
- SOCIOLOGY OF GANGS
- BONDING CAPITAL WITHOUT BRIDGING CAPITAL
- SOCIAL SEGREGRATION IN HOUSING
- DRUG SALES AND THE INFORMAL ECONOMY
59METHODS
- LIMITS OF EPIDEMIOLOGY (CONTD)
- HUMPTY DUMPTY AND C. WRIGHT MILLS
60 Postsecondary Attendance Rates for Low-Income
High Achievers and High-Income Low Achievers
Source NELS 88, Second (1992) and Third Follow
up (1994) in, USDOE, NCES, NCES Condition of
Education 1997 p. 64
61METHODS
- PUBLIC HEALTH NEEDS QUALITATIVE METHODS THAT CAN
HELP US UNDERSTAND HOW PEOPLE EXPERIENCE
CONDITIONS THAT AFFECT HEALTH
62THE FUTURE OF PUBLIC HEALTH AND THE IMPORTANCE OF
THE SOCIAL SCIENCES
- PUBLIC HEALTH NEEDS AN INTELLECTUAL CULTURE
INFORMED BY THE SOCIAL SCIENCES TO HELP PEOPLE
WHO LARGELY HAVE BEEN TRAINED IN BIO-MEDICAL
DISCIPLINES - PUBLIC HEALTH WORKFORCE NEEDS EXPOSURE TO SOCIAL
THEORY AND A WAY OF THINKING ABOUT SOCIAL
ETIOLOGY - PUBLIC HEALTH NEEDS INSIGHTS FROM SOCIOLOGY,
POLITICAL SCIENCE, ECONOMICS, PSYCHOLOGY,
HISTORY, ANTHROPOLOGYHOPEFULLY, IN A WAY THAT
DOES NOT REFLECT THE SEPARTENESS OF THOSE
DISCIPLINES, BUT RATHER THEIR POTENTIAL
INTEGRATION
63www.barhii.org