Health Equity and Social Justice: Community Models, National Priorities

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Health Equity and Social Justice Community
Models, National Priorities

• Adewale Troutman, M.D., M.P.H.
• Director, Fulton County Department of Health and
  Wellness
• Atlanta Georgia

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A Review of the Data
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Some Selected Data

• 278,440 deaths annually in AA community estimated
  80-90,000 excess deaths in 2000
• Almost 1 in 3 deaths were excess deaths
• 16 of the nation is without health insurance,
  38 of Latino adults, 26 of African American
  adults, compared with 14 of white adults
  (Commonwealth Fund)

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Some Selected Data

• Homicide rate for AA is 6xs that for whites
• Hypertension rate is 4xs greater for AA than
  for whites
• AA life expectancy is 71.3, 61.5 for AA men in
  Fulton County
• gt78 for the nation
• Infant mortality rate for AAgt 2x white rate
• In some areas gt6x white rate

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Data (Cont.)

• Breast cancer incidence mortality
• Whites 113.2/100,000 25.7/100,000
• African Americans 99.3/100,000 31.4/100,000
• Latinos 69.4/100,000 15.3/100,000
• Latinos almost twice as likely to die from
  diabetes as whites
• Pima Indians have one of the highest diabetes
  rates in the world

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Data (Cont.)

• African American men have the highest incidence
  mortality rates of prostate cancer in the world
• Prostate cancer rate AA man gt 2x that of white
  men
• African American men 3x more likely to die from
  prostate cancer than white men in Georgia

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Data (Cont.)

• HIV/AIDS 56 of the gt700,000 AIDS cases are
  either African American or Latino
• AA 37 but 12 of population
• Latino 18 but 13 of population
• 81 of female cases with 58 of pediatric cases
  in AA community
• In 1999, AIDS accounted for 50 of all African
  American deaths 18 of Latino deaths

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More Data

• African American age adjusted death rates
  exceeded those for whites
• By 77 in stroke
• By 47 for heart disease
• By 34 for cancer
• By 655 for HIV infection

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Life Expectancy

• Nationally (African American men 67)
• Fulton County 61.5
• White men 70.7
• White women 79

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Socioeconomic Status
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Socioeconomic Status and Health

• Occupation
• Education
• Income
• Believed to be the biggest contributor to health
  status
• SES as correlate to health outcomes
• PQLI and literacy

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Socioeconomic Factors

• Correlate of race
• Must correct for SES when looking at race
• Prevailing measures imperfect proxies
• Multiple variations within SES
• Standard measures have different meanings for
  different races
• Purchasing power will differ between races
• Low SES AA pay more than whites for rent

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SES (Cont.)

• At every level, whites have more assets that
  blacks
• Blacks have less valuable homes
• Whites earn 1.5xs than Blacks, possess 4 times
  as much wealth
• Blacks more likely to be first generation middle
  class
• More likely to be supporting poorer relatives

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SES (Cont.)

• Do not capture effect of lifetime exposure to
  deprivation
• Lack of childhood prevention may have long term
  effects

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The World As We Know It

• The reality of the haves and the have nots
• The growth of the gap
• Concentration of wealth in the hands of a
  shrinking few
• The immorality and unacceptable nature of a
  permanent underclass

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Medical Care
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Medical Care

• Persistence in huge variations in quality and
  quantity of care
• AA more than twice as likely to receive care in
  hospital ERs and clinics where less likely to
  receive continuity of care (different provider
  each visit)
• AA more likely to be dissatisfied with care

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Medical Care

• More likely to receive inadequate information
  about care, instructions, medication information
  and information about presenting problem
• Increased proportion of AA without health
  insurance (increased from18-25 in 10 years)

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More Data

• Survey of physician attitudes (Van Ryn Burke
  2000) after correction for SES
• AA less intelligent, less educated, more likely
  to be alcoholics and drug abusers, more likely to
  fail to comply
• Less likely to have social support
• Less likely to participate in cardiac
  rehabilitation

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Lets Agree on the Terms
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Health

• Not merely the absence of disease but the
  presence of physical, psychological, social
  economic and spiritual well being
• The harmonious balance of mind, body and spirit

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Equity

• Justice according to natural law or right
• Freedom from bias or favoritism

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Justice

• The quality of fairness
• The principle of moral rightness equity
• Conformity to moral rightness in action or
  attitude

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Social Justice

• The application of principles of justice to the
  broadest definition of society
• Implies
• Equity
• Equal access to societal power, goods and
  services
• Universal respect for human and civil rights

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Racism

• An ideology of inferiority that is used to
  justify the unequal treatment of members of
  groups defined as inferior, by both individuals
  and social institutions

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Levels of Racism

• Personally Mediated Differential assumptions and
  about the abilities, motives and intentions of
  others according to their race that may lead to
  differential actions towards members of that race
• Internalized Acceptance by members of the
  stigmatized race of negative messages about their
  own intrinsic self worth (self devaluation,
  helplessness and hopelessness)

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Levels of Racism

• Institutionalized The differential access to
  goods, services and opportunities of society by
  race. May be manifested through law,
  institutional structure, covert or overt
  privilege inherited disadvantage

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Rights Claims or entitlements that are
recognized by legal or moral principles
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Human Rights A higher order right MORALLY based
and UNIVERSAL. It belongs to all persons equally
because they are human beings(Declaration of
Independence)
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Rights are enforced by legislation and rules, the
force of law
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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

• The Declaration of Alma Ata, International
  Conference on Primary Health Care The right to
  health is the most important social goal

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The Right to Health

• The International Declaration of Human Rights
  Everyone has a right to a standard of living
  adequate for the health and well being of his
  family including food, clothing, housing and
  medical care

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The Right to Health

• Affirmed by
• The Covenant of the Rights of the Child
• The Convention on the Elimination of All Forms of
  Racial Discrimination Against Women
• The ICESCR
• The right to the enjoyment of the highest
  standard of physical and mental health

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The International Bill of Human Rights

• The Universal Declaration of Human Rights 1948
• The International Covenant on Civil and Political
  Rights 1966
• The International Covenant on Economic, Social
  and Cultural Rights ( ICESCR )

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The time has come to herald human rights as both
the foundation of public health and the compass
of public policyJAPHA 2000
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The existence of health disparities concentrated
among specific racial groupings is a violation of
United Nations covenants, international
principles of human rights and all principles of
universal justice
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The Minnesota Model
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A Call to Action Advancing Health For All
Through Social and Economic Change

• People with higher income enjoy healthier longer
  life
• Disease and death rates are higher in populations
  that have a greater gap in income
• People are healthiest when they feel safe
• People are healthiest when they feel their job is
  secure

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A Call to Action (Cont.)

• People are healthiest when they feel the work
  they do is important and valued
• Discrimination and racism play a crucial role in
  explaining health status and health disparities

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Race and Racism

• Health and health care industry suffer same
  history as other sectors of American society
• Examples of access limitation secondary to race
• CABG, angioplasty
• AIDS medications
• Referrals for coronary catheterization
• Anecdotes

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Policy Development Public Health Leadership

• A Core Public Health Function

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Policies For Social Justice, Policies For Health
Equity

• Short term and long term solutions
• Short term
• Attention to symptoms (nutrition, physical
  activity, cholesterol, access)
• Creating environment to promote health
• Long term
• Empowerment
• Redistributive policies

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Policies

• Expand focus on the effects of public policy on
  the health of those suffering inequities
• Welfare reform
• Housing and development
• Job development and health insurance
• Literacy and health outcomes
• Tax laws
• Environmental policies

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Policies

• Measuring progress through Social Health
  Indexing
• Living wage
• Educational reform
• Attention to short term only will just create a
  healthier underclass and will not create health
  equity because there is no social justice

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Some Concluding Thoughts
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What Do We Know

• There is a direct relationship between poverty
  and health outcomes
• Disparities in health are linked to disparities
  in wealth
• Health equity and social justice are inseparable
• Racism manifests itself in health disparities

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What Do We Know

• This is a human rights issue
• The right to health and health care
• The civil rights movement didnt go far enough
• Disproportionate share of uninsured, unemployed,
  undereducated
• Radical gaps in income

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What To Do

• The acquisition of the tools of a systematic
  human rights analysis
• Learning the language of human rights
• Determine best practices for evidence based
  health policy
• Balance between promoting and protecting human
  rights and promoting public health as a national
  policy

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What To Do

• The integration of human rights education into
  all levels of academic and professional training
  of health professionals
• Partnering with traditional human rights
  activists
• Public policy aimed at economic equity
• Universal coverage and access to high quality
  single standard of care

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Transformation

• A new paradigm
• Transformation of self
• Movement from victim to empowered position
• Conquer the them vs. us mentality
• The force of self determination

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Social Justice

• Health Status inequities are directly related to
  the continued existence of social injustice
• The existence of social injustice typified by the
  continued growth of the gap between the haves and
  the have-nots, lack of access to services and
  care, preventive and curative is unethical and
  immoral

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Opportunities for Public Health Leadership
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Leadership Development

• The opportunity to change the world view of
  public health
• The institution in the mirror
• Workforce development for social change
• Healthy People 2010 health equity
• Core functions, essential services social
  justice
• MAAP Social Health Indexing

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Leadership Development (Cont.)

• Personal growth and development
• Taking on the challenge of racism
• Cultural competence (consciousness)
• The use of the tools of public health in creating
  health equity through social justice

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Social Justice

• The mere concept of a permanent underclass is
  inherently unethical
• Public health practice must be manifested by a
  new and unrelenting movement for social justice
  and health equity
• NACCHO initiative

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Some Final Thoughts

• The fallacy of improved health for all
• The recognition of social determinants as the
  foundation of health
• SES racism are key elements of causation
• There are universal principles
• Empowerment vs. victimization
• The students role in understanding change

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Moving From Rhetoric to Action

• Definition of Healthy Communities
• Focus on Social Health Social Determinants
• Address race, class health
• Tool of BRFSS
• Curriculum changes (all levels)
• Policy initiative
• Incrementalism vs. Radical Change
• A question of quality
• The tool of regulation (Hill-Burton)

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What we are willing to turn our backs on, ignore
or deny, is the measure of our willingness to
live as hypocrites and deny the core value of
ethics in our daily practice of public health and
more importantly in our very lives.
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We need a social revolution based on social
justice and health equity supported by sound,
sweeping policy aimed at reforming the American
system
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Adewale Troutman,M.D.,M.P.H.Nasanan Health
Consultants 1208 Clearbrook DriveAtlanta
Georgia 30311adedrum_at_aol.com404 730 1202404
691 9608