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CONFRONTING THE SOCIAL DETERMINANTS OF HEALTH INEQUITIES: RETHINKING PUBLIC HEALTH

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REFLECTIONS ON SOME CONTRIBUTIONS OF THE SOCIAL SCIENCES TO ... PUBLIC HEALTH AS GOTH: THE USES OF DEATH AS A MEASURE OF POPULATION HEALTH. INFANT MORTALITY ... – PowerPoint PPT presentation

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Title: CONFRONTING THE SOCIAL DETERMINANTS OF HEALTH INEQUITIES: RETHINKING PUBLIC HEALTH


1
CONFRONTING 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

2
OVERVIEW
  • 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

3
BRIEF HISTORY OF BARHII
4
PROLOGUE1998-2005
  • INFORMAL CONVERSATIONS
  • TWO STEPS FORWARD, ONE STEP BACK
  • EXPANSION AND SUPPORT
  • FROM TOP DOWN TO BROADLY PARTICIPATORY
  • FORMAL BEGINNINGS OCTOBER, 2005

5
BARHII MISSION STATEMENT
  • . . . TO TRANSFORM PUBLIC HEALTH PRACTICE FOR
    THE PURPOSE OF ELIMINATING HEALTH INEQUITIES
    USING A BROAD SPECTRUM OF APPROACHES THAT CREATE
    HEALTHY COMMUNITIES.

6
HEALTH 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

7
Health 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

8
WORLD 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........"
10
A CONCEPTUAL FRAMEWORK FOR RE-THINKING PUBLIC
HEALTH
11
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12
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13
Infant mortality
Mortality
Life expectancy
14
PUBLIC 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

15
Chronic disease
Infectious disease
Injury (intentional and unintentional)
Mortality
Disease and Injury
16
DISEASE AS THE CAUSE OF DEATH Ten Leading
Causes of Death Source Healthy People 2010
17
67
18
BURDEN 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)
19
EXAMPLES OF DISEASE-FOCUSED PROGRAMS IN
CALIFORNIA HEALTH DEPARTMENTS
  • COMMUNICABLE DISEASE
  • TB, STDs, HIV/AIDS, OTHER COMMUNICABLE DISEASES
  • CHRONIC DISEASE INJURY
  • ASTHMA, DIABETES
  • INJURY PREVENTION

20
Smoking
Nutrition
Physical activity
Disease and Injury
Mortality
Risk Factors
Alcohol Drugs Violence
21
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22
Public Health Practice
Disease and Injury
Mortality
Risk Factors
23
BRIEF INTERLUDE 1 TOBACCO vs. NUTRITION AS
EXAMPLES OF PUBLIC HEALTH PRACTICE
Disease and Injury
Risk Factors
Neighbor- hood Conditions
Institutional Power
Mortality
Social Inequalities
24
BRIEF 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
25
Physical environment
Disease and Injury
Risk Behaviors
Mortality
Neighbor- hood Conditions

Social Environment
26
INSTITUTE 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

27
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28
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29
EXAMPLES 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)

30
ALAMEDA COUNTY
31
High school grads 90 Unemployment 4 Poverty
7 Home ownership 64 Non-White 49 (World
rank 15)
32
High school grads 81 Unemployment 6 Poverty
10 Home ownership 52 Non-White 59
33
High school grads 65 Unemployment 12 Poverty
25 Home ownership 38 Non-White 89 (World
rank 88)
34
Corporations and businesses
Disease and Injury
Risk Factors
Neighbor- hood Conditions
Mortality
Institutional Power
Government agencies
Schools
35
(PHOTO OF PORT OF OAKLAND)
36
EXAMPLES 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

37
Class
Gender
Disease and Injury
Risk Factors
Neighbor- hood Conditions
Institutional Power
Mortality
Social Inequalities
Race/ethnicity
Immigration status
38
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39
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40
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41
WHAT DOES TRANSFORMING PUBLIC HEALTH PRACTICE
MEAN?
  • BARHII COMMITTEES
  • DATA
  • COMMUNITY
  • BUILT ENVIRONMENT
  • SOCIAL DETERMINANTS OF HEALTH
  • INTERNAL CAPACITY

42
DATA
  • 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)

43
COMMUNITY
  • FROM ADVISORY COUNCILS AND CBO CONTRACTS
    ORGANIZED AROUND DISEASES AND POPULATIONS TO
    COMMUNITY ORGANIZING
  • COMMUNITY ENGAGEMENT AND CAPACITY BUILDING

44
BUILT ENVIRONMENT
  • LAND USE (SMART GROWTH, NEW URBANISM, etc.)
  • EXPANDED PLATFORM TO INCLUDE TRANSPORTATION,
    ECONOMIC DEVELOPMENT AND REDEVELOPMENT
  • EXPLICIT FOCUS ON HEALTH EQUITY

45
SOCIAL 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

46
INTERNAL CAPACITY
  • TRAININGS ON SOCIAL INEQUALITIES AND HEALTH
  • ORGANIZATIONAL SELF-ASSESSMENT TOOLKIT
  • RECONSIDERING THE FINANCING, WORKFORCE AND
    ORGANIZATION OF LOCAL HEALTH DEPARTMENTS

47
MOVING HEALTH EQUITY FROM THE PERIPHERY TO THE
CENTER OF PUBLIC HEALTH
48
SOME 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

49
BURDEN 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)
50
ACCREDITATION 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

51
SOME 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

52
REFLECTIONS ON SOME CONTRIBUTIONS OF THE SOCIAL
SCIENCES TO PUBLIC HEALTH
53
THEORETICAL 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

54
HEALTH 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?

55
METHODS
  • LIMITS OF EPIDEMIOLOGY
  • POSES QUESTIONS IT CANNOT ANSWER

56
EXAMPLE 1 LATINO PARADOX
57
EXAMPLE 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

58
VIOLENCE (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

59
METHODS
  • 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
61
METHODS
  • PUBLIC HEALTH NEEDS QUALITATIVE METHODS THAT CAN
    HELP US UNDERSTAND HOW PEOPLE EXPERIENCE
    CONDITIONS THAT AFFECT HEALTH

62
THE 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

63
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