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Transforming Public Health Practice to Achieve Health Equity in Alameda County

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Title: Transforming Public Health Practice to Achieve Health Equity in Alameda County


1
Transforming Public Health Practice to Achieve
Health Equity in Alameda County
  • Tony Iton, M.D., J.D., MPH
  • Director Alameda County Public Health Department
  • Place Matters Design Lab
  • Oakland, Ca
  • July 23, 2008

2
Health Inequities
  • Health inequities are differences in health
    status and mortality rates across population
    groups that are systemic, avoidable, unfair, and
    unjust.
  • -Margaret Whitehead

3
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4
BARHII Framework
5
Infant mortality
Mortality
Life expectancy
6
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7
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8
67
9
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10
What Do We Know?
  • Major improvements in health outcomes
  • Major health inequities persist or are growing -
    poorer residents and African Americans bear the
    greatest burden of poor health outcomes
  • Big gap in life expectancy
  • Major inequities in life expectancy and mortality
    driven by chronic diseases

11
Chronic disease
Infectious disease
Injury (intentional and unintentional)
Mortality
Disease and Injury
Access to health care
10 15
Genetics
10 15
12
Smoking
Medical Model
Nutrition
Physical activity
Disease and Injury
Mortality
Risk Behaviors
Individual health knowledge
70 ??
Violence
13
Is This All About Personal Responsibility?
  • The Medical Model Assumes that Risk Behaviors
    are the Missing 70

14
Medical Model InterventionsSERVICES
  • Tend to focus on individuals
  • Tend to be remedial in nature
  • Do not address underlying conditions
  • Expensive and difficult to sustain
  • No sustained impact on health disparities
  • Majority of Health, Social Services Criminal
    Justice budget spent on these kind of
    interventions

15
Services Overkill?
  • How Government Human Service Agencies Behave

16
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17
Recipients as of Oct 2006.
18
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19
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20
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21
Community Trajectories
  • HOW MUCH DOES PLACE MATTER?

22
Physical environment
Social environment
?
Disease and Injury
Risk Behaviors
Mortality
Neighbor- hood Conditions

Residential segregation
23
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24
High school grads 90 Unemployment 4 Poverty
7 Home ownership 64 Non-White 49
25
High school grads 81 Unemployment 6 Poverty
10 Home ownership 52 Non-White 59
26
High school grads 65 Unemployment 12 Poverty
25 Home ownership 38 Non-White 89
27
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28
Life Expectancy by Poverty Group 2000-2003
29
Tract Poverty vs. Life Expectancy
30
Bay Area Poverty vs. Life Expectancy
31
Cost of Poverty in Alameda County
  • Every additional 12,500 in household income buys
    one year of life expectancy
  • (Benefit appears to plateau at household incomes
    above 150,000)

32
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34
1964 Oakland Residential Segregation Study
  • "Shows how lines of discrimination are drawn.
  • Shows the area pattern of social exclusion
    community graded indices of wealth, status,
    health, education, and social behavior.
  • Grades fairly evenly from low to high, beginning
    with the Bay-flats region, and extending to the
    upper portion, the hill area.
  • -Housing Discrimination in Oakland A Study
    Prepared for the Oakland Mayors Committee on
    Full Opportunity and Alameda County Council of
    Social Planning-1964.

35
It is necessary that properties shall continue
to be occupied by the same social and racial
groups- Federal Housing Administration
Underwriting Manual 1938 in recommending racially
restrictive covenants.
36
Life ExpectancyOakland Flats and Hills
(2000-2003)
37
The Neighborhood Context
38
The Neighborhood Context
39
Schools
Corporations and businesses
Disease and Injury
Risk Behaviors
Neighbor- hood Conditions
Mortality
Institutional Power
Government agencies
40
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41
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42
CST 4th Grade Reading Oakland Unified, by
Ethnicity
Source California Department of Education,
http//data1.cde.ca.gov/dataquest/
43
CST 8th Grade ReadingOakland Unified, by
Ethnicity
Source California Department of Education,
http//data1.cde.ca.gov/dataquest/
44
CST 11th Grade ReadingOakland Unified, by
Ethnicity
Source California Department of Education,
http//data1.cde.ca.gov/dataquest/
45
In Oakland, African American and Latino 7th
graders read below the level of White 3rd graders
CAT/6 2005
Source California Department of Education,
http//data1.cde.ca.gov/dataquest/
46
Equal 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
47
The American high school is obsolete. If we
keep the system as it is, millions of children
will never get a chance to fulfill their promise
because of their zip code, their skin color, or
the income of their parents. That is offensive
to our values, and its an insult to who we
are.-Bill Gates addressing the National
Governors Assoc. 2005
48
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49
NIH
  • A review of the scientific literature shows
    associations between education and health across
    a broad range of illnesses, including coronary
    heart disease, many specific cancers, Alzheimer's
    disease, some mental illnesses, diabetes, and
    alcoholism.
  • -NIH RFA OB-03-001-PATHWAYS LINKING EDUCATION TO
    HEALTH

50
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51
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52
Home Ownership by Race/Ethnicity
53
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54
Race/ethnicity
Class
Gender
Disease and Injury
Risk Behaviors
Neighbor- hood Conditions
Institutional Power
Mortality
Social Inequalities
Immigration status
55
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56
Results of the statistical comparison of weather
and deaths over 12 years show that blacks and
those with a high school education or less are
most likely to die on extremely hot days.
Harvard School of Public Health study of almost
8 million deaths in 50 cities from 1989 to 2000.
57
  • The heat wave was a particle accelerator for the
    city It sped up and made visible the hazardous
    social conditions that are always present but
    difficult to perceive.
  • Yes, the weather was extreme. But the deep
    sources of the tragedy were the everyday
    disasters that the city tolerates, takes for
    granted, or has officially forgotten.-

Eric Klineberg, author of Heat Wave
58
Life Expectancy
High school grads 90 Unemployment 4 Poverty
7 Home ownership 64 Non-White 49
gt80
High school grads 81 Unemployment 6 Poverty
10 Home ownership 52 Non-White 59
74.3 - 80
High school grads 65 Unemployment 12 Poverty
25 Home ownership 38 Non-White 89
lt74.3
Toxins
Segregation
Jobs
Housing
Schools
Crime
59
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60
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61
How is the ACPHD Moving Upstream?
  • Community Capacity Building/youth development
  • Internal Capacity Building
  • Local Policy agenda

62
Community Capacity Building/Empowerment

Aims to strengthen characteristics of
communities to plan, develop, implement
maintain effective community programs that
positively affect broader community conditions
that determine health and well being -adapted
from the W. K. Kellogg Foundation
63
Community Capacity Building Place-based
  • Build social, economic and political power in
    communities to advocate for equal distribution of
    resources
  • Win concrete improvements in residents lives
  • Build skills of residents to speak act
    effectively on their behalf
  • Engage residents to influence decisions made by
    those in power
  • Build strong local neighborhood groups that can
    mobilize community for action

64
Internal Capacity Building Goals
  • Improve practice to eradicate health inequities
  • Ensure staff understanding of public health
  • Create a shared vision and unified direction for
    health equity
  • Develop present and future leaders
  • Raise staff awareness and commitment towards a
    common goal

65
Internal Capacity Building Activities
  • Sharing the vision
  • Leadership and Professional Development Programs
  • PH 101 staff training
  • Institutional Racism discussions
  • Strategic Plan focused on Social Justice

66
Leadership Development and Succession Planning
  • Goal
  • Ensure current and future leaders are prepared
    with knowledge, tools and skills for challenges
    they will face in guiding the ACPHD towards
    providing the most effective and highest quality
    public health programs and services to Alameda
    County residents.

67
Public Health 101
Module 1 PH History Public Health System Core
Functions 10 Essential Services
Module 2 Cultural Competency and Cultural
Humility
Module 3 Undoing Racism
Module 4 Health Status/Inequities Social
Determinants of Health
Module 5 Community Capacity Building
68
Institutional Racism Managers Retreat
  • Racism Dialogues for Staff and Community
  • Show the 3 films to all new hires
  • Share with school-age kids
  • Effect Legislation Process to Address Racism
  • Be part of the legislative process to change the
    current laws which perpetuate racism
  • Improve Hiring Process
  • Strive for staff diversity to match county
    diversity
  • Speed up hiring process to allow more people
    ability to access jobs
  • Examine Policies for Racism
  • Examine our policies to see if they perpetuate
    racism

Leadership, senior managers, leadership and
management fellows 120 people
69
Participatory Strategic Plan on Health Equity
  • Goal Create 5 year strategic plan that addresses
    root causes of health inequity in Alameda
    County.

70

71
Strategic Directions
  • Transforming our organizational culture and
    aligning our daily work to achieve health equity
  • Enhancing Public Health communications internally
    and externally.
  • Ensuring organizational accountability through
    measurable outcomes and community involvement.

72
Strategic Directions
  • Supporting the development of a productive,
    creative, and accountable workforce
  • Advocating for policies that address social
    conditions impacting health
  • Cultivating and expanding partnerships that are
    community-driven and innovative

73
Local Policy Agenda
  • The Alameda County Place Matters team promotes
    health equity through a community-centered local
    policy agenda focused on education, economic
    development, incarceration, land use, and
    transportation.

74
Local Policy Agenda - Objectives
  • Identity key priority areas and policies
  • Identify appropriate indicators for each area
  • Collect baseline data and analyze policies
  • Build public dialogue about policies impacts on
    health pro equity lens
  • Influence the policy making processes
  • Improve interdepartmental and interagency
    cooperation to achieve community health goals

75
  • Understanding historical forces
  • Multiple sectors
  • Meaningful public participation
  • Monitoring impact of social policies
  • Cumulative impact
  • Strengthening social fabric
  • Land use policy

76
Changes
  • Increased organizational infrastructure and
    support for isms and health equity work
  • Strategic Plan
  • Leadership with a social justice perspective
  • Increased
  • Understanding of cumulative historical impacts
  • Ability to dialogue using common language
  • Increased support and commitment
  • Residents, leadership, staff, Board of
    Supervisors
  • Increased activities throughout the department

77
Public Health Department
78
World Health Organization. The Social
Determinants of Health-The Solid Facts, 2nd
Edition 2003
79
Contact Information
Tony Iton, MD, JD, MPH Director and Health
Officer Alameda County Public Health
Department Tony.Iton_at_acgov.org (510) 267-8019
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