HEALTH POLICY and VULNERABLE POPULATIONS

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HEALTH POLICY and VULNERABLE POPULATIONS

• M9500
• January 25, 2000
• Kristine M. Gebbie,DrPH, RN

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Introduction

• Health Policy provides direction for action
• Vulnerable populations are a target for action
  because
• social justice imperative
• threat to others

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Why thinking systematically is important

• During 1995, in Zaire (now the Congo)
• in one month, 315 people got Ebola virus and 245
  died.
• In that same month, 10,000 to 15,000 Zaireans got
  HIV
• 4500 to 5000 intentuional injury deaths in USA
  (US 44/day, Japan 38/year1992)
• 3000 new teen smokers each day.

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Vulnerable population can be defined as

• subgroup of the overall population
• higher risk of problem(s)
• may be defined by age, gender, ethnicity, health
  status
• may vary over time and place

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International perspective on vulnerability
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International perspective, cont.
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Public Spending on Health
The percentage of total spending on health by
governments in the USA, neighboring countries and
major industrialized nations
1995 most recent data available
Source World Health Organization, World Health
Report 1999
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Progress on Healthy People 2000 Targets
Total Population (319 Targets)
Special Population (210 Targets)
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Americans in the 20th CenturyLife Expectancy at
Birth
Were living longer.
years
1900-1925, from death-registration states only.
Beginning 1970, excludes nonresidents.
Source United States Census Bureau issued in
Statistical Abstract of the United States
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US Vital Statistics

• Life expectancy
• all races 74.5
• white 76.1
• Years of healthy life
• all races 64.0
• white 65.0
• black 56.0
• hispanic 64.8

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Minorities Are More Likely to Report Difficulty
Getting Needed Health Care
Other includes Native American or Alaska native,
mixed race, some other race, or not sure.
Source The Commonwealth Fund Survey of Health
Care in New York City, 1997 Louis Harris and
Associates, Inc.
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Infant mortality

• black infant rate 2.4 times white
• disparity has not narrowed from 87-92
• Puerto Rican rate rising over 5 years

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Medicare Population by Poverty Level, 1996
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45 with income below 200 of Poverty
16
55
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Note 1996 federal poverty was 7,740 for
individuals 10,360 for couples.
Source Urban Institute estimates based on the
March 1997 Current Population Survey,
non-institutionalized Medicare beneficiaries only.
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HIV/AIDS

• Over 80 children affected are black
• New cases are disproportionately in minority
  communities
• Distribution across country is extremely variable

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AIDS Rates per 100,000 Black Population
Reported in 1998
39.8




24.7
74.1

42.8


187.5
MA
115.8

38.3
RI
107.1
17.4
116.6
27.3
CT
113.2
63.2
NJ
153.6
30.8
40.3
54.7
65.5
DE
119.8
71.7
45.9
34.3
MD
124.5
25.8
61.8
41.7
41.0
DC
324.8
43.9
55.2
54.2
31.8
26.0
57.5
Rate per 100,000
66.7
lt50
39.9
59.1
37.6
50-99
100
80.6
60.5
lt5 cases


183.5
US rate 86.3
34.6
N21,515
Includes cases with unknown state of residence

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AIDS Rates per 100,000 Hispanic Population
Reported in 1998
21.0




16.3
26.9
NH
56.1

17.8

137.3
MA
85.9

14.7
RI
79.3

89.7
27.1
CT
96.6
24.1
NJ
45.9
19.8
20.6
17.8
27.7
DE
62.5
20.9
13.6

MD
18.1
19.1
14.3
22.9
26.3
DC
120.9
19.6
40.2
21.0
25.0
11.6
16.5
23.0
Rate per 100,000
lt20
19.5

17.2
20-49.9
50
21.6
25.5
lt5 cases

29.6
48.3
US rate 39.1
P.R. 58.3
18.9
N9,566
Includes cases with unknown state of residence

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AIDS Rates per 100,000 White Population
Reported in 1998
7.8
3.9
2.9
1.0
2.7
6.9
2.7
NH
3.3
2.9
2.5
2.4
18.2
MA
9.5

4.1
RI
8.1
2.9
6.2
3.6
CT
10.8
15.0
NJ
10.1
4.4
7.4
5.4
7.3
DE
6.7
20.1
7.8
4.6
MD
8.8
4.0
7.6
6.2
6.1
DC
55.8
4.5
8.2
16.0
8.9
6.5
13.0
8.4
Rate per 100,000
lt5
7.1
7.2
5.6
5-9.9
10
17.9
12.2
lt5 cases

3.9
19.0
US rate 9.9
32.6
N16,060
Includes cases with unknown state of residence

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MMWR, January 14, 2000
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Commonwealth Fund, Summer, 1999
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Impact of welfare reform

• In 1995, 88 of poor children received food
  stamps in 1998, 70
• From 1995-1997, average incomes of poorest 20 of
  female headed families fell
• 2 million families, 6 million people
• drop of 580 per family below 3/4 of poverty
  line
• Poorest 10 lost 1/7 of income, 810/year

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Environmental hazards

• siting of waste and toxic sites
• availability of sewers/drinking water

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Pollution ProblemHow Texas ranks on the
environment
Air pollution 27 of the 30 highest ozone readings
this year were in Texas 1st in number of days
with unhealthy ozone 1st in airborne
carcinogens 1st in ozone components 1st in toxic
air releases Spending 46th among states for water
resources protection, devoting 3 per person each
year to this effort. 44th in spending on
environment per capita.
Some of the areas with the highest ozone levels
are in East Texas
Average of peak ozone levels for summer days in
parts per billion (ppb)
Less than 50 ppb 51-55 ppb 55-60 ppb More than 60
ppb
Sources EPA, TNRCC, Environmental Working Group,
Environmental Defense Fun, Council of State
Governments, Public Citizen, Sustainable Energy
Economic Development Coalition, Sierra Club,
Clean Air Task Force, Abt Associaties
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Leading Causes of Death
Figures from 1996 for all ages, all races, both
sexes.
Source National Center for Health Statistics
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Actual Causes of Death, 1990

• Tobacco
• Diet/activity
• Alcohol
• Microbial Agents
• Toxic Agents
• Firearms
• Sexual Behavior
• Motor Vehicles
• Drug Use

• 400,000
• 300,000
• 100,000
• 90,000
• 60,000
• 35,000
• 30,000
• 25.000
• 20,000

McGinnis Foege, 1993 JAMA 27022207-12
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Tobacco and alcohol lead the list

• advertising for both products are targeted at
  vulnerable populations
• minority neighborhoods
• support for community groups and the arts
• adolescent appeal

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What should be the goal for health?

• Healthy people in healthy communities
• A health system which promotes physical and
  mental health and prevents disease injury and
  disability

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How the system fits together
Tertiary Medical Care
Tertiary Prevention
Secondary Medical Care
Secondary Prevention
Primary Medical Care
Clinical Preventive Services
Primary Prevention
2
Population Oriented Prevention
Relative Investment
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The specific responsibilities of public health

• prevent epidemics/spread of disease
• protect against environmental hazards
• prevent injuries
• promote/encourage healthy behavior
• respond to disasters/assist in recovery
• assure quality/accessibility of health services

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Determinants of Health
Social Environment
Physical Environment
Genetic Endowment
Individual Response
Disease
Health Care
Health Function
Well-Being
Evans Stoddard
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Appropriate response requires reallocation of
resources
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HP2010 a policy example

• The development of national health objectives is
  a policy-setting process
• The model being used builds on an understanding
  of the determinants of health beyond a linear
  disease model
• The national goals being set are an attempt to
  minimize threats to the health of vulnerable
  populations.

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Conceptual Framework for Healthy People 2010
Goals
Health Status
Determinants of Health
Policy
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