Creating Health Equity Through Social Justice; Strategies Towards Building Community Health

Fair Society, Healthy Society: Creating Health Equity Through Social Justice and a Focus on the Social Determinants of Health

Adewale Troutman, MD, MPH, MA, CPHUSF College of Public HealthA Case Study; But WhyThe Troutman Group

The Troutman GroupHow you frame an issueThe questions you askDetermines your analysis of the issueDetermines how you prioritize itDetermines your policy choicesDetermines resource allocationCan determine your allies and your enemiesCan define when an issue has been resolvedThe Troutman GroupReframing Health vs. HealthcareIndividual (Medical model) vs. Population HealthMarket Justice vs. Social JusticeRights vs. Privileges Biological/Behavioral Determinants vs. Social DeterminantsCreating Health Equity vs. eliminating Health DisparitiesThe Troutman Group

Of all the injustices, injustices in health are the most shocking and inhumaneMartin Luther King Jr.

Martin Luther King

6Inequity and the GapHistory and EvolutionThe Troutman Group

Vital Statistics:8

What If We Had Eliminated Disparities in the Last Century?Fewer Black DeathsIn 2000 85,000 overall 24,000 from heart disease 7,000 from HIV / AIDS 4,700 infant deaths 22,000 from diabetes 2000 fewer Black women from breast cancerMore Health Insurance Coverage 2.5 million Blacks, including 620,000 childrenCauses of Death 2000245,000-low education175.000-racial segregation162,000-low societal support133,000-individual level poverty119,000-income inequality39,000-area level povertySocial Reforms and Improved HealthAbolition of child laborIntroduction of housing and factory codesShortening of the work dayReductions in the scale of povertyImprovements in standard of livingMinimum wageImproved sanitationFood safetyLegislative Changes;Healthy Public PolicyCivil Rights ActSocial Security ActClean Air ActThe Mine Safety ActOHSAMedicareMedicaidLets get on the same page.The Troutman GroupDeterminants of HealthSocial and Economic EnvironmentPhysical EnvironmentHealth BehaviorsHealth Care AccessPolicies & The Political EnvironmentThe Balance of PowerGenetics/BiologyThe Troutman GroupHealthThe presence of physical, psychological, social, economic and spiritual well being not merely the absence of disease or infirmityThe maintenance of a harmonious balance between mind body and spirit

15Health EquityHealth equity is the realization by ALL people of the highest attainable level of health. Achieving health equity requires valuing all individuals and populations equally, and entails focused and ongoing societal efforts to address avoidable inequalities by assuring the conditions for optimal health for all groups, particularly for those who have experienced historical or contemporary injustices or socioeconomic disadvantage.

The Troutman GroupHealth InequitiesSystemic, avoidable, unfair and unjust differences in health status and mortality rates and in the distribution of disease and illness across population groups. They are sustained over time and generations and beyond the control of individualsThe Troutman Group17The Troutman GroupJusticeThe quality of fairnessThe principle of moral rightness; equityConformity to moral rightness in action or attitude18The Troutman GroupSocial JusticeThe application of principles of justice to the broadest definition of societyImplies EquityEqual access to societal power, goods and servicesUniversal respect for human and civil rights19Social Justice When we approach health from a social justice perspective, we are necessarily concerned with the political, economic and social arrangements that impinge on the lived experiences of social groups. (Jones, Hatch, Troutman)

www.who.int/social_determinantsSocial justice is a matter of life and death. It affects the way people live, their consequent chance of illness, and their risk of premature death The Troutman GroupThe Troutman GroupHealth and Human RightsPreamble 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 condition2222A New Direction; Social DeterminantsThe Troutman Group

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Looking upstream, finding the causes of he causes.The web of causationThe Troutman Group2525So what do we do about that? Tell people to exercise more, eat right and reduce their stress? And that would work lets say if you had groceries in your neighborhood that carried fresh fruits and vegetables, if you werent afraid of violence in your community, if you had recreation areas close to your home and you had control over things that create stress in your life like institutional racism, economic opportunities and pollution in you neighborhood.

Dr. Troutman, the Director of Public Health and Wellness and a nationally renowned expert, always explains the basic premise of the shift we need to make Baby story. Social DeterminantsSocioeconomic StatusOccupationEducationIncomeIncome gapsRacism & discriminationHousingPolitical power

WHOEarly LifeSocial ExclusionWorkUnemploymentSocial SupportAddictionFoodTransportThe Social GradientStressThe Troutman Group26Social Determinants of HealthThe complex, integrated, and overlapping social structures and economic systems that are responsible for most health inequities. SDOHThese social structures and economic systems include the social environment, physical environment, health services, and structural and societal factors.SDOHSocial determinants of health are shaped by the distribution of money, power, and resources throughout local communities, nations, and the world [9]. Socially Determined Risk HIVPoverty can limit access to health care, HIV testing, and medications that can lower levels of HIV in the blood and help prevent transmission. In addition, those who cannot afford the basics in life may end up in circumstances that increase their HIV risk.SES Risk HIVDiscrimination, stigma and homophobia: Far too prevalent in many communities, these factors may discourage individuals from seeking testing, prevention, and treatment services.SES HIVPrevalence of HIV and other STDs in a community: More people living with HIV or infected with STDs can increase an individuals risk of infection with every sexual encounter, especially if, within those communities, people select partners who are from the same ethnicity or raceSES HIVHigher rates of undiagnosed/untreated STDs can increase the risk of both acquiring and transmitting HIVSES HIVHigher rates of incarceration among men can disrupt social and sexual networks in the broader community and decrease the number of available partners for women, which can fuel the spread of HIV.Language barriers and concerns about immigration status present additional prevention challenges.

The social gradientThe Troutman GroupSocieties are Structured Like Social Ladders

Your position on the ladder predicts how long you live and how healthy you are during your lifetime.

The Troutman Group36The rungs of the ladder represent the resources that determine whether people can live a good life prosperous, healthy, and secure or one in which you struggle with insufficient income, poor health, and vulnerability.

People standing on the top rungs are the best educated, have the most respected jobs, ample savings, and comfortable housing. On the bottom rungs are people who are poorly educated, experience long bouts of unemployment or low wage jobs, have nothing to fall back on in the way of savings, and live in substandard homes.

The people in the middle have more resources to rely on than do people at the bottom, but far less than people on the top. In reaching for health, every step up makes a difference.

About a quarter of these excess deaths (those before age 65) cluster among the poorest 8% of the population --- families with annual incomes of less than $10,000. Yet excess death is not just a problem for the very poor. More than half of Americas excess deaths occur in the middle class in families that earn $20,000 to100,000 a year. What this tells us is that the power of social status to impact the most precious resource we have life itself is enormous and pervasive.

StressContinuing existence of anxiety, insecurity, low self esteem and social isolationLack of control over home and work lifeProfound effect on healthCumulativeThe Troutman Group37EducationThe Troutman GroupHow Does Education Influence HealthEducation can improve health by increasing health knowledgeLeads to greater employment opportunitiesLinked with social and psychological factors that affect healthPQLI experience55,000 degreesKalamazoo PromiseIn El Salvador, if mothers had no education their babies have 100 chances in 1000 of dying in their first year of life; if mothers have at least secondary education the infant death rate is a quarter of that (World Bank 2006)The Troutman GroupTell me how a man died and Ill tell you where he livedAristotle

PLACE MATTERSThe Troutman Group

42Life Expectancy: Louisville MetroThe role of residential segregation;The metropolitan areas with the highest segregation levels have the most unequal geographies of opportunityDelores Acevedo-Garcia et alThe Troutman GroupSegregation and Neighborhood Quality Municipal services (transportation, police, fire, garbage)

Purchasing power of income (poorer quality, higher prices).

Access to Medical Care (primary care, hospitals, pharmacies)

Personal and property crime

Environmental toxins

Abandoned buildings, commercial and industrial facilitiesSegregation and Housing Quality Crowding

Sub-standard housing

Noise levels

Environmental hazards (lead, pollutants, allergens)

Ability to regulate temperatureSegregation and Health Behaviors Recreational facilities (playgrounds, swimming pools)

Marketing and outlets for tobacco, alcohol, fast foods

Exposure to stress (violence, financial stress, family separation, chronic illness, death, and family turmoil)Segregation and Medical Care -IPharmacies in segregated neighborhoods are less likely to have adequate medication supplies (Morrison et al. 2000) Hospitals in black neighborhoods are more likely to close (Buchmueller et al 2004; McLafferty, 1982; Whiteis, 1992). MDs are less likely to participate in Medicaid in racially segregated areas. Poverty concentration is unrelated to MD Medicaid participation (Greene et al. 2006) 47African Americans who live in racially segregated areas often encounter multiple barriers in the receipt of health care services.Segregation and Medical Care -II Blacks are more likely than whites to reside in areas (segregated) where the quality of care is low (Baicker, et al 2004). African Americans receive most of their care from a small group of physicians who are less likely than other doctors to be board certified and are less able to provide high quality care and referral to specialty care (Bach, et al. 2004). 48African Americans who live in racially segregated areas often encounter multiple barriers in the receipt of health care services.Racial Differences in Residential EnvironmentSource: Sampson & Wilson 1995In the 171 largest cities in the U.S., there is not even one city where whites live in ecological equality to blacks in terms of poverty rates or rates of single-parent households.The worst urban context in which whites reside is considerably better than the average context of black communities. p.41Opportunity Neighborhoods: What we all desire Sustainable employmentHigh performing schoolsAccess to high quality healthcareAdequate transportationHigh quality childcareNeighborhood safetyInstitutions that facilitate civic engagementThe Troutman GroupHousingThe Troutman Group

The Troutman Group5252

The Troutman Group5353These are pictures from a recent NYT article. Ill talk a little later about how we use our GIS to look at housing, these photos show you the zone in ways that maps cannot. These are examples of environmental interventions in progress and/or environmental problems in the zone. Place and Environment

Income Inequities282 cities in the U.S.Death from income inequities is comparable to the combined loss of life from lung cancer, diabetes, motor vehicle crashes, HIV infection and homicideKennedy, Kawachi and Prothrow Stith (Harvard University of Public Health 1995)The Troutman Group

The Troutman GroupWhat is racism?The Troutman GroupA system of structuring opportunity and assigning value based on the social interpretation of how one looks (race)Unfairly disadvantages some individuals and communitiesUnfairly advantages other individuals and communitiesSaps the strength of the whole society through the waste of human resourcesSource: Jones CP, Phylon 2003

Center for Health Equity (CHE)CHE works to eliminate social and economic barriers to good health, reshape the public health landscape, and serve as a catalyst for capacity building, policy change and evidenced-based initiatives.The Center for Health Equity works to eliminate social and economic barriers to good health, reshape the public health landscape, and serve as a catalyst for collaboration between communities, organizations and government entities through capacity building, policy change and evidenced-based initiatives.

58Food access and food justice

And with the food environmentThe food retail landscape has shifted dramatically in the past four decades.

Both urban and rural areas have seen grocery stores leave

And new, ever larger grocery stores open up in green fields.

Healthy Food Access

Morland K et al. Neighborhood characteristics associated with the location of food stores and food service places. Am J Prev Med 2002;22:23-29.In MS, NC, MD, MN neighborhoods:3x fewer places to consume alcoholic beverages in the wealthiest neighborhoods4x more supermarkets in white neighborhoodsUnequal access a variety of healthy food choices available to non-minority and wealthy communities62Strategy 3: Expand access to and distribution of healthy food.

The Troutman Group

63MIKE BRAMER

Gain stakeholder input from Corner Store owners and make recommendations on how to overcome barriers to stocking and marketing fresh, healthy foods.Expand Farmers Markets and improve marketing capability.Support efforts to develop a year-round, indoor public market.Link farms with restaurants, emergency food providers and institutionsNegotiate reduced prices for CSA shares for lower-income families. Encourage and incentivize restaurants to post nutritional information on menu boards and printed materials.

Increased Neighborhood Access

The Troutman Group64Social ExclusionCorrelated withRacism DiscriminationStigmatizationHostilityUnemployment

Social ExclusionPovertyAbsolute; a lack of the basic material necessities of lifeRelative; living on less that 60% of the national median incomePoverty and social exclusion result in an increased risk of divorce, separation, disability, illness and addiction

WorkHaving little control over work is associated withIncreased CVDAbsence due to sicknessLow back painReceiving inadequate rewards associated with increased CVDUnemploymentUnemployed people and their families suffer from a much higher risk of premature death

Unemployment Rates by Education Level696969AddictionResponse to social breakdownEscapismImportant factor in worsening inequities in healthOne of initial six causes of excess deaths in US ( 1985 Task Force Report )AddictionResponse to social breakdownEscapismImportant factor in worsening inequities in healthOne of initial six causes of excess deaths in US ( 1985 Task Force Report )New Policy DirectionsHealth Impact Assessment

Health in All Policies

The Troutman GroupExploring the Root Causes of Health Inequities(NACCHO)This course considers the root causes of inequity in the distribution of illness, disease, and death. The course, based on a social justice framework, is a conceptual introduction to ground public health practitioners in concepts and strategies for taking action in everyday practice.WWW.NACCHO.ORGCSDH three overarching recommendations:Improve daily living conditions

Tackle the unequal distribution of power, money and resources

Measure and understand the problem and assess the impact of action

The Troutman GroupRio Political Declaration on Social Determinants of Healthto express our determination to achieve social and health equity through action on social determinants of health and well-being by a comprehensive intersectoral approach. ( October 2011, World Conference on the Social Determinants of Health )

The Troutman Group

The Troutman GroupAdewale Troutman, MD, MPH, MA, CPHExecutive Director Public Health Practice and LeadershipUniversity of South FloridaCollege of Public Health813-974-9302atroutm1@health.usf.edu

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