Health Equity

Ron Chapman, MD, MPHDirector and State Health Officer

California Department of Public Health

What causes health inequities?“The social determinants of health are mostly

responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries. The structural roots of health inequities lie within education, taxation, labor and housing markets, urban planning, government regulation, health care systems, all of which are powerful determinants of health, and ones over which individuals have little or no direct personal control but can only be altered through social and economic policies and political processes.”

WHO Commission on the Social Determinants of Health

“Social Determinants of Health” Social-Physical-Economic-Services Determinants

Income & income inequality Education Race/ethnicity/gender & related discrimination Built Environment Stress Social support Early child experiences Employment Housing Transportation Food Environment Social standing

What is the role of health care? Public Health Agency of Canada: “there is

mounting evidence that the contribution of medicine and health care is quite limited, and that spending more on health care will not result in significant further improvements in population health. On the other hand, there are strong and growing indications that other factors such as living and working conditions are crucially important for a healthy population.”

Estimated Deaths Attributable to Social Factors in the US - 2000 Low education: 245,000 Racial segregation: 176,000 Low social support: 162,000 Individual level poverty: 133,000 Income inequality: 119,000 Area level poverty: 39,000

In comparison: Acute MI: 192,898 Cerebrovascular disease: 167,661 Lung cancer: 155,521

Estimated Deaths Attributable to Social Factors in the US. Galea S et.al. AJPH:June 16,2011;eprint.

Oakland, CA

People who live in West Oakland can expect to live on average 10 years less than those who live in the Berkeley Hills.

People who live in Bayview/Hunters Point can expect to live on average 14 years less than their counterparts on Russian Hill

Residents of Bay Point can expect to live on average 11 years less than people in Orinda

Life Expectancy in the Bay Area

Compared to a white child born in the Oakland hills, a black child born in West Oakland is:

Likely to die almost 15 years earlier 5x more likely to be hospitalized with diabetes 2x as likely to die of heart disease 3x more likely to die of stroke 2x more likely to die of cancer 7x more likely to be born into poverty 4x less likely to read at grade level by grade 4 4 x as likely to live in a neighborhood with high

density of fast food and liquor outlets 5.6x more likely to drop out of school

Alameda County Department of Public Health

Inequities in Contra Costa County Hospitalization rate for asthma for African American

children 5x that of White children

Latinas have a rate of births to teens more than twice that of the county overall

Most of the homicide deaths in Contra Costa occurred among African Americans

People living in San Pablo, Oakley, Richmond, Antioch, Brentwood and Pittsburg, as well as African Americans and men overall, are more likely to die from heart disease

Health Equity in California

Lowest Infant Mortality African Americans double

Lowest Teenage Pregnancy Hispanic teens double

Lowest Tobacco Use Low income population double

How could income effect health?

Income directly shapes: Nutrition & physical activity

options Housing quality Neighborhood conditions Social networks & support Stress due to inadequate

resources to face daily challenges

Medical care

Parents’ income shapes the next generation’s:

Education, which shapes their

Working conditions (physical & psychosocial) &

Income

Center on Social Disparities in Health, UCSF

Children Raised in Poverty Have lower levels of educational attainment

more likely to score lower on standardized tests, be held back a grade, drop out of high school,

less likely to get a college degree attend schools with fewer resources suffer from poor nutrition, chronic stress, and other health

problems that interfere with their school work change residences and schools frequently as their families

struggle to find affordable housing Have lower earnings and are more likely to live

in poverty as adults

* BARHII

The Social Gradient in Health

0

5

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15

20

25

30

35

40

45

Black, Non-Hispanic Hispanic White, Non-Hispanic

% o

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25+

who

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* <100% FPL100%-199% FPL200-299% FPL300-399% FPL≥400% FPL

Across racial and ethnic groups, higher income*, more physically active adults

NHIS 2001-2005 Age-adjusted* Similar by education

U.S. • California

6.1 million Californians (16.3%) incomes <FPL 2.2 million Ca children (nearly ¼) in families <FPL

Health Impact of Resolving Racial Disparities 1991 to 2000

Medical advances averted 176,633 deaths Equalizing the mortality rates of Whites and

African Americans would have averted 886,202 deaths

“The prudence of investing billions in the development of new drugs and technologies while investing only a fraction of that amount in the correction of disparities deserves reconsideration. It is an imbalance that may claim more lives than it saves.”

Wolff S. Satcher D., et.al. The Health Impact of Resolving Racial Disparities: An Analysis of US Mortality Data. Am J Public Health. 2004;94:2078–2081

How could a neighborhood affect health?

Safe places to exercise Access to healthy food Exposure to targeted advertising of

harmful substances Social networks & support Norms, role models, peer pressure Fear, anxiety, stress, despair Violence and fear Quality of schools

INSTITUTIONALPOWERCorporations &businessesGovernment agenciesSchoolsLaws & regulationsNot-for-profit organizations

RISK BEHAVIORS Risk BehaviorsSmokingPoor nutritionLow physical activityViolenceAlcohol & other DrugsSexual behavior

LIVING CONDITIONSPhysical environmentLand useTransportationHousingResidential segregationExposure to toxinsSocial environmentExperience of class, racism, gender, immigrationCulture, incl. mediaViolenceEconomic & Work EnvironmentEmploymentIncomeRetail businessesOccupational hazardsService environmentHealth careEducationSocial services

DISEASE& INJURYCommunicable diseaseChronic diseaseInjury (intentional & &unintentional)

MORTALITYInfant mortalityLife expectancy

SOCIALINEQUITIESClass Race/ethnicityImmigration status GenderSexual orientation

UPSTREAM DOWNSTREAM

Community capacity building

Community organizingCivic engagement

Strategic partnerships

Advocacy

Individual health education

Health care

Emerging Public Health Practice

Current Public Health Practice

POLICY

Case management

A PUBLIC HEALTH FRAMEWORK FOR REDUCING HEALTH INEQUITIESBAY AREA REGIONAL HEALTH INEQUITIES INITIATIVE

Go Before You ShowPrenatal Campaign

First trimester prenatal care is key to healthy birth outcomes.

In Solano County, 1st trimester prenatal care was much higher for women on commercial insurance vs. Medi-Cal.

Go Before You Show campaign created to increase 1st trimester prenatal care in Medi-Cal.

Results…

Office of Health Equity Office of Multicultural Health Office of Multicultural Services Office of Women’s Health Health in All Policies Healthy Place Team