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Understanding Health Inequities in Boston
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Understanding Health Inequities in Boston

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    • 1. Understanding Health Inequities in Boston Barbara Ferrer, PH.D., MPH, M.ED Executive Director Boston Public Health Commission
    • 2. Health Indicator Black White Asthma (< 5, hosp) 11.4 per 1000 3.4 Birth Weight (Less than 3.3lbs) 3.0% of births 1.6% Body Weight (Overweight or Obese) 68% 41% Breast Cancer (Morality) 29.7 per 100,000 25.9 Cervical Cancer (Mortality) 5.6 per 100,000 2.3 Death Rate (Mortality) 1116.8 per 100,000 919.6 Diabetes (Mortality) 41.8 per 100,000 16.6 Drug Related Mortality 15.7 per 100,000 19 Heart Disease (Mortality) 239.6 per 100,000 238.1 High Blood Pressure 30.4% 17.2% HIV / AIDS (Mortality) 28.1 per 100,000 6.8 Homicide 27.2 per 100,000 2.2 Hospitalization 163.8 per 1000 108.9 Infant Mortality (Mortality) 8.7 per 1000 4.1 Lung Cancer (Mortality) 61.6 per 100,000 66.2 Prostate Cancer (Mortality) 68.3 per 100,000 31.2 Smoking during pregnancy 6.3% 5.1% Suicide (Mortality) 3.6 6.2 Teen Birth Rate (15 - 17) 14.1 per 1,000 6 Uninsured 9.2% 6.5% Racial Disparities in Boston
    • 3. Life Expectancy of Black and White Boston Residents, 2004-2006 DATA SOURCE: Boston resident deaths and live births, Massachusetts Department of Public Health Data ANALYSIS: Boston Public Health Commission Research Office
    • 4. Infant Mortality Rates by Race/Ethnicity and Year, Boston, 1993-2005 NOTE: Rates for Asians and Others are not presented because each group had less than 5 deaths per year for most of the years shown. DATA SOURCE: Boston resident deaths, Massachusetts Department of Public Health DATA ANALYSIS: Boston Public Health Commission Research Office n<5
    • 5. Cumulative Birthweight Distribution by Race/Ethnicity, Boston: 2000-2005 DATA SOURCE: Boston Resident live births, Massachusetts Department of Public Health DATA ANALYSIS: Boston Public Health Commission Research Office 90.85% 9.15% 4.06% 2.03% 1.17% 0.77% 0.23% Other 93.07% 6.93% 2.79% 1.26% 0.58% 0.28% 0.09% White 92.06% 7.94% 3.05% 1.54% 0.80% 0.51% 0.18% Latino 86.75% 13.25% 5.97% 3.46% 2.02% 1.41% 0.54% Black 93.31% 6.69% 2.04% 0.90% 0.49% 0.19% 0.08% Asian 2,500g+ <2,500g <2,000g <1,500g <1,000g <750g <500g
    • 6. Birthweight-Specific Infant Mortality Rates by Race/Ethnicity, Boston, 2002-2004 * Count is 0; therefore rate not calculated. NOTE: ELBW is <500g, VLBW is <1,500g, LBW is <2,500g, NBW is 2,500g+. DATA SOURCE: Boston resident live births and infant deaths, Massachusetts Department of Public Health DATA ANALYSIS: Boston Public Health Commission Research Office n<5 *
    • 7. IS IT ABOUT EDUCATION OR INCOME?
    • 8. Racial & Ethnic Disparities Infant Mortality & Education NCHS 2002 10.2 6.8
    • 9. Racial & Ethnic Disparities Infant Mortality & Household Income 16.6 11.2
    • 10. IS IT ABOUT HEALTH BEHAVIOR?
    • 11. Racial & Ethnic Disparities Infant Mortality & Cigarette Smoking NCHS 2002 13.2 9.2
    • 12. Low Birthweight by Smoking Status and Race/Ethnicity, Boston, 2005 Percentage of Births Within Race/Ethnicity and Smoking Group NOTE: LBW for Asian smokers not shown because n<5 DATA SOURCE: Boston resident live births, Massachusetts Department of Public Health DATA ANALYSIS: Boston Public Health Commission
    • 13. Racial & Ethnic Disparities Infant Mortality & Prenatal Care NCHS 2002 12.7 7.1
    • 14. NOTE: LBW percentage are not shown where n<5. PNC adequacy was assessed by the Kotelchuck Index (APNCU Index). DATA SOURCE: Boston resident live births, Massachusetts Department of Public Health DATA ANALYSIS: Boston Public Health Commission Research Office Low Birthweight by Adequacy of Prenatal Care and Race/Ethnicity, Boston, 2005 n<5
    • 15. Is It About Race?
      • Race has no clear biologic or genetic basis…”there are no characteristics, no traits, not even one gene that turns up in all members of one so-called race, yet is absent from others” (L. Adelman. Race and Gene Studies)
      • The meanings of racial designations- White, Black, Asian- are subject to historical, cultural and political forces; “race justified social inequalities as natural”.
    • 16. Racial & Ethnic Disparities Infant Mortality & Nativity 9.2 14.2 Per 1,000 Live Births NCHS 2002
    • 17. Low Birthweight by Maternal Birthplace, Boston, 2004 SOURCE: Boston resident live births, Massachusetts Department of Public Health ANALYSIS: Boston Public Health Commission Research Office
    • 18. WHAT ABOUT RACISM ?
    • 19. How Can Racism Affect Health Status?
      • Differences in socio-economic status and environmental conditions
      • Differences in exposure to “stress”
      • Differences in access to health care services
      • Differences in diagnostic testing, treatment, and the quality of care received within the health care system
      • Differences in health behaviors
    • 20. Socio-Economic Conditions
      • Legacy of slavery, segregation and discrimination created social and economic inequities
      • Institutional structures and social relations can serve to maintain these disparities
    • 21. Model of Social Determinants of Health Disparities
    • 22.  
    • 23. Environmental Exposures
      • Exposure to waste disposal sites
      • Exposure to air pollutants
      • Exposure to “unregulated” job sites (housecleaning, sweat shops, farms)
      • Exposure to sub-standard housing (quality, density, location)
      • Exposure to alcohol and tobacco products
    • 24. Low Birthweight by Neighborhood Boston, 2005 NOTE: Back Bay includes the North End/ DATA SOURCE: Boston resident live births, Massachusetts Department of Public Health DATA ANALYSIS: Boston Public Health Commission Research Office
    • 25. Asthma Hospitalizations of Children Under Age 5 by Neighborhood, Boston, 2004-2006 *Includes the North End DATA SOURCE: Acute Care Hospital Case Mix files, Massachusetts Division of Health Care Finance and Policy DATA ANALYSIS: Boston Public Health Commission Research Office
    • 26. Health Behaviors
      • Individual behavior exists within a social context
      • Internalized racism can affect health behavior
      • Health behavior alone does not account for unequal burden of disease and death
    • 27. Number of Youth Per Facility Across Boston Neighborhoods 1999-2000 * Combined Central Area includes Beacon Hill/Back Bay, Central, Fenway/Kenmore, and South End. DATA SOURCE: Play Across Boston: Summary Report, December 2002
    • 28. The Contextual Effect of the Local Food Environment on Residents’ Diets
      • Study by Moreland et al. AJPH . 11/2002
      • Findings:
      • Only 8% of Black Americans lived in a census tract with at least one supermarket compared to 31% of White respondents
      • Presence of supermarkets was associated with meeting dietary recommendations among Black Americans
    • 29. Stress
      • Understanding the biologic impacts of social stress ( Wadhwa et al. 2001., Culhane et al. 2001., Kramer et al. 2001 )
      • Theory of allostatic load (Michael Lu. 2002, Rich-Edwards. 2001)
      • “ ..a woman’s chronic exposure to racism creates an allostatic load ..altering the endocrine milieu in which the placenta is established….” (Rich-Edwards. 2001)
    • 30. Racial and Ethnic Disparities Stress & Preterm Birth Mother Placenta Fetus Stress Hypothalamus Pituitary Adrenal CRH CRH ACTH Cortisol Norepineprhine + + Hypothalamus Pituitary Adrenal Liver CRH ACTH Cortisol DS 16 alpha OH DS Estriol + + Adapted from Hobel 1998
    • 31. Racial & Ethnic Disparities Low Birth Weight & Racism 12% 20% P < 0.01
    • 32. The Provision of Health Care
      • Differences in access to and types of health insurance/health plans
      • Differences in access to pharmaceutical drugs
      • Differences in provision of diagnostic tests, therapeutic procedures, transplants, and preventive services
    • 33.  
    • 34. Evidence of Racial and Ethnic Disparities in Healthcare
      • Disparities consistently found across a wide range of disease areas and clinical services
      • Disparities are found even when clinical factors, such as stage of disease presentation, co-morbidities, age, and severity of disease are taken into account
      • Disparities are found across a range of clinical settings, including public and private hospitals, teaching and non-teaching hospitals, etc.
      • Disparities in care are associated with higher mortality among minorities (e.g., Bach et al., 1999; Peterson et al., 1997; Bennett et al., 1995)
    • 35.
      • “ If racism was constructed, it can be undone.
      • It can be undone if people understand when it was constructed, why it was constructed, how it functions, and how it is maintained.”
      • ---People’s Institute For Survival and Beyond
    • 36. What Next?
      • Need for Institutional Responsibility
      • Understanding the nature of the problem
      • Identifying opportunities for alternative roles
      • Need for Institutional Response
      • Changing policies and procedures
      • Mobilizing for action