Rex Archer, MD, MPH, Director, Kansas City Health Department | Learn more about health equity in Missouri by visiting: http://www.mohec.org/

1. Creating a Culture
of Health Equity
KC Community Conversation
November 14, 2014
Rex Archer, MD MPH
Saving Lives,
Protecting People from Health Threats,
Saving Money through Prevention

2. "The reason we have
government is to solve
problems collectively that
we can not solve
individually."
Dr. Thomas Farley, NYC Health Commissioner (from
the HBO May, 2012 Documentary, "Weight of the Nation"
Saving Lives,
Protecting People from Health Threats,
Saving Money through Prevention

3. “Public health is what we, as a
society, do collectively through
organized actions to assure the
conditions in which all people
can be healthy.”
-Institute of Medicine (1988),
Future of Public Health

4. 79.1
74.6
73.8
65.7
80.3
77.1
75.2
68.7
85
80
75
70
65
60
White
female
Black
female
White
male
Black
male
Life
expectancy
(year)
Life
expectancy,
KCMO
1999-­‐2003
vs.
2009-­‐2013
1999-­‐2003
2009-­‐2013
*Non-­‐Hispanic
white
male
and
female
and
non-­‐Hispanic
black
male
and
female.
+1.2
years
+2.5
years
+3.0
years
+1.4
years

5. -­‐27.2%
14.6
-­‐40.6%
12.1
6.8
5.5
11.2
7.2
6.4
4.0
16
14
12
10
8
6
4
2
0
Black
male
Black
female
White
male
White
female
No.
of
infant
deaths
per
1,000
births)
Infant
mortality
rate,
KCMO
1999-­‐2003
vs.
2009-­‐2013
1999-­‐2003
2009-­‐2013
*Non-­‐Hispanic
white
male
and
female
and
non-­‐Hispanic
black
male
and
female.
-­‐23.4%
-­‐5.9%

6. POPULATION APPROACH VS. INDIVIDUAL APPROACH

7. Life
expectancy
by
zip
code,
Kansas
City,
MO
2008-­‐2012
Life
expectancy
Nonwhite
Below
poverty@
Median
family@
(year)
%
%
income
($)
81-­‐83
years
11.3
8.0
92,258
73-­‐79
years
35.6
21.3
53,264
70-­‐72
years
82.4
37.4
27,899
@ 2008-2012 American Community Survey 5-Year Estimates
*Too
small
popula+on
to
calculate
life
expectancy
64163
64153 64154 64155
64156
64151 64119
64117
64120
64129
64157
64134
64161
64132
64138
64149
64116
64110
64101
64102
64113
64131
64130
64137
64136
64118
64160
64164
64133
64139
64127
64165
64133
64108
64133
64128
64147
64111
64158
64109
64126
64118
64112
64124
64114
6414564146
64152
64079
64106
64166
64123
64125
64012
64152
64105
64167
64030
64079
64081
64079
64152
Life expectancy
80-83 years
73-79 years
70-72 years
Too small pop.*

8. Leading
Causes
Crude
Mortality
Rates
in
Two
Areas,
240
226
66
KCMO
2008-­‐2012
58
53
52
51
46
41
37
126
108
3
28
24
29
34
28
12
10
250
200
150
100
50
0
Rate
per
100,000
populaQon
Shortest
life
expectancy
Longest
life
expectancy
6zipcodes include zip code 64109,
64126, 64127, 64128, 64130, and
64132, which are the shortest life
expectancy; 11zipcodes include zip
code 64112, 64113, 64116, 64118,
64151, 64152, 64153, 64154, 64156,
64157, and 64158, which are the
longest life expectancy.

9. EsSmated
Deaths
AVributable
to
Social
Factors
U.S*
KCMO**
• Less
than
High
School
graduaSon
245,000
234
• Racial
segregaSon
176,000
561
• Low
social
support
162,000
232
• Individual
level
poverty
133,000
236
• Income
inequality
119,000
222
• Community
level
poverty
39,000
349
_____________________________
~47%
of
annual
KCMO
deaths
(41-­‐53%)
Total
1,834***
*Galea,
et.al.,
American
Journal
of
Public
Health
August
2011,
Vol
101
no.
8
**ConservaSve
esSmate
for
Kansas
City,
MO
based
on
Galea,
et.al.
***ConservaSve
esSmates
that
assume
factors
are
not
synergisSc

10. What are the Determinants of Health?
Social and
Economic
Factors
40%
Physical
Environment
What Creates Health?
Health Behaviors
30%
Clinical Care
10%
10%
Genes and
Biology
10%
Tarlov AR. Public policy frameworks for improving population
health. Ann N Y Acad Sci 1999; 896: 281-93.

11. Through inequities
How do disparities arise?
Quality
of care
Access
to care
Exposures
and opportunities

12. Achieving
Health
Equity
by
Addressing
the
Social
Determinants
of
Health
• It
is
Sme
to
stop
thinking
of
health
as
something
we
get
at
the
doctor’s
office
• Health
starts—long
before
illness-­‐-­‐
in
our
homes,
neighborhoods,
schools
and
jobs.
• All
residents
should
have
the
opportunity
to
make
the
choices
that
allow
them
to
live
a
long,
healthy
life,
regardless
of
their
income,
educaSon
or
ethnic
background.
• Your
neighborhood
or
job
shouldn’t
be
hazardous
to
your
health.
• The
more
we
see
the
problem
of
health
this
way,
the
more
opportuniSes
we
have
to
improve
it.
12

13. The Cost J aopaf na Long Life 13

14. We
need
to
restructure
our
investments
KC-CHIP Our goal is to
Chronic Disease Care
Hospitalization
Public Health
work upstream
to keep
Kansas Citians
from falling in
the river of
medical care
and going over
the waterfall of
hospitalization.
Healthy Communities
Healthy Living
Medical System

15. We Have to Change!
• The “System” is broken
• We need to address inequities/injustices
• How can we do things differently?

17. Refocusing Upstream

18. Family &
Culture

20. Family &
Culture
Health
Inequities
Health
Disparities

21. Family &
Culture
Narrative Policy Place

22. Factors that Affect Health
Examples
Condoms, eat healthy,
be physically active
Rx for high blood
pressure, high
cholesterol
Immunizations, brief
intervention, cessation
treatment, colonoscopy
Fluoridation, 0g trans fat,
iodization, smoke-free
laws, tobacco tax
Poverty, education,
housing, inequality
Religious, moral
teachings, beliefs
Smallest
Impact
Largest
Impact
Counseling
& Education
Clinical
Interventions
Long-lasting
Protective Interventions
Changing the Context
to make individuals’ default
decisions healthy
Socioeconomic Factors
Contributory/Distributive
(Social) Justice
Frieden, Archer

24. Social Structure
Class Oppression
Discrimination
and Exploitation
Power and Wealth Imbalance
Institutional
Racism
LABOR
MARKETS
GLOBALIZATION
&
HOUSING DEREGULATION
POLICY
EDUCATION
SYSTEMS
TAX
POLICY
SOCIAL
SAFETY
NET
Social Determinants of Health
Gender
SOCIAL
NETWORKS
Safe
Affordable
Housing
Job
Security
Social
Connection
& Safety
Quality
Education
Living
Wage
Transportation Availability
of Food
Psychosocial Stress / Unhealthy Behaviors
Disparity in the Distribution of Disease, Illness, and Wellbeing

25. Definitions
Social Justice Health Equity
The absence of unfair, unjust
advantage or privilege based on
race, class, gender,
or other forms of difference.
A fair, just distribution of the
social resources and social
opportunities needed to achieve
well-being.
Health Disparity
“A disproportionate difference in
health between groups of
people.”
By itself, disparity does not
address the chain of events that
produces it.
Health Inequity
“Differences in population health
status and mortality rates that are
systemic, patterned, unfair, unjust,
and actionable, as opposed to
random or caused by those who
become ill.” Margaret Whitehead

26. Deaths Prevented And Change In Health Care Costs Plus Program Spending,
Three Intervention Scenarios, At Year 10 And Year 25.
Milstein B et al. Health Aff 2011;30:823-832

27. WE KNOW
HOW TO
REVERSE
EPIDEMICS
Your Kansas City, MO
Health Department

28. 87
-­‐85%
reducSon
20
9
-­‐29%
reducSon
62
3
100
90
80
70
60
50
40
30
20
10
0
City
Aim4Peace
target
area
Number
of
homicides
Number
of
homicides
between
city
and
Aim4Peace
target
area,
YTD
October
17,
2014
YTD2013
2010-­‐2012*
2013
YTD2014
*2010-­‐2012
in
target
area
means
average
number
of
homicides
among
2010-­‐2012

29. Seeing a Wider Set of
Relationships
Centers for Disease Control and Prevention, Bobby Milstein

30. Public Health As A Social Justice Enterprise
JUSTICE = TRUTH + POWER
Public Health Practice
Research + Data
Community
Organizing
=

31. Aligned Campaigns (PH&CO)
• 2012: Cap the Rate, Raise the Wage
• 2013: Ban the Box
• 2013-2014: Low Wage Worker Actions/
Living Wage
• 2014: Ban the Ban
• 2014: Raising of America Kansas City
• 2014: Advance KC Development Scoring
• Other Ongoing: Medicaid Expansion, Early
Voting, Violence/Homicide Prevention

32. Your Nationally Accredited
Rex Archer, MD, MPH
Director of Health
Kansas City, Mo., Health Department
Questions?
Improving Service.
Protecting People. Saving Lives.

33. We are focused on prevention of gun-related
violence that is primarily related to arguments and
retaliation in targeted areas of East Patrol, but we seek
to expand to the entire Metro Area.
A4P Current Target Zone: KCMO Police Sector 330, parts of 320 & 340
KCPD
Beats
2010
(Jan-
Dec)
2011
(Jan-
Dec)
Prepared by: T.Cole
2012
(Jan-
Dec)
2013
(Jan-
Dec)
diff %
change
2014
(Jan-
Oct. 16)
diff %
change
331 4 4 3 3 0 0% 1 -2 -67%
332 3 3 7 1 -6 -86% 0 -1 -100%
333 0 5 2 0 -2 -100% 1 1 0%
334 6 3 4 3 -1 -25% 1 -2 -67%
Total
330
13 15 16 7 -9 -56% 3 -4 -57%
324 4 7 4 2 -2 -50% 0 -2 -100%
Total 17 22 20 9 -11 -55% 3 -6 -67%

34. To Achieve the Vision Participants
Reached Consensus on Six KC-CHIP Strategic
Issues/Goals
Safe
and
Healthy
Community
Encourage
AcQve
Living
and
Healthy
EaQng
Reduce
health
dispariQes/social
determinants
of
health
Ensure
Every
Child
has
a
Healthy
Start
Live
Tobacco
Free
in
KC
Access
to
Clinical
PrevenQve
Services,
Illness
Care,
&
Public
Health
Services
&
IntervenQons
Thriving
people living, learning
and working in a
healthy, active, vibrant,
and safe community,
where there is equitable
access to jobs, quality
health, education and
social services
34

35. Develop
and
Sustain
a
High
Performing
OrganizaQon
Increase
Public
Health
EffecQveness
and
Promote
PrevenQon
Strategies
that
Reduce
Health
InequiQes
and
Improve
the
Health
of
the
Community
Increase Stakeholder
Awareness, and Support
of Mission & Activities
Recruit,
Retain,
and
Invest
in
Quality
Staff
Updated
as
of
5/16/13
Kansas
City,
Missouri
Health
Department
Strategic
Map:
2013-­‐2016
Enrich
and
Support
Community
Partnerships
Lead
Policy
and
Advocacy
Development
Review
Current
Programs,
Services
And
IdenSfy
Gaps
Incorporate
an
EvaluaSon
Component
into
All
Programs
Implement
QI
Focus
into
All
Programs
Align
Partnerships
with
Emerging
Changes
in
Public
Health
Issues
Leverage
CommunicaSons
To
AcSvate
Partners
and
Improve
Efficiency
Ensure
ConSnuing
Face-­‐to-­‐Face
(1
on
1s)
InteracSons
Assure
Quality
of
Services
Delivered
or
Contracted
For
IdenSfy
&
PrioriSze
Department
&
Community
Health
PrioriSes
Develop
Departmental
Capacity
and
Technical
ExperSse
Determine
Framework
for
Policy
and
Advocacy
Issues
Develop
Public
and
Private
Strategic
Alliances
to
Advocate
for
RecommendaSons
Increase
Visibility
Of
KCHD
Services
IdenSfy
&
Respond
to
CommuniSes’
Perceived
Value
of
KCHD
Communicate
the
Meaning
and
Importance
of
Public
Health
Develop
&
Enforce
Agency
CommunicaSon
Plan
Including
an
Integrated
Brand
Framework
Engage
&
Inform
Key
Decision-­‐
Makers
&
Influencers
on
Policy
RecommendaSons
Strengthen
Internal
ProgrammaSc
awareness
And
Linkages
Pursue
and
Maintain
NaSonal
Public
Health
AccreditaSon
Update
and
&
Implement
a
Staff
Training
Plan
IdenSfy
&
OpSmize
Technology
to
Innovate
Public
Health
Strengthen
the
Impact
of
Programs
and
Services
Assure
RecogniSon
of
KCHD/KCMO
for
all
Funded
AcSviSes
(Co-­‐Branding)
Work
with
Community
Organizing
Agencies
to
address
health
inequiSes
Cultural
Competency
Use
Data,
and
Evidence-­‐Based
PracQces
as
Tools
to
Drive
Decision-­‐Making
1
2
3
4
5
6
F
A B C D E
Become
an
Academic
Health
Department
Tracks
of
Work
for
Year
2:
ProgrammaSc
Linkages
(Yellow),
Performance
Management
(Pink),
IntegraSng
Technology
(Orange),
Workforce
Development
(Green),
Stakeholder
Awareness
(Blue),
Cultural
Competency
(Purple)
will
be
added
as
TA
progresses
Expand
and
Sustain
Funding
and
Investment

36. Arenas of Power
Power is the ability to act or produce an effect
• Directly impacting decisions makers
• Developing deeper relationships and
aligning interests
• Consciously shifting the narrative

37. Working with Faith-based
Organizations
We believe:
• Everyone has a story
• In the potential of transformation
(individual, community, society at large)
• Power is a product of relationships
• We get as much justice as we have
power to compel

38. Three Principles of
Community Organizing
v Win concrete improvements
in people's lives
v Make people aware of their
own power
v Alter the relations of power:
§ Build strong organizations
§ Pass new laws and regulations
§ Elect good people who recognize
your power