COMMUNITY ISSUES FORUM PORTLAND OREGON OCTOBER 8, 2009 ADEWALE TROUTMAN, M.D., M.P.H., M.A. THE TROUTMAN GROUP Creating Health Equity; Social Justice, Human Rights and the Social Determinants of Health

The Troutman Group

A Case Study; But Why

Vital Statistics: The Troutman Group

Reframing Health vs. Healthcare Individual vs. Population Health Market Justice vs. Social Justice Rights vs. Privileges Biological/Behavioral Determinants vs Social Determinants Creating Health Equity vs. eliminating Health Disparities The Troutman Group

Health vs. Healthcare

Individual vs. Population Health

Market Justice vs. Social Justice

Rights vs. Privileges

Biological/Behavioral Determinants vs Social Determinants

Creating Health Equity vs. eliminating Health Disparities

TRADITIONAL SOCIAL JUSTICE How can we address risky behavior and target vulnerable populations? How can we target the health depriving conditions and policies that make people vulnerable? Why do people smoke? What economic policies and social conditions predispose people to the stress that encourages smoking? How can we create more green space, bike paths, and farmers’ markets in disadvantaged neighborhoods? What policies and institutional practices by government and corporations discourage access to transportation, recreational resources, and access to nutritious foods in neighborhoods where population is poorest? How can we promote greater personal responsibility for health? How can we create social responsibility and public accountability to protect the public good? How do we treat the consequences of health inequity? How does the prioritization of profit over human need and ecological sustainability affect health inequity? Overarching social justice questions: Why do those who make decisions that negatively affect health make those decisions? Why do they have that power?

Let’s get on the same page.

Health “ The presence of physical, psychological, social, economic and spiritual well being not merely the absence of disease or infirmity” “ The maintenance of a harmonious balance of mind, body and spirit” Community and individual The Troutman Group

“ The presence of physical, psychological, social, economic and spiritual well being not merely the absence of disease or infirmity”

“ The maintenance of a harmonious balance of mind, body and spirit”

Community and individual

Health Equity “ Health 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.”

“ Health 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.”

Health Equity “ The absence of unfair and avoidable or remediable differences in health among social groups” ( The Commission ) A value position supported by an evidence base There is and will be political opposition to the core value of health equity The Troutman Group

“ The absence of unfair and avoidable or remediable differences in health among social groups” ( The Commission )

A value position supported by an evidence base

There is and will be political opposition to the core value of health equity

Health Inequities Systemic, 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 individuals The Troutman Group

Systemic, 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 individuals

The development of society can be judged by: the quality of its populations ’ health the fairness in distribution of health, and the degree of protection provided from disadvantage due to ill-health Marmot 2006 Harveian Oration Health equity as a development outcome

The development of society can be judged by:

the quality of its populations ’ health

the fairness in distribution of health, and

the degree of protection provided from disadvantage due to ill-health

Justice The quality of fairness The principle of moral rightness; equity Conformity to moral rightness in action or attitude The Troutman Group

The quality of fairness

The principle of moral rightness; equity

Conformity to moral rightness in action or attitude

Social Justice The application of principles of justice to the broadest definition of society Implies Equity Equal access to societal power, goods and services Universal respect for human and civil rights The Troutman Group

The application of principles of justice to the broadest definition of society

Implies

Equity

Equal access to societal power, goods and services

Universal respect for human and civil rights

Rights Claims or entitlements that are recognized by legal or moral principles Enforced by legislation and rules, the force of law The Troutman Group

Claims or entitlements that are recognized by legal or moral principles

Enforced by legislation and rules, the force of law

Human Rights A higher order right MORALLY based and UNIVERSAL. It belongs to all persons equally because they are human beings (Declaration of Independence) The Troutman Group

A higher order right MORALLY based and UNIVERSAL. It belongs to all persons equally because they are human beings (Declaration of Independence)

The Right to Health Preamble 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 condition The Troutman Group

Preamble 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 condition

Market Justice vs. Social Justice

Market Justice Emphasizes personal responsibility as the basis for distributing burdens and benefits Individuals assume prime responsibility for their own health Little expectation that society should act to protect or promote the health of its members Social Darwinism The Troutman Group

Emphasizes personal responsibility as the basis for distributing burdens and benefits

Individuals assume prime responsibility for their own health

Little expectation that society should act to protect or promote the health of its members

Social Darwinism

Social Justice Significant factors within society impede fair distribution of benefits and burdens Social class distinctions, heredity, racism, ethnism play significant roles Collective action necessary to neutralize or overcome forces The Troutman Group

Significant factors within society impede fair distribution of benefits and burdens

Social class distinctions, heredity, racism, ethnism play significant roles

Collective action necessary to neutralize or overcome forces

Social 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… www.who.int/social_determinants

The Case for Action The moral, ethical , this is the right thing to do because it is case The pragmatic , this is costing the system countless dollars and self interest in the financial crisis around health inequities make it a must do. The Troutman Group

The moral, ethical , this is the right thing to do because it is case

The pragmatic , this is costing the system countless dollars and self interest in the financial crisis around health inequities make it a must do.

The Economic Burden of Health Inequities in the United States Direct medical costs of health inequalities Indirect cost of health inequalities Cost of premature death ( The pragmatic case ) THomas LaViest et al John Hopkins,University of Maryland

Direct medical costs of health inequalities

Indirect cost of health inequalities

Cost of premature death

( The pragmatic case )

Economic Burden Findings Between 2003 and 2006 combined cost of health inequalities and premature death was $1.24 trillion Eliminating health disparities for minorities would have reduced direct medical care expenditures by $229.4 billion Between 2003 and 2006, 30.6% of direct medical care expenditures for African Americans, Asians and Latinos were excess costs due to health inequalities THomas LaViest et al John Hopkins,University of Maryland

Between 2003 and 2006 combined cost of health inequalities and premature death was $1.24 trillion

Eliminating health disparities for minorities would have reduced direct medical care expenditures by $229.4 billion

Between 2003 and 2006, 30.6% of direct medical care expenditures for African Americans, Asians and Latinos were excess costs due to health inequalities

Findings ( Cont ) Eliminating health inequalities for minorities would have reduces indirect costs associated with illness and premature death by more than one trillion dollars between 2003 and 2006 THomas LaViest et al John Hopkins,University of Maryland

Eliminating health inequalities for minorities would have reduces indirect costs associated with illness and premature death by more than one trillion dollars between 2003 and 2006

A New Direction

Looking upstream, finding the causes of he causes. The Troutman Group

Socioeconomic Status WHO Occupation Education Income Income gaps Racism & discrimination Housing Political power Early Life Social Exclusion Work Unemployment Social Support Addiction Food Transport The Social Gradient Stress Social Determinants The Troutman Group

Socioeconomic Status

WHO

Occupation

Education

Income

Income gaps

Racism & discrimination

Housing

Political power

Early Life

Social Exclusion

Work

Unemployment

Social Support

Addiction

Food

Transport

The Social Gradient

Stress

Stress Continuing existence of anxiety, insecurity, low self esteem and social isolation Lack of control over home and work life Profound effect on health Cumulative The Troutman Group

Continuing existence of anxiety, insecurity, low self esteem and social isolation

Lack of control over home and work life

Profound effect on health

Cumulative

The Power of Poverty The Troutman Group

Income Inequities 1995 study Kennedy, Kawachi and Prothrow-Stith 282 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 homicide” The Troutman Group

1995 study Kennedy, Kawachi and Prothrow-Stith

282 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 homicide”

The Troutman Group

The Troutman Group

The Elephant in the Room: Racism The Troutman Group

What is racism? A system The Troutman Group

A system

What is racism? A system of structuring opportunity and assigning value The Troutman Group

A system of structuring opportunity and assigning value

What is racism? A system of structuring opportunity and assigning value based on the social interpretation of how one looks (“race”) The Troutman Group

A system of structuring opportunity and assigning value based on the social interpretation of how one looks (“race”)

What is racism? A system of structuring opportunity and assigning value based on the social interpretation of how one looks (“race”) Unfairly disadvantages some individuals and communities The Troutman Group

A system of structuring opportunity and assigning value based on the social interpretation of how one looks (“race”)

Unfairly disadvantages some individuals and communities

What is racism? A system of structuring opportunity and assigning value based on the social interpretation of how one looks (“race”) Unfairly disadvantages some individuals and communities Unfairly advantages other individuals and communities The Troutman Group

A system of structuring opportunity and assigning value based on the social interpretation of how one looks (“race”)

Unfairly disadvantages some individuals and communities

Unfairly advantages other individuals and communities

What is racism? A system of structuring opportunity and assigning value based on the social interpretation of how one looks (“race”) Unfairly disadvantages some individuals and communities Unfairly advantages other individuals and communities Saps the strength of the whole society through the waste of human resources The Troutman Group Source: Jones CP, Phylon 2003

A system of structuring opportunity and assigning value based on the social interpretation of how one looks (“race”)

Unfairly disadvantages some individuals and communities

Unfairly advantages other individuals and communities

Saps the strength of the whole society through the waste of human resources

Levels of Racism Individually Mediated People make assumptions about one abilities based on their race and act differently towards them ( discrimination) Institutionalized Differential access to goods and services, access to power, economic and social mobility based on race. May be supported by law or institutional structure and practice. The Troutman Group

Individually Mediated

People make assumptions about one abilities based on their race and act differently towards them ( discrimination)

Institutionalized

Differential access to goods and services, access to power, economic and social mobility based on race. May be supported by law or institutional structure and practice.

Levels of Racism Internalized Acceptance by members of the racial or ethnic group of the negative beliefs of their own abilities and value. May lead to depression, hopelessness, helplessness and living as victim The Troutman Group

Internalized

Acceptance by members of the racial or ethnic group of the negative beliefs of their own abilities and value.

May lead to depression, hopelessness, helplessness and living as victim

“ Patients” experiencing symptoms of heart disease, from Schulman et al. (1999)

“ Patients” experiencing symptoms of heart disease, from Schulman et al. (1999)

Place Matters The Troutman Group

Tell me how a man died and I’ll tell you where he lived Aristotle The Troutman Group

The role of residential segregation; “The metropolitan areas with the highest segregation levels have the most unequal geographies of opportunity” Delores Acevedo-Garcia et al The Troutman Group

Opportunity Neighborhoods Sustainable employment High performing schools Access to high quality healthcare Adequate transportation High quality childcare Neighborhood safety Institutions that facilitate civic engagement The Troutman Group

Sustainable employment

High performing schools

Access to high quality healthcare

Adequate transportation

High quality childcare

Neighborhood safety

Institutions that facilitate civic engagement

Housing The Troutman Group

Built Environment Issues Hope six Where did all the poor people go? The segregation of poverty Grids, green space and gentrification Rural infrastructure The Troutman Group

Hope six

Where did all the poor people go?

The segregation of poverty

Grids, green space and gentrification

Rural infrastructure

Cotter Lane The Troutman Group

Park DuValle The Troutman Group

Park DuValle The Troutman Group

Education The Troutman Group

In 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 Group

How Does Education Influence Health Education can improve health by increasing health knowledge Leads to greater employment opportunities Linked with social and psychological factors that affect health

Education can improve health by increasing health knowledge

Leads to greater employment opportunities

Linked with social and psychological factors that affect health

Takin’ it to a Higher Level Power Policy Place Advocacy The Troutman Group

Power

Policy

Place

Advocacy

www.who.int/social_determinants

CSDH 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

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 Center for Health Equity The Troutman Group

The Troutman Group

The Importance of Leadership and Political Will The Troutman Group

The Troutman Group

The CHE is dedicated to a civic process that builds social engagement, autonomy and movement to strengthen communities and influence public policy in an effort to Create Health Equity

The Center focuses its work to eliminate health inequities due to race, ethnicity and socioeconomic status

Current Work Framing research Health Equity Community Hearings Civic capacity building mini grants Health Equity Speaker Series Web based learning Retraining workforce ( Dialogue process ) Outreach workers as community organizers Undoing Racism workshops ( community wide) Health Equity Summit

Framing research

Health Equity Community Hearings

Civic capacity building mini grants

Health Equity Speaker Series

Web based learning

Retraining workforce ( Dialogue process )

Outreach workers as community organizers

Undoing Racism workshops ( community wide)

Health Equity Summit

Current Work ( Cont ) Photo voice Community dialogues Operationalizing Health Equity within the department CHI project HIA-Shepard Square ( Hope 6 ) The cabinet dialogue Food justice

Photo voice

Community dialogues

Operationalizing Health Equity within the department

CHI project

HIA-Shepard Square ( Hope 6 )

The cabinet dialogue

Food justice

Food Justice Individual choice vs structure and systems Food access, transportation and quality Decreased access to healthy foods, increased access to unhealthy foods ( Food Security Task Force ) Economic development and community health The Troutman Group

Individual choice vs structure and systems

Food access, transportation and quality

Decreased access to healthy foods, increased access to unhealthy foods ( Food Security Task Force )

Economic development and community health

Strategy 3: Expand access to and distribution of healthy food. The Troutman Group

Increased Neighborhood Access The Troutman Group

From the Dinner Table to the Policy Table

Health Policy Is Social Policy

Policies For Social Justice, Policies For Health Equity Short term and long term solutions Short term Attention to symptoms( nutrition, physical activity, cholesterol, access) Creating environment to promote health Long term Empowerment Redistributive policies Poverty Elimination

Short term and long term solutions

Short term

Attention to symptoms( nutrition, physical activity, cholesterol, access)

Creating environment to promote health

Long term

Empowerment

Redistributive policies

Poverty Elimination

Policies ( Cont ) Environmental change Housing reform Job creation tied to insurance National Health Program to Insure Universal Access and Universal Coverage Land Use Health Impact Assessment The Troutman Group

Environmental change

Housing reform

Job creation tied to insurance

National Health Program to Insure Universal Access and Universal Coverage

Land Use

Health Impact Assessment

Policies ( Cont ) Zoning policies ( Concentration of business types) Nutrition School meals Trans fat Restaurant labeling Physical education in schools Built environment with attention to gentrification Smoking The Troutman Group

Zoning policies ( Concentration of business types)

Nutrition

School meals

Trans fat

Restaurant labeling

Physical education in schools

Built environment with attention to gentrification

Smoking

Policies… Measuring progress through “Social Health Indexing” Living wage Educational reform Class size Teacher experience Funding mechanisms Attention to short term only ,will just create a healthier underclass and will not create health equity because there is no social justice The Troutman Group

Measuring progress through “Social Health Indexing”

Living wage

Educational reform

Class size

Teacher experience

Funding mechanisms

Attention to short term only ,will just create a healthier underclass and will not create health equity because there is no social justice

The Troutman Group

A fragmented non system of sick care where inequity is common, prevention and wellness are after thoughts and outcomes correlate to societal status The Troutman Group

Universal access to a single standard of high quality care National Health Insurance Single Payer The Troutman Group

Health in All Policies addresses the effects on health across all policies such as agriculture, education, the environment, fiscal policies, housing, and transport . It seeks to improve health and at the same time contribute to the well-being and the wealth of the nations through structures, mechanisms and actions planned and managed mainly by sectors other than health. Thus HiAP is not confined to the health sector and to the public health community, but is a complementary strategy with a high potential towards improving a population’s health, with health determinants as the bridge between policies and health outcomes.

Phillis Wheatley Students present Photo-voice Exhibits on Health Policy Issues

Photo Voice Youth empowerment through engagement Community health and barriers Youth as creators, producers, interpreters Raise awareness about the policy process Presentation to policy makers ( Mayor Metro Council, Board of Health, Business Community

Youth empowerment through engagement

Community health and barriers

Youth as creators, producers, interpreters

Raise awareness about the policy process

Presentation to policy makers ( Mayor Metro Council, Board of Health, Business Community

If my community were healthy it would look like, no people littering, people riding bikes, no people dealing drugs, kids playing at the park, no gunshots, parents and kids walking their dogs, no people smoking, parents taking their baby’s in a stroller to the park to walk them around the park. Denzel: age 10

My neighborhood has many train tracks and a really big factory that does something, I don’t know what. There is a church, a community center but there is no store close to where I live. D’coreyan: age 10

Every day I go to the community center on the side of it, they are selling drugs or showing off their guns and sometimes I am scared to walk pass because I think they will shoot me. Michael: age 10

From Theory to Practice Cross discipline collaboration based on social determinants Public awareness of determinants of health and health equity Civic capacity building Community assessment Policy process and community engagement Curriculum change Staff reorientation Think holistically ( Housing and HIA’s etc.)

Cross discipline collaboration based on social determinants

Public awareness of determinants of health and health equity

Civic capacity building

Community assessment

Policy process and community engagement

Curriculum change

Staff reorientation

Think holistically ( Housing and HIA’s etc.)

Taking a Personal Inventory Commitment to honesty Exploration of beliefs, practices. Internal messaging The person and the organization in the mirror Are you happy with what you see? Where do I get to make changes

Commitment to honesty

Exploration of beliefs, practices. Internal messaging

The person and the organization in the mirror

Are you happy with what you see?

Where do I get to make changes

Building a Social Movement

Social Movements A type of group action Large informal groupings of individuals and/or organizations focused on specific political or social issue Based on coalitions and alliances It’s about social change The United Farm Workers movement The Anti-Apartheid Movement The Civil Rights movement Women’s liberation movem ent The Troutman Group

A type of group action

Large informal groupings of individuals and/or organizations focused on specific political or social issue

Based on coalitions and alliances

It’s about social change

The United Farm Workers movement

The Anti-Apartheid Movement

The Civil Rights movement

Women’s liberation movem ent

The Troutman Group

Are You Willing to Take the Risk?

Adewale Troutman, M.D.,M.P.H. The Troutman Group 5109 Forrest Grove Place Louisville, KY 40059 [email_address] 502 544 8570 www.thetroutmangroup.org The Troutman Group