Putting Social Determinants in Perspective for Policymakers


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Presentation by Steven H. Woolf, MD, MPH at the 2009 Virginia Health Equity Conference.

Dr. Woolf shared research on the dramatic influences of social conditions on health inequities nationally and in the Commonwealth of Virginia. He also discussed the importance of packaging the evidence in compelling formats for policymakers and the public.

Published in: Health & Medicine, Technology
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Putting Social Determinants in Perspective for Policymakers

  1. 1. Putting Social Determinants in Perspective for Policymakers Health Equity Conference Richmond, Virginia September 11, 2009 Steven H. Woolf, MD, MPH Departments of Family Medicine, Epidemiology and Community Health Virginia Commonwealth University
  2. 2. Economic & Social Opportunities and Resources Living & Working Conditions in Homes and Communities Personal Behavior Medical Care HEALTH Finding solutions: Understanding the importance of social factors Policies to promote healthier homes, neighborhoods, schools and workplaces Policies to promote child and youth development and education, infancy through college Policies to promote economic development and reduce poverty Robert Wood Johnson Foundation Commission to Build a Healthier America www.commissiononhealth.org
  3. 7. Copyright ©2007 by Project HOPE, all rights reserved. Chapin White, Health Care Spending Growth: How Different Is The United States From The Rest Of The OECD?, Health Affairs, Vol 26, Issue 1, 154-161
  4. 12. “ Health is more than health care.”
  5. 16. Determinants of Population Health Social determinants of health Primary prevention Secondary prevention Tertiary prevention
  6. 17. Societal Preference
  7. 20. June 11, 1963
  8. 21. <ul><li>“… The Negro baby born in America today, regardless of the section of the Nation in which he is born, has about one-half as much chance of completing a high school as a white baby born in the same place on the same day, one-third as much chance of completing college, one-third as much chance of becoming a professional man, twice as much chance of becoming unemployed, about one-seventh as much chance of earning $10,000 a year, a life expectancy which is 7 years shorter, and the prospects of earning only half as much…” </li></ul>Televised address on civil rights June 11, 1963 Oval Office address, John F. Kennedy
  9. 22. HealthUS, National Center for Health Statistics
  10. 23. From: Satcher et al. Health Affairs 2005;24:459-64.
  11. 25. County Life Expectancies by Race Murray CJL, Kulkarni SC, Michaud C, Tomijima N, Bulzacchelli MT, et al. PLoS Medicine Vol. 3, No. 9, e260 doi:10.1371/journal.pmed.0030260
  12. 26. Murray CJ, Kulkarni S, Ezzati M. Eight Americas: new perspectives on U.S. health disparities. Am J Prev Med 2005;29(5 Suppl 1):4-10. 8.2 74.9 66.7 Black high-risk urban 8 6.9 74.6 67.7 Black poor rural South 7 6.4 75.9 69.6 Black middle America 6 6.6 75.9 69.4 Western Native Americans 5 6.1 77.8 71.8 White poor Appalachia/ Mississippi Valley 4 5.0 80.2 75.2 Middle America 3 5.6 81.8 76.2 White low-income rural Northland 2 4.9 87.7 82.8 Asians 1 Female–male difference in life expectancy Female life expectancy at birth Male life expectancy at birth General description America
  13. 27. A Tale of Two Choices <ul><li>Effectiveness </li></ul><ul><li>Equity </li></ul>
  14. 30. Age-Adjusted Mortality (1991-2000) Disparity of 24-29%
  15. 31. Study Question <ul><li>Decade of 1991-2000 </li></ul><ul><li>Comparison of lives saved by: </li></ul><ul><ul><li>generic improvements in health care vs. </li></ul></ul><ul><ul><li>correction of racial disparities in mortality rates </li></ul></ul><ul><li>Reduction in population all-cause mortality attributed entirely to improvements in medical care </li></ul>
  16. 32. From: Woolf SH, Johnson RE. Am J Public Health 2004;94:2078-81
  17. 33. From: Woolf SH, Johnson RE. Am J Public Health 2004;94:2078-81
  18. 34. Am J Public Health. 2007;97:679–683
  19. 36. Methods <ul><li>Period of 1996-2002 </li></ul><ul><li>Comparison of lives saved by: </li></ul><ul><ul><li>generic improvements in health care vs. </li></ul></ul><ul><ul><li>correction of disparities in mortality rates by educational attainment </li></ul></ul><ul><li>US adults age 18-64 years* </li></ul><ul><li>Children and adolescents excluded for lack of relevant mortality data </li></ul><ul><li>Educational attainment </li></ul><ul><ul><li>Less than high school </li></ul></ul><ul><ul><li>High school but no college </li></ul></ul><ul><ul><li>1 or more years of college </li></ul></ul>*For analysis of education-associated excess death; all age groups were included for analysis of benefits from generic improvements in health care.
  20. 37. Methods (continued) <ul><li>Indirect standardization of mortality rates </li></ul><ul><ul><li>For estimating benefits of generic improvements in health care </li></ul></ul><ul><ul><ul><li>Deaths that would not have occurred if mortality rates of the prior year applied. </li></ul></ul></ul><ul><ul><li>For estimating effects of eliminating education-associated excess mortality </li></ul></ul><ul><ul><ul><li>Deaths that would not have occurred if all adults had the mortality rate of those with a college education </li></ul></ul></ul>
  21. 38. Educational attainment, by race and ethnicity
  22. 39. Mortality rates, by educational attainment
  23. 40. Am J Public Health. 2007;97:679–683
  24. 41. Results <ul><li>Lives saved by generic medical advances </li></ul><ul><ul><li>24,456 lives per year </li></ul></ul><ul><ul><li>178,193 lives in 1996-2002 </li></ul></ul><ul><li>Lives saved by eliminating education-associated excess mortality </li></ul><ul><ul><li>195,619 lives per year </li></ul></ul><ul><ul><li>1,369,335 lives in 1996-2002 </li></ul></ul><ul><li>Ratio of 8:1 </li></ul>
  25. 42. Limitations <ul><li>Methodologic </li></ul><ul><li>Expectation of 100% elimination of disparities </li></ul><ul><li>“ Magic wand” effects </li></ul><ul><li>Focus on mortality </li></ul><ul><li>Crediting medical advances with changes in all-cause mortality </li></ul><ul><li>Different comparison populations </li></ul><ul><li>Death certificate data </li></ul><ul><li>Policy </li></ul><ul><li>Improving education would not resolve the disparity—confounding variables </li></ul><ul><li>Improving education faces formidable barriers </li></ul>
  26. 51. U.S. Census Bureau, American Community Survey Reports, ACS-09, Income, Earnings, and Poverty: Data From the 2007 American Community Survey, U.S. Government Printing Office, Washington, DC, 2008.
  27. 55. Proportion of Deaths in Virginia Associated With Reduced Household Income
  28. 56. Absolute Number of Deaths in Virginia That Would be Averted
  29. 64. <ul><li>We must recognize the full human equality of all of our people before God, before the law, and in the councils of government. We must do this, not because it is economically advantageous, although it is; not because of the laws of God command it, although they do; not because people in other lands wish it so. We must do it for the single and fundamental reason that it is the right thing to do. </li></ul>Robert F. Kennedy, University of Cape Town Cape Town, South Africa June 6, 1966