This document summarizes a presentation given by Jim Bloyd on confronting the politics of health inequity and escaping the "fantasy world" often created in public health. Some key points made in the presentation include: - Public health often focuses on downstream behavioral factors and medical care rather than upstream social and economic determinants of health inequity. - Health inequities are influenced by political and economic forces like neoliberalism that make it difficult for governments to address root causes like inequality. - The views and policy preferences of wealthy Americans have a disproportionate influence on policymaking compared to the general public. - Addressing health inequities requires confronting issues of power, politics, and social injustice rather

1. Escaping the public health fantasy world to
confront the poli6cs of health inequity
Jim Bloyd, MPH
Cook County Department of Public Health
Collabora6ve for Health Equity Cook County
September 6, 2016 Board Mee6ng
Health and Medicine Policy Research Group
Chicago, Illinois

2. My points…
• Neoliberal context dominant in Chicago,
Illinois & USA
• Public health has created a fantasy (“fantasy
paradigms”) in which it believes—against the
evidence--that focus on behavior change,
medical care, and ‘downstream’ factors will
eliminate health inequi6es
• Opportuni6es & examples exist to escape the
fantasy & live up to our charge & ethics

3. ScoZ-Samuel & Smith:
“…while it can be poli6cally expedient for
governments to engage with health inequali6es,
they cannot, within the confines of neo-liberalism,
realis6cally propose ac6ons that evidence suggests
will effec6vely reduce them - such as tackling
power inequali6es, social status and connec6ons or
class inequality.”
“…some policy actors and researchers have devised
a parallel fantasy world in which proximal,
downstream, easily tackled exposures are posited
as poten6al solu6ons to health inequali6es.”
ScoZ-Samuel & Smith 2015 p.1

4. RWJF Overcoming Obstacles to Health WHO CSDH Report
“Good health depends on personal choice
and responsibility . . . . Each of us must
make a commitment to:
“Social injus6ce is killing people on a
grand scale”
Eat a healthy diet “health inequi6es… are caused by the
unequal distribu6on of power, income,
goods, and services, globally and
na6onally, the consequent unfairness in
the immediate, visible circumstances of
people’s lives”
Physical ac6vity “This unequal distribu6on of health
damaging experience . . . is the result of a
toxic combina6on of poor social policies
and programmes, unfair economic
arrangements and bad poli6cs.”
Avoid risky behaviors
Avoid health and safety hazards at home
and at work
Nurture children”
Source: Marmot & Bell (2011)

5. • the answer to our health disadvantage cannot
be solved by reforming health care alone or by
admonishing Americans to adopt healthier
habits. Rather, the social and fiscal issues that
dominate today’s news may maZer as much
or even more to our health than any cure
medicine can render. (Woolf & Aron 2016)

6. Public health is poli6cal
The health of popula,ons and places is not only
under the control of individual ci,zens or local
communi,es, but it is also subject to the wider
poli,cal rela,ons of the state, the economy and
society. Further, changing society is only
achievable through poli,cs and poli,cal
struggle.
Bambra 2016

7. The policy views of the 1%: more
conserva6ve and more influen6al
• Page et al (2013)
Democracy and the policy
preferences of wealthy
Americans
• McElwee (2016) How
Chicago's White Donor
Class Distorts City Policy.
• Gilens (2012) Affluence
and influence: Economic
inequality and poli,cal
power in america

8. Disagreements about USA Fed Govt Spending
Levels ‘expand,’ ‘cut back,’ or ‘keep the same’
-100 -80 -60 -40 -20 0 20 40 60
Improve infrastructure-
scien6fic research
aid to educa6on
Jobs programs
Environmental protec6on
Homeland security
Health care
Food stamps
Social Security
Defense spending
Economic aid to other na6ons
Farm subsidies
General
Public
Wealthy
(1%)
Cut back Expand
(Page,
Bartels &
Seawright
2013)
2/15/16
Collabora6ve For Health Equity Cook
County WHERE PEOPLE PLACE AND POWER
MATTER
8

9. Page et al 2013
8
32
35
53
61
87
0 10 20 30 40 50 60 70 80 90 100
The federal government should
provide jobs for everyone able
and willing to work who cannot
find a job in private
employment
Favor na6onal health
insurance, which would be
financed by tax money, paying
for most forms of health care
The federal government should
spend whatever is necessary to
ensure that all children have
really good public schools they
can go to
%
General
Public
%
Wealthy
2/15/16
Collabora6ve For Health Equity Cook
County WHERE PEOPLE PLACE AND POWER
MATTER
9

10. Affluence and Influence: The
“preference/policy link” (Gilens 2012)
• “…under most circumstances, the preferences of
the vast majority of Americans appear to have
essen6ally no impact on which policies the
government does or doesn’t adopt.” [loca6on 203]
• “When less-well-off Americans hold preferences
that diverge from those of the affluent, policy
responsiveness to the well-off remains strong but
responsiveness to lower-income groups all but
disappears.” [Loca6on 285]
2/15/16
Collabora6ve For Health Equity Cook
County WHERE PEOPLE PLACE AND POWER
MATTER
10

12. When we fight, We win!
Jobin-Leeds & AgitArte 2016
The New Press. New York
• Movements are sources of lessons
• Trying is the path to victory
• Winning requires a “we”
• Transforma6ve change, in the face of powerful
forces, requires a fight
• We win our own personal transforma6on
• Claiming our humanity and right to fight is a win
When we fight we win: voices of cusng edge
leaders addressing root causes of inequi6es
2/15/16
Collabora6ve For Health Equity Cook
County WHERE PEOPLE PLACE AND POWER
MATTER
12

13. Illinois Tipped Min Wage $4.95 (AllegreZo & Cooper 2014)

14. “The right to search
for truth implies
also a duty; one
must not conceal
any part of what
one has recognized
to be true.”
Albert Einstein
Source: Na6onal Academies of Sciences;
Tsao etal 2016; Komro etal 2016)

15. Customers subsidize businesses in US two-6ered
wage system AllegreZo & Cooper (2014); Jayaraman (2016)
Workers
advocates
NRA Pres Herman Cain 1996
US Congress
1996 Deal Freezes
Tipped workers wages

16. Chicago Census Tract Income Distribu6on
Nolan (2015) Voorhees Center

17. Nolan (2015) Voorhees Center

18. Structural Racism-20-24 year-olds not
working/in school (Great Ci6es Ins6tute 2016)

19. • www.checookcounty.org @CHECookCounty
• Spearheading CCDPH structural racism-health
inequi6es priority in WePLAN2020
• 17-Member governing Steering CommiZee
• 1 of 19 teams in the US Na6onal
Collabora6ves for Health Equity; community
of prac6ce; Brian Smedley

20. CHE Leadership Development: Video applica6on to Robert Wood
Johnson Founda6on Culture of Health available at hZps://youtu.be/
ZzfvuktE0jo

22. ICE Measure
Data & Map Prepared by: Jasmine Smith & Erika Marshall
Projection: NAD 1983 State Plane Illinois East
Data Source: U.S. Census Bureau, ACS 2014 5-Year Estimate;
Chicago Data Portal, Community Area boundaries 2015l;
CMAP, Municipality boundaries 2014
July 15, 2016
For CHE Cook County: http://www.checookcounty.org/
Index of Concentration at the Extremes (ICE)
Income by Census Tract in Cook County 2012
Draft
¯0 3.5 7 10.5 141.75
Miles
Where:
Ai = # Affluent Households
in Census Tract
(>=$100,000 Household Income)
Pi = # Poor Households
in Census Tract
(<$25,000 Household Income)
Ti = Total # Households
in Census Tract
-1 = 100% of Pop. Concentrated Deprivation
0 = Equal Concentration Deprivation/Privilege
1 = 100% of Pop. Concentrated Privilege
ICEi = (Ai - Pi)/Ti
ICE: Income
(in Quintiles)
-1.00 - -0.30
-0.31 - -0.11
-0.12 - 0.03
0.04 - 0.22
0.23 - 0.81
1. Steeper gradients with health
inequity in NYC than typical %
poverty measure (Krieger 2016)
2. Focus on concentrated
privilege as well as
depriva6on
3. Can jointly measure income &
race-ethnicity segrea6on
4. Unlike Gini & dissimilarity
index, has meaning at small
geographies (Massey)
5. CHE Cook County (Jasmine
Smith; Erika Marshall),
DePaul, UIC, CCDPH, CDPH

23. Thank You !
www.checookcounty.org
www.cookcountypublichealth.org
@CHECookCounty @CookCoHealth
Youtube.com/ccplacemaZers
Jim Bloyd, MPH, Regional Health Officer
Cook County Department of Pubic Health
15900 S. Cicero Avenue
Oak Forest, Illinois 60452
jbloyd@cookcountyhhs.org
708-633-8314

24. Addi6onal material to discuss-- 6me
permisng!

25. Challenges
• Censorship/ Use of language
• Lack of explicitness of framework
• Lack of explicitness of values

26. Tes6ng Fundamental Cause theory: implica6ons
for ac6on to reduce health inequali6es
ScoZ etal (2013)

27. Behavior is determined by social factors (Marmot 2007)

28. Behavior is determined by social factors
(Marmot 2007)

29. RWJF, framing, social gradient (Marmot Bell 2011)

30. Life Expectancy Gradient Cook County

31. US Policy Choice: Child Poverty Outlier Marmot (2007)

32. “We in health care need to do a beZer job of
suppor6ng efforts for preven6on in other
sectors –like child care, educa6on, housing, and
urban planning—that are the largest
determinants of who gets sick in the first place.
Doctors and other clinicians need to be part of
that work and be involved in gesng their clinics
to do more to address social determinants of
health. They need tools, examples and role
models.” Paula Braveman Manchanda (2013)

33. “For many decades, the field has been
constrained by self-imposed limita6ons and, all
too o}en, has avoided engagement with those
who challenge complacency and exis6ng power
rela6onships.”
Amy Fairchild (Fairchild etal 2010)

34. Health Divides: Where you live can kill
you (Bambra 2016)
Place both creates and contains social, economic
and poli,cal rela,ons as well as physical
resources. Spa,al inequali,es in health are
therefore a result of a complex mix of economic,
social, environmental and poli,cal processes-
coming together in par,cular places.

35. It is not inequali,es that kill people, […]it is
those who are responsible for these inequali,es
that kill people.
Vicente Navarro 2009 (emphasis in the original)

36. “The result [of the social situa6on] is the same
as if twenty or thirty thousand of these people
were annually taken out of their wretched
dwelling and put to death.”
Edwin Chadwick, Commissioner of the Board of Health of Great Britain (1848-1854)
(Chernomas & Hudson 2009)

37. Stra6fica6on
• All socie6es are stra6fied along lines of
ethnicity, race, gender, educa6on, occupa6on,
income, and class. Health inequi6es result
from unequal distribu6on of power, pres6ge,
and resources among groups in society. Marmot 2007

38. Commission on the Social Determinants of
Health Conceptual Framework (WHO Solar & Irwin 2010)

39. References
AllegreZo, S. A., & Cooper, D. (2014). Twenty-three years and s,ll wai,ng for change: Why it's ,me to give ,pped workers the regular minimum wage (p. 27). Washington, DC: Economic Policy
Ins6tute. (Original work published July 10, 2014) Retrieved from hZp://www.irle.berkeley.edu/cwed/briefs/EPI-CWED-BP379-1.pdfBambra, C. (2016). Health divides: Where you live can kill you.
Bristol, UK: Policy Press
Chernomas, R., & Hudson, I. (2009). Social murder and conserva6ve economics. Criminal Jus,ce MaVers, 77(1), 2-3. doi:10.1080/09627250903138852
Fairchild, A. L., Rosner, D., Colgrove, J., Bayer, R., & Fried, L. P. (2010). The EXODUS of public health. What history can tell us about the future. American Journal of Public Health, 100(1), 54-63. doi:
10.2105/AJPH.2009.16395
Fafard, P. (2008). Evidence and healthy public policy insights from health and poli,cal sciences. OZawa, Ont.: Canadian Policy Research Networks. Retrieved from Na6onal Collabora6ng Centre for
Healthy Public Policy: hZp://www.ncchpp.ca/docs/FafardEvidence08June.pd
Gilens, M. (2012). Affluence and influence : Economic inequality and poli,cal power in america. Princeton, N.J: Princeton University Press ; New York : Russell Sage Founda6on.
Internal Revenue Services. Schedule H Form 990. (n.d.). Schedule H form 990. [Pamphlet)
Jayaraman, S. (2016). Forked: A new standard for american dining. New York, NY: Oxford
Komro, K. A., Livingston, M. D., Markowitz, S., & Wagenaar, A. C. (2016). The effect of an increased minimum wage on infant mortality and birth weight. American Journal of Public Health, 106(8),
1514-6. doi:10.2105/AJPH.2016.30326
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Manchanda, R. (2013). The US health disadvantage and clinicians: An interview with paula braveman. Health affairs blog [Web page]. Retrieved from
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Marmot, M. (2007). Achieving health equity: From root causes to fair outcomes. Lancet, 370(9593), 1153-1163. doi:10.1016/s0140-6736(07)61385-
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