This document discusses structural determinants of health inequities in Cook County, Illinois. It provides examples of structural inequities like inequities in the labor market, education system, and safety net that lead to inequities in social position and intermediate factors, and ultimately inequities in health outcomes. It emphasizes that public health departments should address the fundamental social and political causes of inequities rather than just proximal causes, and notes the link between lack of power and greater health inequities.

1. Tackling health inequities by
focusing on structural
determinants
Jim Bloyd, MPH
June 29, 2016
Advancing the Work: A Social
Determinants of Health
Toolkit for Reducing Infant Mortality

2. Cook County Department of Public Health
1$ Minimum wage increase in 2014 would have
likely resulted in 518 fewer post neo-natal deaths;
2790 fewer LBW births (Komro et al 2016 AmJPH)
Leaders of CHE Cook County May 25, 2016 join march at Oak Brook McDonalds shareholder meeting in
#FightFor15 and a Union. Photo: Jim Bloyd

3. Cook County Department of Public Health
Structural Racism: WePLAN2020
Priority
www.cookcountypublichealth.org
http://www.cookcountypublichealth.org/about/weplan-feedback
WePLAN2020 Forces of Change Assessment http://bit.ly/1V5sKWR
Health Issue Prioritization Process Summary http://bit.ly/1VEKWF6

4. Cook County Department of Public Health
Public Health Leadership Society
(2002)
“…addressing the
fundamental
causes rather than
more proximal
causes is more
truly preven8ve.”

5. Cook County Department of Public Health
Public Health
Departments should:
• Use social epidemiology
• Understand community
power structure
• Maximize and work with
grassroots power
• Emphasis on human rights
• Monitor and track
institutions that create
inequities
• Democratize data
Source: Public Health Accredita8on
Board (2014) hHp://
www.phaboard.org/wp-content/
uploads/FINAL_Annual-Report-
Sec8on-II-Guidance-Explana8ons-
of-Terms-February-2014.pdf

6. Cook County Department of Public Health
Inequity in the conditions of
daily lives is shaped by deeper
social structures and
processes.
World Health Organization, 2008

7. Cook County Department of Public Health
We have repeatedly referred to Hilary
Graham’s warning about the tendency to
conflate the social determinants of health and
the social processes that shape these
determinants’ unequal distribution, by
lumping the two phenomena together under a
single label. Maintaining the distinction is
more than a matter of precision in language.
As Graham argues, blurring these concepts
may lead to seriously misguided policy
choices.
[emphasis added] Source: Solar & Irwin (2010) p.47

8. Cook County Department of Public Health
Structural Determinants of
health inequities
• “…structural mechanisms are those
that generate stratification and social
class divisions in the society and that
define individual socioeconomic
position within hierarchies of power,
prestige and access to resources.
Structural mechanisms are rooted in
the key institutions and processes of
the socioeconomic and political
context.”

9. Cook County Department of Public Health
Social Determinants of health
• material circumstances;
• psychosocial circumstances;
• behavioral and/or biological factors;
and
• the health system itself.
Source: WHO, 2010

10. Cook County Department of Public Health
All diseases have two causes,
one pathological the other
political. Rudolph Virchow (1821-1902)
Fair Housing Act Violations
CC v. Wells Fargo
Education Financing
Minimum wage; One Fair
Wage, Tipped Income Laws;
sick leave
Accountability for
Police Shootings
Implementation of US
Title IX
Pregnant & Parenting
Students Civil Right to
Equal Education:
Distribution of:
Killings by police;
Education quality;
Income;
working
conditions;
exposure to
sexual assault &
harassment
Health
Inequities
in Cook
County

11. Cook County Department of Public Health
Structural inequities to inequities
in health outcomes (Graham 2007 modified)
Inequities
in the
Labor
Market
Inequities
in the
Safety Net
Inequities
in the
Education
System
SOCIAL
STRUCTURAL
INEQUITIES
(EXAMPLES)
INEQUITIES
IN SOCIAL
POSITION
(EXAMPLES)
Inequities
linked to
sexuality
Race /
ethnic
inequities
Gender
inequities
Social
economic
inequities
Inequities
in health
Behavioral
inequities
Environmental
inequities
INEQUITIES IN
INTERMEDIARY
FACTORS
INEQUITIES
IN HEALTH
OUTCOMES

12. Cook County Department of Public Health
Power and Health Inequities
“Power, after all, is the heart of the matter—and the
science of health inequities can no more shy away from
this question than can physicists ignore gravity or
physicians ignore pain.”
Jason
Beckfield & Nancy Krieger
Source: Epi + demos + cracy: Linking political systems and priorities to the
magnitude of health inequities--evidence, gaps, and a research agenda.
Epidemiologic Reviews, 31, 152-77. p. 169

13. Cook County Department of Public Health
Contact Information
Jim Bloyd, MPH
Regional Health Officer
Community Epidemiology & Health Planning
708-633-8314
jbloyd@cookcountyhhs.org
cookcountypublichealth.org

14. Cook County Department of Public Health
Social Causes Can Be Linked to
Health- Estimated Deaths,USA
2000 Source: Galea etal (2011) doi:10.2105/AJPH.2010.300086
Low
Education
245,000
Racial
Segregati
on
176,000
Low social
support
162,000
Individual
level
poverty
133,000
Income
inequality
119,000
Area level
poverty
39,000
Acute
Myocardial Inf
193,000
Cerebrovascular
Disease
167,700
Lung Cancer 155,600

15. Cook County Department of Public Health
Source: Center for Tax and Budget Accountability. (2015) http://bit.ly/1qB3qeA

16. Cook County Department of Public Health
Child poverty more than 6 times
greater in Harvey, IL vs. North
Suburban Cook County

17. Cook County Department of Public Health
Metro Chicago: Most poor children of color live in
concentrated poverty,
while most poor white children do not
Source: Diversitydata.org, (2011, from 2000 Census Data)
Neighborhood poverty
level

18. Cook County Department of Public Health
Housing: Nov 28, 2014: Cook
County v. Wells Fargo, Inc.
• Staff paid to steer Blacks,
Latinos, Women to hi-cost loans
• “ongoing discriminatory practice
of ‘equity-stripping’”
• “maximizes lender profits”
• “Defendant’s discriminatory
behavior maximized Defendant’s
revenue and income”
• “actually resulting in
foreclosure…the ultimate denial
of housing”
• “violations continue to this very
day”
• “segregation…provided an
efficient means for Defendants to
target potential borrowers”

19. Cook County Department of Public Health
CCDPH Strategic Plan (2011)
• “To optimize health and achieve health
equity for all people and communities of
Cook County through our leadership and
collaborations….”
• “…we need to make significant changes in
how we work…”
• “Because health depends causally on its
environmental, economic, technological,
informational, cultural and political contexts,
social justice is prerequisite to achieving
optimal and equitable public health.”