Racial Health Inequities in San Francisco: Trauma-informed approach to systems & community transformation

1. Racial Health Inequities in San Francisco, CA
Trauma-informed approach to systems & community transformation
Tomás J. Aragón, MD, DrPH
CCLHO/HOAC Semi-annual Meeting, Bakersfield, CA, May 4, 2017
Health Officer, City & County of San Francisco
Director, Population Health Division (PHD)
San Francisco Department of Public Health
http://phlean.org (view or download slides)
http://phdata.science (data science)
tomas.aragon@sfdph.org (email)
415-78-SALUD (415-787-2583)
PDF slides produced in Rmarkdown LATEX Beamer—Metropolis theme
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2. 1 Background and introduction
2 Trauma-informed approach in S.F.
3 San Francisco Public health examples
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3. 1 Background and introduction
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4. Special acknowledgments (in alphabetical order)
• Ayanna Bennett, Lead, Black/African American Health Initiative
• Barbara A. Garcia, Director of Health, SFDPH LEAD Initiative
• Jacque McCright, SFHN Hypertension Equity Workgroup, PHD representative
• Ellen Chen, Lead, SFHN Hypertension Equity Workgroup
• Emily Weinstein, Trauma-Informed Community Building
• Jessica Wolin, Trauma-Informed Community Building
• Kenneth Epstein, DPH Trauma-informed Systems Initiative
• Kenneth Hardy, Racial Humility consultant/trainer
• Lakisha Garduño, SFHN Hypertension Equity Workgroup
• Rhonda Simmons, Division of Diversity, Inclusion and Workforce Development, HR
• Richa Dhanju, Division of Diversity, Inclusion and Workforce Development, HR
• Rita Nguyen, SFHN Hypertension Equity Workgroup, PHD representative
• Sarah Cox, SFHN Hypertension Equity Workgroup
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5. Some definitions
Health is a state of complete physical, mental and social well-being and not merely the
absence of disease or infirmity (World Health Organization, 1946).
Public health is what we, as a society, do collectively to assure the conditions in which
people can be healthy (Institute of Medicine, 1988).
Population health1 is a systems2 framework for studying and improving the health of
populations through collective action and learning (Aragon & Garcia, 2017).3
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Essential population health goals include (1) protecting and promoting health and equity, (2)
transforming people and place, (3) ensuring a healthy planet, and (4) achieving health equity.
2
Complex adaptive socioecological systems (CASES)
3
For discussion of the term "population health" see http://www.phdata.science/p/about.html
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6. More definitions4
Health disparities are “differences that exist among specific population groups in the
United States in the attainment of full health potential that can be measured by
differences in incidence, prevalence, mortality, burden of disease, and other adverse
health conditions.”
Health equity is “the state in which everyone has the opportunity to attain full health
potential and no one is disadvantaged from achieving this potential because of social
position or any other socially defined circumstance.”
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National Academies of Sciences, Engineering, and Medicine. 2017. Communities in action: Pathways
to health equity. Washington, DC: The National Academies Press. doi: 10.17226/24624.
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7. Health inequity arises from root causes in two clusters:5
1. Intrapersonal, interpersonal, institutional, and systemic mechanisms (also referred
to as structural inequities) that organize the distribution of power and resources
differentially across lines of race, gender, class, sexual orientation, gender
expression, and other dimensions of individual and group identity.
2. The unequal allocation of power and resources—including goods, services, and
societal attention—which manifests itself in unequal social, economic, and
environmental conditions, also called the determinants of health.
5
National Academies of Sciences, Engineering, and Medicine. 2017. Communities in action: Pathways
to health equity. Washington, DC: The National Academies Press. doi: 10.17226/24624.
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8. Health includes the 8 dimensions of wellness6
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Source: http://www.samhsa.gov/wellness-initiative
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9. Population health socioecological framework7
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Source: California Department of Public Health, Office of Health Equity
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10. Causes of premature deaths in men and women, San Francisco, 2003–2004
Age-adjusted Expected Years of Life Lost (eYLL): Male (left), Female (right); Black (colored red),
Latino, × Asian/PI, + White; Source: Aragón TJ, et al. PubMed ID: 18402698 10

11. San Francisco residents do not have equitable opportunities for good health
Unevenly distributed obstacles to health (left); Health inequities (right)
Source: San Francisco Community Health Needs Assessment, 2016 (http://sfhip.org)
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12. Structural trauma and toxic stress—The roots of racial health inequities
Foundational themes
• Communities suffer from the effects of chronic trauma/stress
• Life-course of toxic stress, structural racism, and discrimination
• Toxic stress effects a child’s learning, behavior, and health for life
• Policy, systems, structural priorities must reach the most vulnerable
• Neighborhood, Family-centered, Life-course (NFL)8 focus is essential
• Trauma effects are transmitted across generations socially and biologically
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The acronym NFL makes us think of the “National Football League” who is infamous for the
systematic denial of permanent brain injury (chronic trauma encephalopathy [CTE]) from playing
football (see http://www.pbs.org/wgbh/frontline/film/league-of-denial/). For us, NFL means
having a relentless focus on the Neighborhood, Family-centered, Life-course (NFL) approach when we
prioritize social policy: we aim to always reach the most vulnerable—children ages 0 to 5 years.
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13. Childhood adversities and mental health outcomes in homeless adults
San Francisco, 2016 (Am J Geriatr Psychiatry 2016)
Source: http://www.centerforyouthwellness.org/
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14. How our core capabilities work (1/2)
Executive function, attention, and automatic and intentional self-regulation
Executive function skill proficiency
Source: Center on the Developing Child (http://developingchild.harvard.edu/)
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15. How our core capabilities work (2/2)
Executive function, attention, and automatic and intentional self-regulation
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16. 2 Trauma-informed approach in S.F.
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17. Designing a healing and learning organization, transforming people and place
Lead: Barbara Garcia, and inspired by the Kresge Emerging Leaders in Public Health
Adapted from the Lean Transformation Framework (http://www.lean.org)
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18. Core principles of trauma-informed systems
SFDPH initiative led by Dr. Kenneth Epstein
We serve diverse, traumatized communities under chronic, toxic stress. Our diverse staff
often live in or come from these communities. Therefore, we need to design healing
organizations. Here are six core principles of healing, trauma-informed systems:
1. Understanding trauma and stress
2. Compassion and dependability
3. Safety and stability
4. Collaboration and empowerment
5. Cultural humility and responsiveness
6. Resilience and recovery
For more information visit http://www.t2bayarea.org.
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19. Cultural/Racial Humility
In 1998, Melanie Tervalon and Jann Murray-García published a groundbreaking article
that challenged the concept of “cultural competency” with the concept of “cultural
humility.” Cultural humility9 is committing to lifelong learning, critical self-reflection,
and personal and institutional transformation.
1. Commit to lifelong learning and critical self-reflection.
2. Cultivate humility,10 opening our hearts to transformation.
3. Realize our own power, privilege, and prejudices.
4. Redress power imbalances for respectful partnerships.
5. Recognize and validate our common humanity.
6. Promote institutional accountability.
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Adapted from Drs. Melanie Tervalon, Jann Murray-García, and Kenneth Hardy
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“Humility is the noble choice to forgo your status and use your influence for the good of others. It is to
hold your power in service of others.” (Source: John Dickson https://youtu.be/dBfKYgLhiEg)
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20. 3 San Francisco Public health
examples
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21. Black/African American Health Initiative (BAAHI), April, 2014
Lead: Ayanna Bennett, San Francisco Department of Public Health
BAAHI components
1. Collective impact
2. Workforce development
3. Cultural humility training
Collective impact
1. Heart health (focus: hypertension)
2. Behavioral health (focus: alcohol)
3. Women’s Health (focus: breast cancer)
4. Sexual Health (focus: Chlamydia)
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22. SF Health Network Primary Care Hypertension Equity Workgroup
Leads: Ellen Chen, Lakisha Garduño, and Sarah Cox (1/4)—Lean performance improvement
Equity is a True North metric for
all SFDPH Lean programs.
Lean thinking and practicea is
“systematically developing people to
solve problems and consuming the
fewest possible resources while
continuously improving processes
to provide value to community
members and prosperity to society.”
a
http://www.lean.org
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23. SF Health Network Primary Care Hypertension Equity Workgroup
Lead: Ellen Chen, Lakisha Garduño, and Sarah Cox (2/4)—Headline Performance Indicator
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24. SF Health Network Primary Care Hypertension Equity Workgroup
Leads: Ellen Chen, Lakisha Garduño, and Sarah Cox (3/4)—Performance Indicators, by Clinic
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25. SF Health Network Primary Care Hypertension Equity Workgroup
Leads: Ellen Chen, Lakisha Garduño, and Sarah Cox (4/4)—Monthly True North messaging
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26. Healthy Hearts San Francisco (HHSF)—CDC REACH Grant
Leads: Jacque McCright, Kathleen Edmunds, Giuliana Martinez, Wanda Anderson
HHSF Focus Areas
1. Targeting lowest-income African
American and Latino census tracts
2. Mobilizing free physical activity
resources in the community
3. Primary care “green” prescriptions for
physical activity
4. Community navigators in the clinics
Web site: http://healthyhearts.org
YouTube: https://youtu.be/aZIjTSfc2lk
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27. Healthy Hearts San Francisco (HHSF)—CDC REACH Grant
Leads: Jacque McCright, Kathleen Edmunds, Giuliana Martinez, Wanda Anderson
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28. Trauma-informed community building (San Francisco)
Leads: Emily Weinstein, Bridge Housing and Jessica Wolin, San Francisco State University
TRAUMA INFORMED
COMMUNITY BUILDING
A Model for Strengthening Community in
Trauma Affected Neighborhoods
Weinstein, Wolin, Rose
Source: http://bridgehousing.com/PDFs/TICB.Paper5.14.pdf
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29. The Leading Population Health Framework—Overall concepts
Transforming self, teams, organizations, and communities
Source: http://www.phlean.org 29

30. The Leading Population Health Framework—Putting it all together!
“Leadership is getter results in a
way that inspires trust.”
. . . Stephen M.R. Covey
Population health goals:
1. Protecting and promoting
health and equity
2. Transforming people and place;
3. Ensuring a healthy planet; and
4. Achieving health equity.
Source: http://www.phlean.org
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31. Questions? Preguntas? Mga katanungan? Des questions?
Acknowledgments (in alphabetical order)
Abbie Yant, Alice Chen, Amor Santiago, Anda Kuo, Aneeka Chaudhry, Ayanna Bennett, Barbara
A Garcia, Barry Lawlor, Belle Taylor-McGhee, Brittney Doyle, Cecilia Thomas, Christine Siador,
Cindy Garcia, Colleen Chawla, Colleen Matthews, Curtis Chan, Darlene Daevu, David Serrano
Sewell, Deborah Sherwood, Deena Lahn, Dianne M. Easton, Ellen Chen, Estela Garcia, Greg
Wagner, Guliana Martinez, Hali Hammer, Iman Nazeeri-Simmons, Isela Ford, Israel
Nieves-Rivera, Jacque McCright, James Illig, Jeannie Balido, Jenee Johnson, Jessica Wolin, John
Grimes, Jonathan Butler, Jonathan Fuchs, Judith Martin, Karen Pierce, Karen Strickland,
Kavoos Ghane Bassiri, Kenneth Epstein, Kenneth Hardy, Kevin Grumbach, Kim Shine, Kirsten
Bibbins-Domingo, Leigh Kimberg, Lisa Golden, Maria X Martinez, Marlo Simmons, Mary Hansell,
Maximilian Rocha, Michelle A. Albert, Michelle Kirian, Michelle Long, Muntu Davis, Nadine
Burke Harris, Neal Halfon, Patricia Erwin, Paula Fleisher, Paula Jones, Perry Lang, Rachael
Kagan, Rhea Bailey, Rhonda Simmons, Roberto Vargas, Robin George, Roland Pickens, Ron
Weigelt, Stuart Fong, Susan Ehrlich, Susan Philip, Tessa Rouverol Collejo, Thomas Boyce,
Tracey Packer, Veronica Shepard, Wanda Materre, Wanetta Davis, Wilma Wooten, Wylie Liu 31

32. Key online resources
• BARHII Bay Area Regional Health Inequities Initiative
http://barhii.org/
• Government Alliance on Race and Equity
http://www.racialequityalliance.org/
• Center for Social Inclusion
http://www.centerforsocialinclusion.org/
• Center on the Developing Child
http://developingchild.harvard.edu/
• The Raising of America
http://www.raisingofamerica.org/
• Population Health Lean (TJA)
http://www.phlean.org/
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