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Social Determinants of Health - Dr. Adewale Troutman


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Social Determinants of Health - Dr. Adewale Troutman

  1. 1. 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
  2. 2. The Troutman Group
  3. 3. A Case Study; But Why
  4. 5. Vital Statistics: The Troutman Group
  5. 6. Reframing <ul><li>Health vs. Healthcare </li></ul><ul><li>Individual vs. Population Health </li></ul><ul><li>Market Justice vs. Social Justice </li></ul><ul><li>Rights vs. Privileges </li></ul><ul><li>Biological/Behavioral Determinants vs Social Determinants </li></ul><ul><li>Creating Health Equity vs. eliminating Health Disparities </li></ul>The Troutman Group
  6. 7. 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?
  7. 8. Let’s get on the same page.
  8. 9. Health <ul><li>“ The presence of physical, psychological, social, economic and spiritual well being not merely the absence of disease or infirmity” </li></ul><ul><li>“ The maintenance of a harmonious balance of mind, body and spirit” </li></ul><ul><ul><li>Community and individual </li></ul></ul>The Troutman Group
  9. 10. Health Equity <ul><li>“ 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.” </li></ul>
  10. 11. Health Equity <ul><li>“ The absence of unfair and avoidable or remediable differences in health among social groups” ( The Commission ) </li></ul><ul><li>A value position supported by an evidence base </li></ul><ul><li>There is and will be political opposition to the core value of health equity </li></ul>The Troutman Group
  11. 12. Health Inequities <ul><li>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 </li></ul>The Troutman Group
  12. 13. <ul><li>The development of society can be judged by: </li></ul><ul><li>the quality of its populations ’ health </li></ul><ul><li>the fairness in distribution of health, and </li></ul><ul><li>the degree of protection provided from disadvantage due to ill-health </li></ul>Marmot 2006 Harveian Oration Health equity as a development outcome
  13. 14. Justice <ul><li>The quality of fairness </li></ul><ul><li>The principle of moral rightness; equity </li></ul><ul><li>Conformity to moral rightness in action or attitude </li></ul>The Troutman Group
  14. 15. Social Justice <ul><li>The application of principles of justice to the broadest definition of society </li></ul><ul><li>Implies </li></ul><ul><ul><li>Equity </li></ul></ul><ul><ul><li>Equal access to societal power, goods and services </li></ul></ul><ul><li>Universal respect for human and civil rights </li></ul>The Troutman Group
  15. 16. Rights <ul><li>Claims or entitlements that are recognized by legal or moral principles </li></ul><ul><li>Enforced by legislation and rules, the force of law </li></ul>The Troutman Group
  16. 17. Human Rights <ul><li>A higher order right MORALLY based and UNIVERSAL. It belongs to all persons equally because they are human beings (Declaration of Independence) </li></ul>The Troutman Group
  17. 18. The Right to Health <ul><li>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 </li></ul>The Troutman Group
  18. 19. Market Justice vs. Social Justice
  19. 20. Market Justice <ul><li>Emphasizes personal responsibility as the basis for distributing burdens and benefits </li></ul><ul><li>Individuals assume prime responsibility for their own health </li></ul><ul><li>Little expectation that society should act to protect or promote the health of its members </li></ul><ul><li>Social Darwinism </li></ul>The Troutman Group
  20. 21. Social Justice <ul><li>Significant factors within society impede fair distribution of benefits and burdens </li></ul><ul><li>Social class distinctions, heredity, racism, ethnism play significant roles </li></ul><ul><li>Collective action necessary to neutralize or overcome forces </li></ul>The Troutman Group
  21. 22. 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…
  22. 23. The Case for Action <ul><li>The moral, ethical , this is the right thing to do because it is case </li></ul><ul><li>The pragmatic , this is costing the system countless dollars and self interest in the financial crisis around health inequities make it a must do. </li></ul>The Troutman Group
  23. 24. The Economic Burden of Health Inequities in the United States <ul><li>Direct medical costs of health inequalities </li></ul><ul><li>Indirect cost of health inequalities </li></ul><ul><li>Cost of premature death </li></ul><ul><li>( The pragmatic case ) </li></ul>THomas LaViest et al John Hopkins,University of Maryland
  24. 25. Economic Burden Findings <ul><li>Between 2003 and 2006 combined cost of health inequalities and premature death was $1.24 trillion </li></ul><ul><li>Eliminating health disparities for minorities would have reduced direct medical care expenditures by $229.4 billion </li></ul><ul><li>Between 2003 and 2006, 30.6% of direct medical care expenditures for African Americans, Asians and Latinos were excess costs due to health inequalities </li></ul>THomas LaViest et al John Hopkins,University of Maryland
  25. 26. Findings ( Cont ) <ul><li>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 </li></ul>THomas LaViest et al John Hopkins,University of Maryland
  26. 27. A New Direction
  27. 28. Looking upstream, finding the causes of he causes. The Troutman Group
  28. 29. <ul><li>Socioeconomic Status </li></ul><ul><li>WHO </li></ul><ul><li>Occupation </li></ul><ul><li>Education </li></ul><ul><li>Income </li></ul><ul><ul><li>Income gaps </li></ul></ul><ul><li>Racism & discrimination </li></ul><ul><li>Housing </li></ul><ul><li>Political power </li></ul><ul><li>Early Life </li></ul><ul><li>Social Exclusion </li></ul><ul><li>Work </li></ul><ul><li>Unemployment </li></ul><ul><li>Social Support </li></ul><ul><li>Addiction </li></ul><ul><li>Food </li></ul><ul><li>Transport </li></ul><ul><li>The Social Gradient </li></ul><ul><li>Stress </li></ul>Social Determinants The Troutman Group
  29. 30. Stress <ul><li>Continuing existence of anxiety, insecurity, low self esteem and social isolation </li></ul><ul><li>Lack of control over home and work life </li></ul><ul><li>Profound effect on health </li></ul><ul><li>Cumulative </li></ul>The Troutman Group
  30. 31. The Power of Poverty The Troutman Group
  31. 32. Income Inequities <ul><ul><li>1995 study Kennedy, Kawachi and Prothrow-Stith </li></ul></ul><ul><li>282 cities in the U.S. </li></ul><ul><li>Death from income inequities “ is comparable to the combined loss of life from lung cancer, diabetes, motor vehicle crashes, HIV infection and homicide” </li></ul>The Troutman Group
  32. 33. The Troutman Group
  33. 34. The Troutman Group
  34. 35. The Elephant in the Room: Racism The Troutman Group
  35. 36. What is racism? <ul><li>A system </li></ul>The Troutman Group
  36. 37. What is racism? <ul><li>A system of structuring opportunity and assigning value </li></ul>The Troutman Group
  37. 38. What is racism? <ul><li>A system of structuring opportunity and assigning value based on the social interpretation of how one looks (“race”) </li></ul>The Troutman Group
  38. 39. What is racism? <ul><li>A system of structuring opportunity and assigning value based on the social interpretation of how one looks (“race”) </li></ul><ul><ul><li>Unfairly disadvantages some individuals and communities </li></ul></ul>The Troutman Group
  39. 40. What is racism? <ul><li>A system of structuring opportunity and assigning value based on the social interpretation of how one looks (“race”) </li></ul><ul><ul><li>Unfairly disadvantages some individuals and communities </li></ul></ul><ul><ul><li>Unfairly advantages other individuals and communities </li></ul></ul>The Troutman Group
  40. 41. What is racism? <ul><li>A system of structuring opportunity and assigning value based on the social interpretation of how one looks (“race”) </li></ul><ul><ul><li>Unfairly disadvantages some individuals and communities </li></ul></ul><ul><ul><li>Unfairly advantages other individuals and communities </li></ul></ul><ul><ul><li>Saps the strength of the whole society through the waste of human resources </li></ul></ul>The Troutman Group Source: Jones CP, Phylon 2003
  41. 42. Levels of Racism <ul><li>Individually Mediated </li></ul><ul><ul><li>People make assumptions about one abilities based on their race and act differently towards them ( discrimination) </li></ul></ul><ul><li>Institutionalized </li></ul><ul><ul><li>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. </li></ul></ul>The Troutman Group
  42. 43. Levels of Racism <ul><li>Internalized </li></ul><ul><ul><li>Acceptance by members of the racial or ethnic group of the negative beliefs of their own abilities and value. </li></ul></ul><ul><ul><ul><li>May lead to depression, hopelessness, helplessness and living as victim </li></ul></ul></ul>The Troutman Group
  43. 45. “ Patients” experiencing symptoms of heart disease, from Schulman et al. (1999)
  44. 46. “ Patients” experiencing symptoms of heart disease, from Schulman et al. (1999)
  45. 47. Place Matters The Troutman Group
  46. 48. Tell me how a man died and I’ll tell you where he lived Aristotle The Troutman Group
  47. 49. 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
  48. 50. Opportunity Neighborhoods <ul><li>Sustainable employment </li></ul><ul><li>High performing schools </li></ul><ul><li>Access to high quality healthcare </li></ul><ul><li>Adequate transportation </li></ul><ul><li>High quality childcare </li></ul><ul><li>Neighborhood safety </li></ul><ul><li>Institutions that facilitate civic engagement </li></ul>The Troutman Group
  49. 51. Housing The Troutman Group
  50. 52. Built Environment Issues <ul><li>Hope six </li></ul><ul><li>Where did all the poor people go? </li></ul><ul><li>The segregation of poverty </li></ul><ul><li>Grids, green space and gentrification </li></ul><ul><li>Rural infrastructure </li></ul>The Troutman Group
  51. 53. Cotter Lane The Troutman Group
  52. 54. Park DuValle The Troutman Group
  53. 55. Park DuValle The Troutman Group
  54. 56. Education The Troutman Group
  55. 57. 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
  56. 58. How Does Education Influence Health <ul><li>Education can improve health by increasing health knowledge </li></ul><ul><li>Leads to greater employment opportunities </li></ul><ul><li>Linked with social and psychological factors that affect health </li></ul>
  57. 59. Takin’ it to a Higher Level <ul><li>Power </li></ul><ul><li>Policy </li></ul><ul><li>Place </li></ul><ul><li>Advocacy </li></ul>The Troutman Group
  58. 60.
  59. 61. CSDH three overarching recommendations : <ul><li>Improve daily living conditions </li></ul><ul><li>Tackle the unequal distribution of power, money and resources </li></ul><ul><li>Measure and understand the problem and assess the impact of action </li></ul>
  60. 62. The Center for Health Equity The Troutman Group
  61. 63. The Troutman Group
  62. 64. The Importance of Leadership and Political Will The Troutman Group
  63. 65. The Troutman Group
  64. 66. 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
  65. 67. The Center focuses its work to eliminate health inequities due to race, ethnicity and socioeconomic status
  66. 68. Current Work <ul><li>Framing research </li></ul><ul><li>Health Equity Community Hearings </li></ul><ul><li>Civic capacity building mini grants </li></ul><ul><li>Health Equity Speaker Series </li></ul><ul><li>Web based learning </li></ul><ul><li>Retraining workforce ( Dialogue process ) </li></ul><ul><ul><li>Outreach workers as community organizers </li></ul></ul><ul><li>Undoing Racism workshops ( community wide) </li></ul><ul><li>Health Equity Summit </li></ul>
  67. 69. Current Work ( Cont ) <ul><li>Photo voice </li></ul><ul><li>Community dialogues </li></ul><ul><li>Operationalizing Health Equity within the department </li></ul><ul><li>CHI project </li></ul><ul><li>HIA-Shepard Square ( Hope 6 ) </li></ul><ul><li>The cabinet dialogue </li></ul><ul><li>Food justice </li></ul>
  68. 70. Food Justice <ul><li>Individual choice vs structure and systems </li></ul><ul><li>Food access, transportation and quality </li></ul><ul><li>Decreased access to healthy foods, increased access to unhealthy foods ( Food Security Task Force ) </li></ul><ul><li>Economic development and community health </li></ul>The Troutman Group
  69. 71. Strategy 3: Expand access to and distribution of healthy food. The Troutman Group
  70. 72. Increased Neighborhood Access The Troutman Group
  71. 73. From the Dinner Table to the Policy Table
  72. 74. Health Policy Is Social Policy
  73. 75. Policies For Social Justice, Policies For Health Equity <ul><li>Short term and long term solutions </li></ul><ul><li>Short term </li></ul><ul><ul><li>Attention to symptoms( nutrition, physical activity, cholesterol, access) </li></ul></ul><ul><ul><li>Creating environment to promote health </li></ul></ul><ul><li>Long term </li></ul><ul><ul><li>Empowerment </li></ul></ul><ul><ul><li>Redistributive policies </li></ul></ul><ul><ul><li>Poverty Elimination </li></ul></ul>
  74. 76. Policies ( Cont ) <ul><li>Environmental change </li></ul><ul><li>Housing reform </li></ul><ul><li>Job creation tied to insurance </li></ul><ul><li>National Health Program to Insure Universal Access and Universal Coverage </li></ul><ul><li>Land Use </li></ul><ul><li>Health Impact Assessment </li></ul>The Troutman Group
  75. 77. Policies ( Cont ) <ul><li>Zoning policies ( Concentration of business types) </li></ul><ul><li>Nutrition </li></ul><ul><ul><li>School meals </li></ul></ul><ul><ul><li>Trans fat </li></ul></ul><ul><ul><li>Restaurant labeling </li></ul></ul><ul><li>Physical education in schools </li></ul><ul><li>Built environment with attention to gentrification </li></ul><ul><li>Smoking </li></ul>The Troutman Group
  76. 78. Policies… <ul><li>Measuring progress through “Social Health Indexing” </li></ul><ul><li>Living wage </li></ul><ul><li>Educational reform </li></ul><ul><ul><li>Class size </li></ul></ul><ul><ul><li>Teacher experience </li></ul></ul><ul><ul><li>Funding mechanisms </li></ul></ul><ul><li>Attention to short term only ,will just create a healthier underclass and will not create health equity because there is no social justice </li></ul>The Troutman Group
  77. 79. The Troutman Group
  78. 80. 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
  79. 81. Universal access to a single standard of high quality care National Health Insurance Single Payer The Troutman Group
  80. 82. 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.
  81. 83. Phillis Wheatley Students present Photo-voice Exhibits on Health Policy Issues
  82. 84. Photo Voice <ul><li>Youth empowerment through engagement </li></ul><ul><li>Community health and barriers </li></ul><ul><li>Youth as creators, producers, interpreters </li></ul><ul><li>Raise awareness about the policy process </li></ul><ul><li>Presentation to policy makers ( Mayor Metro Council, Board of Health, Business Community </li></ul>
  83. 85. 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
  84. 86. 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
  85. 87. 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
  86. 88. From Theory to Practice <ul><li>Cross discipline collaboration based on social determinants </li></ul><ul><li>Public awareness of determinants of health and health equity </li></ul><ul><li>Civic capacity building </li></ul><ul><li>Community assessment </li></ul><ul><li>Policy process and community engagement </li></ul><ul><li>Curriculum change </li></ul><ul><li>Staff reorientation </li></ul><ul><li>Think holistically ( Housing and HIA’s etc.) </li></ul>
  87. 89. Taking a Personal Inventory <ul><li>Commitment to honesty </li></ul><ul><li>Exploration of beliefs, practices. Internal messaging </li></ul><ul><li>The person and the organization in the mirror </li></ul><ul><li>Are you happy with what you see? </li></ul><ul><li>Where do I get to make changes </li></ul>
  88. 90. Building a Social Movement
  89. 91. Social Movements <ul><li>A type of group action </li></ul><ul><li>Large informal groupings of individuals and/or organizations focused on specific political or social issue </li></ul><ul><li>Based on coalitions and alliances </li></ul><ul><li>It’s about social change </li></ul><ul><li>The United Farm Workers movement </li></ul><ul><li>The Anti-Apartheid Movement </li></ul><ul><li>The Civil Rights movement </li></ul><ul><li>Women’s liberation movem ent </li></ul>The Troutman Group
  90. 94. The Troutman Group
  91. 95. Are You Willing to Take the Risk?
  92. 96. Adewale Troutman, M.D.,M.P.H. The Troutman Group 5109 Forrest Grove Place Louisville, KY 40059 [email_address] 502 544 8570 The Troutman Group