Achieving Health Equity Will Require More than Equity in Health Care

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Presentation by Paula Braveman, MD, MPH at the 2009 Virginia Health Equity Conference.

Dr. Braveman described the Robert Wood Johnson Foundation (RWJF) Commission to Build a Healthier America and explained the RWJF’s rationale for creating the Commission and for the Commission’s work to focus on the social determinants of health, and its relevance to health equity. She also discussed the Commission’s recommendations.

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  • OECD data
  • And now could these next slides add a few clues? Huge disparities within US, by income, by education, not explained by race Note gradient but the dramatically larger risks for the poor and near-poor
  • In each racial/ethnic group, we see a gradient. Differences between poor and highest-income group are most dramatic, with the near-poor next But we see health differences even among different “middle-income” groups
  • Slide 1: I want to pose a Q to you? How can it be that the US is the wealthiest country in the world AND spends more on medical care –overall and per person– than anyone else, yet we consistently rank at or near the bottom among industrialized countries on key measures of health? Could this slide give us some clues?
  • *Health care *Income **Education *Housing **Working conditions **Control *Stress *Social Support *Neighborhood conditions *Income directly determines this **Parents’ income shapes this for children
  • How does poverty affect health?
  • How does low educational attainment/poor job lead to poor health? **Use an example: ?heart disesase (#1 cause of premature death in US)
  • Not just features of individuals and families that shape health, but characteristics of the neighborhoods where they spend their time Poverty and race: Poor Blacks/Hispanics live in very different (health-damaging) neighborhoods from poor whites
  • Psychosocial Compared with higher-income women, poor women more than 10 times as likely to experience separation or divorce during their pg Similar pattern for: Domestic violence Woman or her partner were incarcerated during pg (negligible above 400% FPL) Practical support Emotional support
  • The prevailing approach: it’s up to you to make yourself healthy/ get rid of stress Doesn’t acknowledge that many people, particularly the poor and near-poor, face obstacles to health and healthy behaviors that none of us could surmount, despite tremendous motivation
  • The recommendations are rooted in a twin philosophy: good health requires individuals to make responsible personal choices and requires a societal commitment to remove the obstacles preventing too many Americans from making healthy decisions. The recommendations focus on people and the places where we spend the bulk of our time: homes and communities, schools and workplaces.
  • Achieving Health Equity Will Require More than Equity in Health Care

    1. 1. Achieving Health Equity Will Require More Than Equity in Health Care September 11, 2009 Virginia Health Equity Conference Paula Braveman, MD, MPH Professor of Family & Community Medicine Director, Center on Social Disparities in Health University of California, San Francisco
    2. 2. 2 questions <ul><li>Why did the Robert Wood Johnson Foundation create a national commission on health disparities that focused on factors other than health care? </li></ul><ul><li>Why does the U.S. spend more than any other country on health care, yet have relatively poor health indicators? </li></ul>
    3. 3. We spend more on health care but are less healthy than people in many other countries Life Expectancy – 2004 Infant Mortality - 2002 <ul><li>Iceland IMR = 2.3 </li></ul><ul><li>Finland </li></ul><ul><li>Japan </li></ul><ul><li>Sweden </li></ul><ul><li>Norway </li></ul><ul><li>Austria </li></ul><ul><li>Czech Republic </li></ul><ul><li>France </li></ul><ul><li>Spain </li></ul><ul><li>Germany </li></ul><ul><li>Belgium </li></ul><ul><li>Denmark </li></ul><ul><li>Italy </li></ul><ul><li>Australia </li></ul><ul><li>Netherlands </li></ul><ul><li>Portugal </li></ul><ul><li>Switzerland </li></ul><ul><li>Greece </li></ul><ul><li>Ireland </li></ul><ul><li>Luxembourg </li></ul><ul><li>Untied Kingdom </li></ul><ul><li>Korea </li></ul><ul><li>Canada </li></ul><ul><li>New Zealand </li></ul><ul><li>United States IMR = 7.0 </li></ul><ul><li>Hungary </li></ul><ul><li>Poland </li></ul><ul><li>Slovak Republic </li></ul><ul><li>Mexico </li></ul><ul><li>Turkey </li></ul><ul><li>Japan LE = 82.1 </li></ul><ul><li>Switzerland </li></ul><ul><li>Iceland </li></ul><ul><li>Italy </li></ul><ul><li>Australia </li></ul><ul><li>Sweden </li></ul><ul><li>France </li></ul><ul><li>Spain </li></ul><ul><li>Canada </li></ul><ul><li>Norway </li></ul><ul><li>New Zealand </li></ul><ul><li>Austria </li></ul><ul><li>Germany </li></ul><ul><li>Netherlands </li></ul><ul><li>Greece </li></ul><ul><li>Luxembourg </li></ul><ul><li>Finland </li></ul><ul><li>Belgium </li></ul><ul><li>Ireland </li></ul><ul><li>United Kingdom </li></ul><ul><li>Portugal </li></ul><ul><li>Korea </li></ul><ul><li>Denmark </li></ul><ul><li>United States LE = 77.8 </li></ul><ul><li>Czech Republic </li></ul><ul><li>Mexico </li></ul><ul><li>Poland </li></ul><ul><li>Slovak Republic </li></ul><ul><li>Hungary </li></ul><ul><li>Turkey </li></ul>
    4. 4. And we have huge disparities, e.g.: Higher income, longer life LIFE EXPECTANCY AT AGE 25 WOMEN Center on Social Disparities in Health, University of CA, San Francisco
    5. 5. Huge disparities: Children’s health varies by parents’ income % OF CHILDREN, AGE 17 & YOUNGER, IN POOR/FAIR HEALTH Center on Social Disparities in Health, University of CA, San Francisco
    6. 6. Disparities in activity-limiting chronic illness, by income. Similar patterns by education and for diabetes & heart disease % OF ADULTS, AGE 25+, WITH ANY ACTIVITY LIMITATION Center on Social Disparities in Health, University of CA, San Francisco
    7. 7. Racial/ethnic differences are important but do not explain the income/education disparities % OF ADULTS, AGE 25+, IN POOR/FAIR HEALTH Center on Social Disparities in Health, University of CA, San Francisco
    8. 8. Clues? Scarlet fever death rate in children <15: England & Wales Sulpha drugs Penicillin Thomas McKeown, 1974
    9. 9. Measles– mean annual death rate of children under 15: England and Wales Immunization began
    10. 10. Infant mortality rate: England and Wales
    11. 11. Respiratory tuberculosis– mean annual death rate: England and Wales
    12. 12. What influences health? <ul><li>Medical care </li></ul><ul><li>Genetic makeup </li></ul><ul><li>Climate & natural physical environment </li></ul><ul><li>Behaviors, nutrition </li></ul><ul><li>What else? </li></ul><ul><li>And what influences these influences? </li></ul>
    13. 13. What affects the factors that affect health? E.g., income <ul><li>Income directly shapes: </li></ul><ul><li>Medical care </li></ul><ul><li>Housing </li></ul><ul><li>Nutrition & physical activity </li></ul><ul><li>Neighborhood conditions </li></ul><ul><li>Stress </li></ul><ul><li>Social support </li></ul><ul><li>Parents’ income shapes the next generation’s: </li></ul><ul><li>Education </li></ul><ul><li>Working conditions, including control </li></ul><ul><li>Income </li></ul>Center on Social Disparities in Health, University of CA, San Francisco
    14. 14. Poverty Poor Health Poor Health Low Educational Attainment Poor Job Poverty Vicious cycle of poverty and poor health Center on Social Disparities in Health, University of CA, San Francisco
    15. 15. Poor Health <ul><li>Low income  </li></ul><ul><li>Unhealthy housing </li></ul><ul><li>Unhealthy neighborhood </li></ul><ul><li>Poor nutrition </li></ul><ul><li>Lack of exercise </li></ul><ul><li>Stress </li></ul><ul><li>Poor working conditions </li></ul><ul><li>Low control, helplessness, </li></ul><ul><li>despair </li></ul><ul><li>Stress </li></ul>Low Educational Attainment Poor Job How low educational attainment and a poor job lead to poor health Center on Social Disparities in Health, University of CA, San Francisco
    16. 16. Health knowledge, literacy & behaviors Educational attainment <ul><li>Nutrition </li></ul><ul><li>Exercise </li></ul><ul><li>Smoking </li></ul><ul><li>Drugs & alcohol </li></ul>Social standing <ul><li>Exposure to hazards </li></ul><ul><li>Control / demand imbalance </li></ul><ul><li>Stress </li></ul>Work-related resources <ul><li>Housing </li></ul><ul><li>Neighborhood environment </li></ul><ul><li>Nutrition </li></ul><ul><li>Stress </li></ul>Work Sense of control <ul><li>Health insurance </li></ul><ul><li>Sick leave </li></ul><ul><li>Other benefits </li></ul><ul><li>Social networks & social support </li></ul><ul><li>Subjective social status </li></ul>Working conditions Income What influences health? And what influences the influences? L E H T A H
    17. 17. How could your neighborhood affect your health? <ul><li>Physical danger, e.g., crime </li></ul><ul><li>Safe places to exercise </li></ul><ul><li>Pollution </li></ul><ul><li>Access to healthy food </li></ul><ul><li>Role models, peer pressure </li></ul><ul><ul><li>Substance abuse </li></ul></ul><ul><li>Social networks & support </li></ul><ul><li>Stress, fear, anxiety, despair </li></ul><ul><li>Blacks & Hispanics of given income level live in different kinds of neighborhoods than whites of similar income level </li></ul>Center on Social Disparities in Health, University of CA, San Francisco
    18. 18. Biological mechanisms <ul><li>Nutrition </li></ul><ul><li>Exposure to physical hazards, toxins, carcinogens, crime </li></ul><ul><li>Health-related behaviors lead to different exposures (health-promoting or –damaging) </li></ul><ul><li>Direct health effects of psychosocial experiences </li></ul><ul><ul><li>E.g., chronic stress  neuroendocrine, sympathetic nervous system effects  vascular effects, immune suppression, inflammation </li></ul></ul>
    19. 19. CRH AFFECTS MULTIPLE ORGANS & SYSTEMS STRESSOR CORTISOL Hypothalamus Pituitary Gland Adrenal Glands ACTH Stress pathway from brain to body Center on Social Disparities in Health, University of CA, San Francisco
    20. 20. Chronic stress in childhood? Cumulative effects of stress? <ul><li>Poverty/low income is stressful – limited resources to cope with challenges </li></ul><ul><li>African Americans more likely than whites to have grown up in worse-off households </li></ul><ul><li>Cumulative stress over lifetime </li></ul><ul><li>For example, childhood stress or chronic stress could lead to adverse birth outcomes even if pregnancy itself is relatively stress-free </li></ul><ul><ul><li>via neuro-endocrine dysregulation </li></ul></ul>
    21. 21. Income & stress: Lower income means more stressors during pregnancy, e.g.,: separation or divorce during pregnancy Center on Social Disparities in Health, University of CA, San Francisco % OF WOMEN
    22. 22. Considering income/education is not enough: Racism can harm health in other ways <ul><li>Structural racism tracks people by race into different socioeconomic opportunities </li></ul><ul><ul><li>Job opportunities </li></ul></ul><ul><ul><li>Educational opportunities </li></ul></ul><ul><ul><li>Options for where to live  schools, jobs, housing quality </li></ul></ul><ul><li>In addition, living in a society with a legacy of discrimination can harm health through pathways involving stress </li></ul><ul><ul><li>Not only overt incidents </li></ul></ul><ul><ul><li>Constant vigilance </li></ul></ul><ul><ul><li>Awareness of racism can undermine self-esteem and confidence even if no clear-cut incident occurs; implications for school/job performance </li></ul></ul>
    23. 24. 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
    24. 25. Understanding how health is transmitted by social factors across lifetimes and generations Robert Wood Johnson Foundation Commission to Build a Healthier America
    25. 26. The Social Determinants of Health and Health Equity <ul><li>Social factors are crucial influences on health and health disparities </li></ul><ul><ul><li>The causes of the causes </li></ul></ul><ul><ul><li>Social factors like education, income, race/ethnicity influence health through many complex pathways </li></ul></ul><ul><li>The role of racism in health disparities </li></ul><ul><li>When health data identify race/ethnicity but not other social factors, they can reinforce stereotypes and unfounded assumptions about biology or “culture” </li></ul><ul><li>It’s not either/or. We need to address both racial/ethnic group and socioeconomic factors </li></ul>
    26. 27. A twin philosophy: Good health requires personal responsibility and a societal commitment to remove the obstacles preventing too many Americans from making healthy decisions The Commission’s Recommendations Building a healthier America is feasible The recommendations focus on people and the places where we spend most of our time: <ul><li>Homes and Communities </li></ul><ul><li>Schools </li></ul><ul><li>Workplaces </li></ul>
    27. 28. Starting Early Ensure that all children have high-quality early developmental support (child care, education and other services). This will require committing substantial additional resources to meet the early developmental needs particularly of children in low-income families. Feed children only healthy foods in schools. Require all schools (K-12) to include time for all children to be physically active every day.
    28. 29. Create public-private partnerships to open and sustain full-service grocery stores in communities without access to healthful foods. Fund and design WIC and SNAP (Food Stamps) programs to meet the needs of hungry families with nutritious food. Accessing Healthy Foods
    29. 30. Creating Healthy Communities Become a smoke-free nation. Eliminating smoking remains one of the most important contributions to longer, healthier lives. Integrate safety and wellness into every aspect of community life. Develop a “health impact” rating for housing and infrastructure projects that reflects the projected effects on community health and provides incentives for projects that earn the rating. Create “healthy community” demonstrations to evaluate the effects of a full complement of health-promoting policies and programs.
    30. 31. Decision makers at national, state, and local levels need reliable data on health status, disparities, and the effects of social determinants of health. Better data must be developed for use at the local level, in particular. Fund research to understand the health effects of social factors and promote application of findings by decision makers. Measuring Progress, Building In Accountability
    31. 32. Resources <ul><li>www.commissiononhealth.org </li></ul><ul><ul><li>Commission’s recommendations </li></ul></ul><ul><ul><li>Array of reports and tools, including information at state and county levels, intended to be useful to decision-makers </li></ul></ul><ul><ul><li>Background material, e.g.: </li></ul></ul><ul><li>State-by-State Chartbooks on Child Health and on Adult Health </li></ul><ul><li>Overcoming Obstacles to Health. Robert Wood Johnson Foundation, February 2008. www.commissiononhealth.org </li></ul><ul><ul><li>Overview of key issues and literature on the social determinants of health. </li></ul></ul><ul><li>Race and Socioeconomic Factors Affect Opportunities for Better Health. Robert Wood Johnson Foundation March 2009. www.commissiononhealth.org </li></ul><ul><ul><li>Overview and synthesis of literature on how race and socioeconomic factors jointly influence health </li></ul></ul>

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