Overview of the Health Equity Framework Through Social Justice


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Presentation by Adewale Troutman, MD, MPH, MA at the 2009 Virginia Health Equity Conference - Provides an overview of the health equity and social justice framework that is gaining support nationally as a paradigm to understand and address the root causes of health inequity. Highlights specific strategies being led by the National Association of County and City Health Officials (NACCHO) and the Louisville Metro Health Department to promote health equity.

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  • The Commission believes that the inequalities in health outcomes previously described are avoidable and therefore unjust. It considers health as a marker of development. And that contributing to development (and ultimately health) is both national economic growth and empowerment; empowerment of individuals, communities and nations. So what is meant by empowerment: this relates to having both basic material needs AND control, power and agency to lead lives with dignity and security
  • So what do we do about that? Tell people to exercise more, eat right and reduce their stress? And that would work – let’s say if you had groceries in your neighborhood that carried fresh fruits and vegetables, if you weren’t afraid of violence in your community, if you had recreation areas close to your home and you had control over things that create stress in your life – like institutional racism, economic opportunities and pollution in you neighborhood. Dr. Troutman, the Director of Public Health and Wellness and a nationally renowned expert, always explains the basic premise of the shift we need to make – Baby story.
  • MIKE BRAMER Gain stakeholder input from Corner Store owners and make recommendations on how to overcome barriers to stocking and marketing fresh, healthy foods. Expand Farmers’ Markets and improve marketing capability. Support efforts to develop a year-round, indoor public market. Link farms with restaurants, emergency food providers and institutions Negotiate reduced prices for CSA shares for lower-income families. Encourage and incentivize restaurants to post nutritional information on menu boards and printed materials.
  • Overview of the Health Equity Framework Through Social Justice

    1. 1. Richmond Virginia
    2. 2. ADEWALE TROUTMAN , M.D., M.P.H., M.A. THE TROUTMAN GROUP Building Health Equity Through Social Justice :Theory and Practice
    3. 3. The Troutman Group
    4. 4. A Case Study; But Why
    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. Foundation for Discussion The Troutman Group
    7. 8. 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
    8. 9. Equity <ul><li>Justice according to natural law or right </li></ul><ul><li>Freedom from bias or favoritism </li></ul>The Troutman Group
    9. 10. <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
    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 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>
    12. 13. 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
    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. Traditional/Market Approach to Health Underlying assumptions Social Justice/Human Rights Approach To Health Alternative assumptions Health is a medical concept Health is a social concept Health is what you get from a health service Health is what you get from meeting basic needs General approach: acceptance of risk as a fact of life General approach: activist perspective to creating conditions for health Health promotion: education of individuals about healthy choices Health promotion: conduct health impact assessments; policy change Causes of inequity: genes, bad behavior, lifestyle, accident Causes of inequity: racism, class exploitation, sexism
    22. 23. 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… www.who.int/social_determinants
    23. 24. The Nature of the Problem; An Inequitably Unhealthy America The Troutman Group
    24. 25. 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
    25. 26. Looking upstream, finding the causes of he causes. The Troutman Group
    26. 27. <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
    27. 28. Politics and Health <ul><li>“ The primary determinants of disease are mainly economic and social, and therefore its remedies must also be economic and social. Medicine and politics cannot and should not be kept apart.” </li></ul><ul><li>-Geoffrey Rose </li></ul><ul><li>The strategy of preventive medicine. Oxford (Oxford University Press), 1992, p. 129. </li></ul>
    28. 29. Traditional/Market Approach to Health Key Features Social Justice/Human Rights Approach to Health Key Features Addresses symptoms, short term, through programs and services Addresses root causes, long term, macro forces through organizing for social change Promotes ‘magic medical bullets’ and technology Promotes the meeting of basic needs Promotes interventions delivered through health services Promotes public works to free people from miserable living conditions Identifies charity and international aid as only sources of funds for health Identifies redistribution and economic justice as sources of funds for health Maintains the status quo of extreme concentrations of wealth and power Demands a fair and rational international economic order Focuses on individual behavior and tends to blame victims Focuses on structural poverty and violence and tends to blame the ‘system’ Personal responsibility and individual rights Social responsibility to protect the common good Tracking and monitoring: individual demographics, disease rates Tracking and monitoring: social conditions, investments in neighborhood infrastructure, processes, structures, institutions, historical trends in exposures
    29. 30. What is the nature of the issue? <ul><li>Health equity is a cross cutting, broad issue associated with fundamental social values and well-being. </li></ul><ul><li>Health equity is connected to all aspects of public health work and the most basic influences on the health of populations </li></ul><ul><li>Working to achieve health equity requires multidisciplinary approaches and a more holistic, comprehensive view of health and coordinated strategies </li></ul>
    30. 31. What is the nature of the issue? <ul><li>The distribution of disease and differentials in mortality rates are connected to class distinctions, racism, and sexism. </li></ul><ul><li>Most health inequity is preventable and avoidable and therefore actionable. </li></ul><ul><li>Health equity involves attention to public and political decisions because health and well-being reflect the decisions and actions of society as a whole </li></ul><ul><li>The issues involve the foundations of existence and the connections among economics, government, and the well-being of the community </li></ul>
    31. 33. Changing the Questions TRADITIONAL SOCIAL JUSTICE What interventions are necessary to address health disparities? What generates health inequity in the first place? Why is there inequality? How can we reduce inequity in the distribution of disease and illness? How can we eliminate inequity in the distribution of disease and illness? What social programs and services are necessary to address health inequity? What types of institutional and social change is necessary to tackle health inequity? How can individuals protect themselves against health disparities? What kind of collective action is necessary to tackle health inequity? How can we promote healthy behavior? How can we reorganize land use and transportation policies to ensure healthy spaces and places?
    32. 34. Vital Statistics: The Troutman Group
    33. 35. The Center for Health Equity
    34. 37. 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
    35. 38. The Center focuses its work to eliminate health inequities due to race, ethnicity and socioeconomic status
    36. 39. 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><li>Undoing Racism workshops ( community wide) </li></ul><ul><li>Health Equity Summit </li></ul>
    37. 40. 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>
    38. 41. 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 </li></ul><ul><li>Economic development and community health </li></ul>The Troutman Group
    39. 42. Strategy 3: Expand access to and distribution of healthy food. The Troutman Group
    40. 43. Increased Neighborhood Access The Troutman Group
    41. 44. 2006 <ul><li>Dr. Troutman and the Health Department partner with former Olympian Tommie Smith to host Tommie Smith Youth Track Meet at the University of Louisville. More than 300 youngsters, ages 5-18, participate. </li></ul>
    42. 45. From the Dinner Table to the Policy Table
    43. 46. 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>
    44. 47. Health Policy Is Social Policy
    45. 48. 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.
    46. 49. 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
    47. 50. Building a Social Movement
    48. 51. 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
    49. 52. www.who.int/social_determinants
    50. 53. 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>
    51. 54. The Power of One
    52. 55. Transforming Practice <ul><li>Challenges and Opportunities </li></ul>
    53. 56. What Do I Do? <ul><li>Identify community leadership both formal and informal </li></ul><ul><li>Reframing of focus; Analysis of social determinants of health in communities and work on upstream solutions </li></ul><ul><li>Foster new coalitions with nontraditional partners </li></ul><ul><li>Seek out health departments ( local, state ) </li></ul>The Troutman Group
    54. 57. What Do I Do <ul><li>System wide consciousness raising using “Unnatural Causes; Is Inequality Making Us Sick ?” with facilitated discussion including action steps. </li></ul><ul><li>Multi-Cultural Collaboration </li></ul><ul><li>Building a Social Movement </li></ul><ul><li>Taking the Risk </li></ul>The Troutman Group
    55. 58. “ Resistance is futile” The Borg Barriers to Implementing a Health Equity Framework
    56. 59. Leadership
    57. 60. Communications and Media
    58. 61. Building Strategic Alliances and Coalitions
    59. 62. Workforce Development
    60. 63. Policy Analysis, Development and Advocacy
    61. 64. Beyond the Surveillance Function: Active Data Collection and Analysis
    62. 65. Community Collaboration
    63. 66. T here are obvious barriers to institutionalizing social justice into a local health department, especially for a new local health official (LHO).
    64. 67. H ow does one engage board of health members to become invested in health equity issues when they may not see that there is a problem in their specific area (e.g., some members come from a financially stable, predominantly upscale area of our county & do not see the relevance to them)?
    65. 68. Tackling health equity and social justice are risky initiatives involving much opposition.  Although, the risk isn't apparent until the community and the agency behind the initiative become effective and/or making a great impact.  Do you find leaders &quot;truly&quot; willing to go far enough to push the policy/system change to make a difference in health equity even with great opposition? or are the leaders just willing to dabble in community program development to say they are addressing health disparities?
    66. 69. Funding
    67. 70. Why are you on my turf? ( Silos at all levels )
    68. 71. Are you willing to take the risk?
    69. 72. 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>
    70. 73. Is the organization representing true dramatic change or a modified view of the status quo? Where is profit in our hierarchy of values ?
    71. 76. The Troutman Group
    72. 77. Adewale Troutman, M.D.,M.P.H. The Troutman Group 5109 Forrest Grove Place Louisville, KY 40059 [email_address] 502 544 8570 www.thetroutmangroup.org The Troutman Group