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Eliminating Health Inequalities Intersections and Ethics

Eliminating Health Inequalities Intersections and Ethics . John R. Stone, MD, PhD Creighton University School of Medicine Center for Health Policy and Ethics. Aims. Summarize that: Health inequalities are significant

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Eliminating Health Inequalities Intersections and Ethics

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  1. Eliminating Health Inequalities Intersections and Ethics John R. Stone, MD, PhD Creighton University School of Medicine Center for Health Policy and Ethics

  2. Aims • Summarize that: • Health inequalities are significant • Eliminating health inequalities should involve what justice demands in light of intersecting bases of well-being. • Intersectional, multidimensional approaches are essential, including affected communities • Have a discussion

  3. Healthcare and HealthEmbeddedness and Perspective Humility Arrogance Ignorance

  4. Inequalities (Disparities) in Health Status and Healthcare • Tragic • Horrendous • Ethically unacceptable • Moral problems of the first order

  5. Universal and Substantial Healthcare • Respect and justice demand such healthcare. BUT • To eliminate disparities in health status, much more must be done.

  6. Influence on Excess Mortality: Poor & Minorities H. Jack Geiger. Health Disparities: What do we know? What do we need to know? What should we do?. In Gender, Race, & Health: Intersectional Approaches. Edit by Amy J. Schulz & Leith Mullings. San Francisco. Jossey-Bass, 2006, p. 265.

  7. Interactive Determinants • “The determinants that interact to create good or ill health derive from various sources and sectors. Among other factors, health is shaped by laws and policies, employment and income, and social norms and influences.” The Future of the Public's Health in the 21st Century (2002). Board on Health Promotion and Disease Prevention (HPDP) Institute of Medicine (IOM). The National Academies Press. P. 2 http://books.nap.edu/openbook.php?record_id=10548&page=R1 (Accessed 4/13/2007)

  8. Missoula County*Gender, “Race,” Ethnicity Health Status? * 2000 Census, http://www.dphhs.mt.gov/PHSD/health-profiles/pdf/missoula.pdf, accessed 4/13/2007

  9. Missoula County: Income * 1 2000 Census, 2 MT. Dept. Labor & Industry 2001 http://www.dphhs.mt.gov/PHSD/health-profiles/pdf/missoula.pdf, accessed 4/13/2007

  10.  Less than 10%  10% to 12%  13% to 17%  More than 17% Health Insurance Coverage of Children 0-18 Living Near Poverty (100% - 199% FPL) States (2004-2005), U.S. (2005) http://www.statehealthfacts.org/cgi-bin/healthfacts.cgi?action=compare&category=Health+Coverage+%26+Uninsured&subcategory=Health+Insurance+Status&topic=Near+Poor+Children&link_category=&link_subcategory=&link_topic=&datatype=&printerfriendly=0&viewas=map&showregions=0&from=none&sortby=Uninsured (Accessed 4/13/2007)

  11. Health Insurance Coverage of Children 0-18 States (2004-2005), U.S. (2005) States with 15% uninsured: 2 States with > 15% uninsured: 4 Range of uninsured: 6%-20% http://www.statehealthfacts.org/cgi-bin/healthfacts.cgi?action=compare&category=Health+Coverage+%26+Uninsured&subcategory=Health+Insurance+Status&topic=Children+%280%2d18%29&link_category=&link_subcategory=&link_topic=&printerfriendly=0&from=none&viewas=table (Accessed 4/13/2007)

  12. Health Insurance Coverage of Adults 19-64States (2004-2005), U.S. (2005) http://www.statehealthfacts.org/cgi-bin/healthfacts.cgi?action=compare&category=Health+Coverage+%26+Uninsured&subcategory=Health+Insurance+Status&topic=Adults+%2819%2d64%29&link_category=&link_subcategory=&link_topic=&printerfriendly=0&from=none&viewas=table (Accessed 4/15/2007)

  13. Healthcare’s Major Influences • Disability • Pain • Suffering • Quality of life H. Jack Geiger. Health Disparities: What do we know? What do we need to know? What should we do?. In Gender, Race, & Health: Intersectional Approaches. Edit by Amy J. Schulz & Leith Mullings. San Francisco. Jossey-Bass, 2006, p. 272.

  14. Health Status: Major Determinants • Providers • Institutions • Systems • Policies H. Jack Geiger. Health Disparities: What do we know? What do we need to know? What should we do?. In Gender, Race, & Health: Intersectional Approaches. Edit by Amy J. Schulz & Leith Mullings. San Francisco. Jossey-Bass, 2006.

  15. Collaborative Effort • “There is a growing recognition that individuals, communities, and various social institutions can form powerful collaborative relationships to improve health that government alone cannot replicate.” The Future of the Public's Health in the 21st Century (2002). Board on Health Promotion and Disease Prevention (HPDP) Institute of Medicine (IOM). The National Academies Press. P. 2 http://books.nap.edu/openbook.php?record_id=10548&page=R1 (Accessed 4/13/2007)

  16. Proposed “areas of action and change” • “Adopting a population health approach that considers the multiple determinants of health;” • “Building a new generation of intersectoral partnerships that also draw on the perspectives and resources of diverse communities and actively engage them in health action;” [bold added] The Future of the Public's Health in the 21st Century (2002). Board on Health Promotion and Disease Prevention (HPDP) Institute of Medicine (IOM). The National Academies Press. P. 4 http://books.nap.edu/openbook.php?record_id=10548&page=R1 (Accessed 4/13/2007)

  17. Public HealthPotential Agents • Governmental Public Health • Healthcare • Academia • Communities • Community organizations • Businesses The Future of the Public's Health in the 21st Century (2002). Board on Health Promotion and Disease Prevention (HPDP) Institute of Medicine (IOM). The National Academies Press. P. 2 http://books.nap.edu/openbook.php?record_id=10548&page=R1 (Accessed 4/13/2007)

  18. Centers University Disciplines Professionals Healthcare Institutions IntersectionsEliminating Health Inequalities Public Health Government Community Community Agencies & Orgs Businesses

  19. Intersectional WorkEthically/morally guided by what?

  20. Ethics & Health of the PublicEthical Foundations Amartya Sen John Rawls Martha Nussbaum Norman Daniels Madison Powers Ruth Faden Public Health Consequentialism Social Justice: The Moral Foundations of Public Health and Health Policy. NY. Oxford, 2006.

  21. Madison Powers & Ruth FadenSocial Justice: The Moral Foundations of Public Health and Health Policy • Health: one of six major, interactive, components of well-being • “Sufficiency” account • Denial of separate spheres of justice • Community involvement • Reduced significance of healthcare

  22. Well-being & JusticePowers & Faden • “Sufficiency” of the “essential dimensions” • Understanding of dimensions’ interactions • Assume “inequalities beget inequalities”: e.g. oppression and subordination involved in racism and sexism (p. 8) • Target systematic patterns that influence self-determination. • Stress “children and their futures” (p. 8)

  23. Justice: Powers and Faden • “Justice in our view requires ensuring for everyone a sufficient amount of each of the essential dimensions of well-being, of which health is one.” (p. 9) “Insofar as possible.” (16) • Essential dimensions are those “characteristically present within a decent life” (p. 15)

  24. “The Job of Justice”Powers & Faden • “The achievement of a sufficiency of six essential dimensions of human well-being” (p. 5) • A “nonideal theory” that addresses “which inequalities matter most” in “a concrete empirical context” (p. 5) • Concerned not just with distrubutive principles, but also inter-personal relations (p. 6)

  25. Madison Powers & Ruth FadenSocial Justice: The Moral Foundations of Public Health and Health Policy • Cost-effectiveness analysis is not paramount • Denial of public health’s primary focus on aggregative health, constrained by justice and liberty • Job of justice: “to specify those background social and economic conditions that determine whether…inequalities…are unfair.”(xi)

  26. Group Situations Powers & Faden Biomed Culture Structures Policy Healthcare Health History Well-being Social Determinants Social Context Dominance Power Multiculturalism Lens of Social Justice & Public Health

  27. Related Concerns • Cross-cultural health and healthcare • Principles • Respect • Justice • Care • Community • Insurgent multiculturalism

  28. Health inequalities are important and tragic Powers & Faden’s ethical framework is promising Research and interventions should be in light of interactive dimensions of well-being Intra-academic partnering is essential Multi-dimensional collaboration is crucial Healthcare institutions and professionals must be part of the solution Dominant hierarchies & power structures need changing, including whiteness & male dominance Conclusions

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