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CONFRONTING THE SOCIAL DETERMINANTS OF HEALTH INEQUITIES: RETHINKING PUBLIC HEALTH

CONFRONTING THE SOCIAL DETERMINANTS OF HEALTH INEQUITIES: RETHINKING PUBLIC HEALTH. Bob Prentice, PhD Director Bay Area Regional Health Inequities Initiative (BARHII) University of New Mexico February 26, 2009. OVERVIEW. BRIEF HISTORY OF BARHII

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CONFRONTING THE SOCIAL DETERMINANTS OF HEALTH INEQUITIES: RETHINKING PUBLIC HEALTH

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  1. CONFRONTING THE SOCIAL DETERMINANTS OF HEALTH INEQUITIES:RETHINKING PUBLIC HEALTH Bob Prentice, PhD Director Bay Area Regional Health Inequities Initiative (BARHII) University of New Mexico February 26, 2009

  2. OVERVIEW • BRIEF HISTORY OF BARHII • A CONCEPTUAL FRAMEWORK FOR RE-THINKING PUBLIC HEALTH • MOVING HEALTH EQUITY FROM THE PERIPHERY TO THE CENTER OF PUBLIC HEALTH • REFLECTIONS ON SOME CONTRIBUTIONS OF THE SOCIAL SCIENCES TO PUBLIC HEALTH

  3. BRIEF HISTORY OF BARHII

  4. PROLOGUE1998-2005 • INFORMAL CONVERSATIONS • TWO STEPS FORWARD, ONE STEP BACK • EXPANSION AND SUPPORT • FROM TOP DOWN TO BROADLY PARTICIPATORY • FORMAL BEGINNINGS: OCTOBER, 2005

  5. BARHII MISSION STATEMENT • “. . . TO TRANSFORM PUBLIC HEALTH PRACTICE FOR THE PURPOSE OF ELIMINATING HEALTH INEQUITIES USING A BROAD SPECTRUM OF APPROACHES THAT CREATE HEALTHY COMMUNITIES.”

  6. HEALTH DISPARITIES vs. HEALTH INEQUITIES • UNITED STATES • ELIMINATING HEALTH DISPARITIES ONE OF TWO OVERARCHING GOALS OF HEALTHY PEOPLE 2010 • CENTERS FOR DISEASE CONTROL & PREVENTION’S RACIAL AND ETHNIC APPROACHES TO COMMUNITY HEALTH (REACH) • CENTERS OF EXCELLENCE FOR ELIMINATING DISPARITIES (CEEDS) FOCUS ON A DISEASE AND A POPULATION

  7. Health Inequities “Health inequities are differences in health status and mortality rates across population groups that are systemic, avoidable, unfair, and unjust.” Margaret Whitehead World Health Organization

  8. WORLD HEALTH ORGANIZATION EXECUTIVE BOARD RECOMMENDATIONSFebruary 4, 2009 ".........Confirming the importance of addressing the wider determinantsof health and considering the actions and recommendations set out in theseries of international health promotion conferences, from the OttawaCharter on Health Promotion to the Bangkok Charter for Health Promotionin a Globalized World making the promotion of health central to theglobal development agenda as a core responsibility of all governments(resolution WHA60.24);"........URGES Member States:(1) to develop and implement goals and strategies to improve publichealth with a focus on health inequities;(2) totake into account health equity in all national policies thataddress social determinants of health and to ensure equitable access tohealth promotion, disease prevention and health care;(3) to ensure dialogue and cooperation among relevant sectors with theaim of integrating a consideration of health into relevant publicpolicies;

  9. (4) to increase awareness among public and private health providers onhow to take account of social determinants when delivering care to theirpatients;(5) to contribute to the improvement of the daily living conditionscontributing to health and social well-being across the lifespan byinvolving all relevant partners, including civil society and the privatesector;(6) to contribute to the empowerment of individuals and groups,especially those who are marginalized, and take steps to improve thesocietal conditions that affect their health;(7) to generate new, or make use of existing, methods and evidence,tailored to national contexts in order to address the socialdeterminants and social gradients of health and health inequities;(8) to develop, make use of, and if necessary, improve healthinformation systems in order to monitor and measure the health ofnational populations, with data disaggregated according to the majorsocial determinants in each context (such as age, gender, ethnicity,education, employment and socioeconomic status) so that healthinequities can be detected and the impact of policies monitored in orderto devise appropriate policy interventions to minimize health inequities........"

  10. A CONCEPTUAL FRAMEWORK FOR RE-THINKING PUBLIC HEALTH

  11. FRAMEWORK FOR UNDERSTANDING HEALTH INEQUITIES BAY AREA REGIONAL HEALTH INEQUITIES INITIATIVE UPSTREAM INDIVB IDUAL HEALTH KNOWLEDGE GENETICS DOWNSTREAM Social Factors Health Status SOCIAL INEQUALITIES Class Race/ethnicity Gender Immigration Status INSTITUTIONAL POWER Corporations & other businesses Gov't agencies Schools NEIGHBORHOOD CONDITIONS Physical environment Land use Transportation Housing Residential segregation Social environment Experience of class Experience of racism Experience of gender Cultural assimilation /isolation Population histories RISK FACTORS Smoking Nutrition Physical activity Alcohol & other drugs Violence DISEASE & INJURY Infectious disease Chronic disease Injury (intentional & unintentional) MORTALITY Infant mortality Life expectancy HEALTH EDUCATION HEALTHCARE

  12. Infant mortality Mortality Life expectancy

  13. PUBLIC HEALTH AS GOTH: THE USES OF DEATH AS A MEASURE OF POPULATION HEALTH • INFANT MORTALITY • MORTALITY RATES • LIFE EXPECTANCY • GLOBAL RANKINGS • YEARS OF POTENTIAL LIFE LOST

  14. Chronic disease Infectious disease Injury (intentional and unintentional) Disease and Injury Mortality

  15. DISEASE AS THE CAUSE OF DEATH: Ten Leading Causes of Death Source: Healthy People 2010

  16. 67%

  17. BURDEN OF DISEASEDISABILITY ADJUSTED LIFE YEARS (DALYs)LOS ANGELES COUNTY(SOURCE: JONATHON FIELDING, MD, MPH, MBA, DIRECTOR AND HEALTH OFFICER, LOS ANGELES COUNTY DEPARTMENT OF PUBLIC HEALTH)

  18. EXAMPLES OF DISEASE-FOCUSED PROGRAMS IN CALIFORNIA HEALTH DEPARTMENTS • COMMUNICABLE DISEASE • TB, STDs, HIV/AIDS, OTHER COMMUNICABLE DISEASES • CHRONIC DISEASE & INJURY • ASTHMA, DIABETES • INJURY PREVENTION

  19. Smoking Nutrition Physical activity Risk Factors Disease and Injury Mortality Alcohol Drugs Violence

  20. Public Health Practice Risk Factors Disease and Injury Mortality

  21. BRIEF INTERLUDE 1: TOBACCO vs. NUTRITION AS EXAMPLES OF PUBLIC HEALTH PRACTICE Social Inequalities Institutional Power Neighbor- hood Conditions Risk Factors Disease and Injury Mortality

  22. BRIEF INTERLUDE 2: ASTHMA AS AN EXAMPLE OF A CENTER OF EXCELLENCE FOR ELIMINATING DISPARITIES (CEED) Social Inequalities Institutional Power Neighbor- hood Conditions Risk Factors Disease and Injury Mortality

  23. Physical environment Neighbor- hood Conditions Risk Behaviors Disease and Injury Mortality Social Environment

  24. INSTITUTE OF MEDICINETHE FUTURE OF PUBLIC HEALTH (1988) • IT IS THE MISSION OF PUBLIC HEALTH TO “. . .ASSUR(E) THE CONDITIONS IN WHICH PEOPLE CAN BE HEALTHY”

  25. EXAMPLES OF DIFFERENCES IN LIFE EXPECTANCY BY NEIGHBORHOOD • Bayview/Hunters Point <14 years compared with Russian Hill (City and County of San Francisco) • Bay Point <11 years compared with Orinda (Contra Costa County) • West Oakland <14 years compared with the hills (Alameda County)

  26. ALAMEDA COUNTY

  27. High school grads: 90% Unemployment: 4% Poverty: 7% Home ownership: 64% Non-White: 49% (World rank: 15)

  28. High school grads: 81% Unemployment: 6% Poverty: 10% Home ownership: 52% Non-White: 59%

  29. High school grads: 65% Unemployment: 12% Poverty: 25% Home ownership: 38% Non-White: 89% (World rank: 88)

  30. Corporations and businesses Institutional Power Neighbor- hood Conditions Risk Factors Disease and Injury Mortality Government agencies Schools

  31. (PHOTO OF PORT OF OAKLAND)

  32. EXAMPLES OF INSTITUTIONAL POWERS THAT INFLUENCE NEIGHBORHOOD CONDITIONS • “BUILT” ENVIRONMENT • LAND USE PLANNING • TRANSPORTATION • ECONOMIC DEVELOPMENT • REDEVELOPMENT • PORT • “NATURAL” ENVIRONMENT • AIR, WATER, SOIL • SOCIAL ENVIRONMENT • ECONOMIC INVESTMENT, EMPLOYMENT • CLASS, RACIAL/ETHNIC COMPOSITION • SCHOOLS

  33. Class Gender Social Inequalities Institutional Power Neighbor- hood Conditions Risk Factors Disease and Injury Mortality Race/ethnicity Immigration status

  34. WHAT DOES “TRANSFORMING PUBLIC HEALTH PRACTICE” MEAN? • BARHII COMMITTEES • DATA • COMMUNITY • BUILT ENVIRONMENT • SOCIAL DETERMINANTS OF HEALTH • INTERNAL CAPACITY

  35. DATA • PROVIDE EVIDENCE BASE TO SUPPORT EXPANDED PUBLIC HEALTH PRACTICE • FROM PASSIVE (SURVEILLANCE, TRACKING, MONITORING) TO ACTIVE • MEASURES OF NEIGHBORHOOD CONDITIONS THAT INFLUENCE HEALTH (PREVENTION) • HEALTH IMPACT ASSESSMENTS [HIAs] OF POLICIES THAT HAVE HEALTH CONSEQUENCES • SAN FRANCISCO’S HEALTHY DEVELOPMENT MEASUREMENT TOOL (www.thehdmt.org)

  36. COMMUNITY • FROM ADVISORY COUNCILS AND CBO CONTRACTS ORGANIZED AROUND DISEASES AND POPULATIONS TO COMMUNITY ORGANIZING • COMMUNITY ENGAGEMENT AND CAPACITY BUILDING

  37. BUILT ENVIRONMENT • LAND USE (SMART GROWTH, NEW URBANISM, etc.) • EXPANDED PLATFORM TO INCLUDE TRANSPORTATION, ECONOMIC DEVELOPMENT AND REDEVELOPMENT • EXPLICIT FOCUS ON HEALTH EQUITY

  38. SOCIAL DETERMINANTS OF HEALTH • A PHRASE THAT IS INCREASINGLY USED BUT POORLY UNDERSTOOD • INITIAL RESEARCH PROJECT TO GATHER WORK THAT IS BEING DONE • MacARTHUR FOUNDATION RESEARCH NETWORK ON SES AND HEALTH • RWJ COMMISSION FOR A HEALTHIER AMERICA • CONNECTICUT HEALTH DIRECTORS SOCIAL DETERMINANTS OF HEALTH EQUITY INDEX • COMMISSIONED PAPERS • OTHER • HOW TO TRANSLATE IT INTO PUBLIC HEALTH PRACTICE

  39. INTERNAL CAPACITY • TRAININGS ON SOCIAL INEQUALITIES AND HEALTH • ORGANIZATIONAL SELF-ASSESSMENT TOOLKIT • RECONSIDERING THE FINANCING, WORKFORCE AND ORGANIZATION OF LOCAL HEALTH DEPARTMENTS

  40. MOVING HEALTH EQUITY FROM THE PERIPHERY TO THE CENTER OF PUBLIC HEALTH

  41. SOME FORCES SHAPING THE CONTOURS OF PUBLIC HEALTH • ON THE ONE HAND . . . • PUBLIC HEALTH FINANCING, WORKFORCE AND ORGANIZATION STILL LARGELY REFLECT 19th, EARLY 20th CENTURY ORIGINS • ACCREDITATION AND CREDENTIALING • CDC FOCUS ON HEALTH “DISPARITIES” AS DISEASES AND POPULATIONS

  42. BURDEN OF DISEASE: DISABILITY ADJUSTED LIFE YEARS (DALYs)LOS ANGELES COUNTY(SOURCE: JONATHON FIELDING, MD, MPH, MBA, DIRECTOR AND HEALTH OFFICER, LOS ANGELES COUNTY DEPARTMENT OF PUBLIC HEALTH)

  43. ACCREDITATION DRAFT STANDARDS • DOMAIN 1: CONDUCT ASSESSMENT ACTIVITIES FOCUSED ON POPULATION HEALTH STATUS AND HEALTH ISSUES FACING THE COMMUNITY • DOMAIN 2: INVESTIGATE HEATLH PROBLEMS AND ENVIRONMENTAL PUBLIC HEALTH HAZARDS TO PROTECT THE COMMUNITY • DOMAIN 3: INFORM AND EDUCATE ABOUT PUBLIC HEALTH ISSUES AND FUNCTIONS • DOMAIN 4: ENGAGE WITH THE COMMUNITY TO IDENTIFY AND SOLVE HEALTH PROBLEMS • DOMAIN 5: DEVELOP PUBLIC HEALTH POLICIES AND PLANS • DOMAIN 6: ENFORCE PUBLIC HEALTH LAWS AND REGULATIONS • DOMAIN 7: PROMOTE STRATEGIES TO IMPROVE ACCESS TO HEALTH CARE SERVICES • DOMAIN 8: MAINTAIN A COMPETENT PUBLIC HEALTH WORKFORCE • DOMAIN 9: EVALUATE AND CONTINUOUSLY IMPROVE PROCESSES, PROGRAMS AND INTERVENTIONS • DOMAIN 10: CONTRIBUTE TO AND APPLY THE EVIDENCE BASE OF PUBLIC HEALTH

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