Health Equity: The Evolution of Public Health Practice in the 21 st Century December 4, 2013

1. Health Equity: The Evolution of Public Health Practice in the 21st Century December 4, 2013 Rex Archer, MD MPH Director of Health Kansas City, Missouri Saving Lives, Protecting People from Health Threats, Saving Money through Prevention

2. “Public health is what we, as a society, do collectively through organized actionsto assure the conditions in which allpeople can be healthy.” -Institute of Medicine (1988),  Future of Public Health

3. “Show-Me” Health Overall National Rank 2012: 42 2011 Rank: 40 1990 Rank 24

4. "The reason we have government is to solve problems collectively that we can not solve individually." Dr. Thomas Farley, NYC Health Commissioner (from the HBO May, 2012 Documentary, "Weight of the Nation" Saving Lives, Protecting People from Health Threats, Saving Money through Prevention

5. Life Expectancy by Zip Code, Kansas City, MO, 2008-2009 10-16 years difference *Zip codes with population >5,000 people.

6. Life expectancy by zip code, Kansas City, MO 2008-2009 *Too small population to calculate life expectancy

7. Longest and Shortest Life Expectancy Area by Zip Code, KCMO 4zipcodes area has 55,846 residents 5zipcodes area has 46,162 residents Kansas city, MO has 459,787 residents Longest life expectancy Shortest life expectancy

8. Leading Causes Crude Mortality Rates in Two Areas, CMO 2005-2009 4zipcodes include zip code 64109, 64128, 64130, 64132, which are the shortest life expectancy; 5zipcodes include zip code 64112, 64113, 64156, 64157, and 64158, which are the longest life expectancy.

9. How Are Epidemics Reversed? 3. CHANGE COMMUNITY NORMS • INTERRUPT TRANSMISSION 2. BEHAVIOR CHANGE

10. The Cure Violence / Aim4Peace Model to Stop Shootings and Killings Identification and Detection Interruption, Intervention and Risk Reduction Change Behaviors and Norms Data and Monitoring

11. Interrupt Transmission: Anger Image: Neil Slade

12. Exhibit A EPD Sector 330 – YellowEPD Sectors 320 & 340 - Grey

13. Aim4Peace is not a silver bullet… We are focused on prevention of gun-related violence that is primarily related to arguments and retaliation in targeted areas of East Patrol, but we seek to expand to the entire Kansas and Missouri Region. A4P Current Target Zone: Kansas City Police Sector 330 (Beat 324 is of keen interest. We monitor, without proper staffing level.)

14. January – October 2013 Results A4P Current Target Zone: Kansas City Police Sector 330 • Provide Alternatives to violence: • 47 Conflicts mediated • 34 Dispute intakes (calls for service)

15. Annualized infant mortality rates by zip code median family income, KCMo, 2003-2007 Saving Lives, Protecting People from Health Threats, Saving Money through Prevention

16. Kansas City’s Geography of Health Inequity Source: Map produced by and data derived from the Kansas City Health Department, 2010 Community Health Assessment

17. Saving Lives, Protecting People from Health Threats, Saving Money through Prevention

18. Family & Culture

20. Health Inequities Health Disparities Family & Culture

21. Family & Culture Narrative Policy Place POWER

22. Health System Dynamics Presented by: Jeanne F. Ayers, Minnesota Department of Health - Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Syndemics Prevention Network, Centers for Disease Control and Prevention; April 15, 2008. Available at:  http://www.cdc.gov/syndemics/monograph/index.htm

23. Areas of Emphasis Society's Health Response Healthy Public Policy & Public Work Medical and Public Health Policy General Targeted Primary Secondary Tertiary protection protection prevention prevention prevention Becoming no longer vulnerable Afflicted Afflicted with Safer, Vulnerable without Complications Healthier Population Developing Complications Becoming Becoming Population Complications Vulnerable Afflicted Dying from Complications Adverse Living Conditions DEMOCRATIC SELF-GOVERNANCE DISEASE AND RISK MANAGEMENT • World of Transforming… • Deprivation • Dependency • Violence • Disconnection • Environmental decay • Stress • Insecurity • Etc… • By Strengthening… • Leaders and institutions • Foresight and precaution • The meaning of work • Mutual accountability • Plurality • Democracy • Freedom • Etc… • World of Providing… • Education • Screening • Disease management • Pharmaceuticals • Clinical services • Physical and financial access • Etc… Presented by: Jeanne F. Ayers, Minnesota Department of Health - Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Syndemics Prevention Network, Centers for Disease Control and Prevention; April 15, 2008. Available at:  http://www.cdc.gov/syndemics/monograph/index.htm

24. Refocusing Upstream

25. Health Capacity to Act Living Conditions Seeing a Wider Set of Relationships Centers for Disease Control and Prevention, Bobby Milstein

26. Power • Ability to act or produce an effect

27. Arena’s of Power • Directly impacting decision makers • Developing deeper relationships and aligning interests • Consciously shifting the narrative

28. Latinos/Hispanics in Kansas City, Missouri 2001-2010

29. Hispanic Population, 2000 and 2010

30. Hispanic Males, 2000 and 2010

31. Hispanic Females, 2000 and 2010

32. Births

33. Deaths

34. Poverty and income

35. Language

36. Expansion of Medicaid coverage reduces mortality among adults For every 300,000 additional Missourians insured by Medicaid ~1,700 lives saved per year ~150 KCMO lives Saved per year 176 insured to prevent one death per year For every 10M more insured, ~57,000 lives saved per year Benjamin D. Sommers DB et al. Mortality and Access to Care among Adults after State Medicaid Expansions. N Engl J Med 2012; 367:1025-1034

37. Your Nationally Accredited Questions? Kansas City, Mo., Health Department Improving Service. Protecting People. Saving Lives.

38. POPULATION APPROACH VS. INDIVIDUAL APPROACH

39. Public Health As A Social Justice Enterprise = = + JUSTICE TRUTH POWER Community Organizing Public Health Practice Research + Data

40. Of all the forms of inequality, injustice in health is the most shocking and inhumane.-- Martin Luther King, Jr. Presentation at: The Second National Convention of the Medical Committee for Human Rights; March 25, 1966; Chicago, IL.

41. In U.S., Latinos outlive whites by 2 1/2 years CDC's report on life expectancy yields surprising results-Associated Press 10-13-10

43. January – October 2013 Results A4P Current Target Zone: Kansas City Police Sector 330

44. Smallest Impact Largest Impact Factors that Affect Health Examples Condoms, eat healthy, be physically active Counseling & Education Rx for high blood pressure, high cholesterol Clinical Interventions Immunizations, brief intervention, cessation treatment, colonoscopy Long-lasting Protective Interventions Changing the Context to make individuals’ default decisions healthy Fluoridation, 0g trans fat, iodization, smoke-free laws, tobacco tax Poverty, education, housing, inequality Socioeconomic Factors Religious, moral teachings, beliefs Contributory (Social) Justice Frieden, Archer

45. Population and Employment