Adewale Troutman, MD, MPH, MA, CPH USF College of Public Health

1. Fair Society, Healthy Society: Creating Health Equity Through Social Justice and a Focus on the Social Determinants of Health Adewale Troutman, MD, MPH, MA, CPH USF College of Public Health

2. A Case Study; But Why The Troutman Group

3. The Troutman Group

4. How you frame an issue • The questions you ask • Determines your analysis of the issue • Determines how you prioritize it • Determines your policy choices • Determines resource allocation • Can determine your allies and your enemies • Can define when an issue has been resolved The Troutman Group

5. Reframing • Health vs. Healthcare • Individual (Medical model) vs. Population Health • Market Justice vs. Social Justice • Rights vs. Privileges • Biological/Behavioral Determinants vs. Social Determinants • Creating Health Equity vs. eliminating Health Disparities The Troutman Group

6. “Of all the injustices, injustices in health are the most shocking and inhumane” • Martin Luther King Jr. • Martin Luther King

7. Inequity and “the Gap”History and Evolution

8. Vital Statistics: The Troutman Group

9. What If We Had Eliminated Disparities in the Last Century?

10. Causes of Death 2000 • 245,000-low education • 175.000-racial segregation • 162,000-low societal support • 133,000-individual level poverty • 119,000-income inequality • 39,000-area level poverty

11. Social Reforms and Improved Health • Abolition of child labor • Introduction of housing and factory codes • Shortening of the work day • Reductions in the scale of poverty • Improvements in standard of living • Minimum wage • Improved sanitation • Food safety

12. Legislative Changes;Healthy Public Policy • Civil Rights Act • Social Security Act • Clean Air Act • The Mine Safety Act • OHSA • Medicare • Medicaid

13. Let’s get on the same page. The Troutman Group

14. Determinants of Health • Social and Economic Environment • Physical Environment • Health Behaviors • Health Care Access • Policies & The Political Environment • The Balance of Power • Genetics/Biology

15. Health “The presence of physical, psychological, social, economic and spiritual well being not merely the absence of disease or infirmity” “The maintenance of a harmonious balance between mind body and spirit “ The Troutman Group

16. Health Equity • “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.” The Troutman Group

17. Health Inequities • 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 The Troutman Group

18. Justice The quality of fairness The principle of moral rightness; equity Conformity to moral rightness in action or attitude The Troutman Group

19. Social Justice The application of principles of justice to the broadest definition of society Implies Equity Equal access to societal power, goods and services Universal respect for human and civil rights The Troutman Group

20. Social Justice • “When we approach health from a social justice perspective, we are necessarily concerned with the political, economic and social arrangements that impinge on the lived experiences of social groups.” (Jones, Hatch, Troutman)

21. 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… The Troutman Group www.who.int/social_determinants

22. Health and Human Rights 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 The Troutman Group

23. A New Direction; Social Determinants The Troutman Group

25. Looking upstream, finding the causes of he causes. “The web of causation” The Troutman Group

26. Social Determinants Socioeconomic Status WHO Early Life Social Exclusion Work Unemployment Social Support Addiction Food Transport The Social Gradient Stress • Occupation • Education • Income • Income gaps • Racism & discrimination • Housing • Political power The Troutman Group

27. Social Determinants of Health • The complex, integrated, and overlapping social structures and economic systems that are responsible for most health inequities.  

28. SDOH • These social structures and economic systems include the social environment, physical environment, health services, and structural and societal factors.

29. SDOH •  Social determinants of health are shaped by the distribution of money, power, and resources throughout local communities, nations, and the world [9].

30. Socially Determined Risk HIV • Poverty can limit access to health care, HIV testing, and medications that can lower levels of HIV in the blood and help prevent transmission. In addition, those who cannot afford the basics in life may end up in circumstances that increase their HIV risk.

31. SES Risk HIV • Discrimination, stigma and homophobia: Far too prevalent in many communities, these factors may discourage individuals from seeking testing, prevention, and treatment services.

32. SES HIV • Prevalence of HIV and other STDs in a community: More people living with HIV or infected with STDs can increase an individual’s risk of infection with every sexual encounter, especially if, within those communities, people select partners who are from the same ethnicity or race

33. SES HIV • Higher rates of undiagnosed/untreated STDs can increase the risk of both acquiring and transmitting HIV

34. SES HIV • Higher rates of incarceration among men can disrupt social and sexual networks in the broader community and decrease the number of available partners for women, which can fuel the spread of HIV. • Language barriers and concerns about immigration status present additional prevention challenges.

35. The social gradient The Troutman Group

36. Societies are Structured Like Social Ladders Your position on the ladder predicts how long you live and how healthy you are during your lifetime. The Troutman Group

37. Stress • Continuing existence of anxiety, insecurity, low self esteem and social isolation • Lack of control over home and work life • Profound effect on health • Cumulative The Troutman Group

38. Education The Troutman Group

39. How Does Education Influence Health Education can improve health by increasing health knowledge Leads to greater employment opportunities Linked with social and psychological factors that affect health PQLI experience “55,000 degrees” Kalamazoo Promise

40. In El Salvador, if mothers had no education their babies have 100 chances in 1000 of dying in their first year of life; if mothers have at least secondary education the infant death rate is a quarter of that (World Bank 2006) The Troutman Group

41. Tell me how a man died and I’ll tell you where he livedAristotlePLACE MATTERS The Troutman Group

42. Life Expectancy: Louisville Metro

43. The role of residential segregation;“The metropolitan areas with the highest segregation levels have the most unequal geographies of opportunity”Delores Acevedo-Garcia et al The Troutman Group

44. Segregation and Neighborhood Quality • Municipal services (transportation, police, fire, garbage) • Purchasing power of income (poorer quality, higher prices). • Access to Medical Care (primary care, hospitals, pharmacies) • Personal and property crime • Environmental toxins • Abandoned buildings, commercial and industrial facilities

45. Segregation and Housing Quality Crowding Sub-standard housing Noise levels Environmental hazards (lead, pollutants, allergens) Ability to regulate temperature

46. Segregation and Health Behaviors Recreational facilities (playgrounds, swimming pools) Marketing and outlets for tobacco, alcohol, fast foods Exposure to stress (violence, financial stress, family separation, chronic illness, death, and family turmoil)

47. Segregation and Medical Care -I • Pharmacies in segregated neighborhoods are less likely to have adequate medication supplies (Morrison et al. 2000) • Hospitals in black neighborhoods are more likely to close (Buchmueller et al 2004; McLafferty, 1982; Whiteis, 1992). • MDs are less likely to participate in Medicaid in racially segregated areas. Poverty concentration is unrelated to MD Medicaid participation (Greene et al. 2006)

48. Segregation and Medical Care -II • Blacks are more likely than whites to reside in areas (segregated) where the quality of care is low (Baicker, et al 2004). • African Americans receive most of their care from a small group of physicians who are less likely than other doctors to be board certified and are less able to provide high quality care and referral to specialty care (Bach, et al. 2004).

49. Racial Differences in Residential Environment • In the 171 largest cities in the U.S., there is not even one city where whites live in ecological equality to blacks in terms of poverty rates or rates of single-parent households. • “The worst urban context in which whites reside is considerably better than the average context of black communities.” p.41 Source: Sampson & Wilson 1995

50. Opportunity Neighborhoods: What we all desire • Sustainable employment • High performing schools • Access to high quality healthcare • Adequate transportation • High quality childcare • Neighborhood safety • Institutions that facilitate civic engagement The Troutman Group