Achieving Health Equity Will Require More than Equity in Health Care

Achieving Health Equity Will Require More Than Equity in Health Care September 11, 2009 Virginia Health Equity Conference Paula Braveman, MD, MPH Professor of Family & Community Medicine Director, Center on Social Disparities in Health University of California, San Francisco

2 questions Why did the Robert Wood Johnson Foundation create a national commission on health disparities that focused on factors other than health care? Why does the U.S. spend more than any other country on health care, yet have relatively poor health indicators?

We spend more on health care but are less healthy than people in many other countries Life Expectancy – 2004 Infant Mortality - 2002 Iceland IMR = 2.3 Finland Japan Sweden Norway Austria Czech Republic France Spain Germany Belgium Denmark Italy Australia Netherlands Portugal Switzerland Greece Ireland Luxembourg Untied Kingdom Korea Canada New Zealand United States IMR = 7.0 Hungary Poland Slovak Republic Mexico Turkey Japan LE = 82.1 Switzerland Iceland Italy Australia Sweden France Spain Canada Norway New Zealand Austria Germany Netherlands Greece Luxembourg Finland Belgium Ireland United Kingdom Portugal Korea Denmark United States LE = 77.8 Czech Republic Mexico Poland Slovak Republic Hungary Turkey

And we have huge disparities, e.g.: Higher income, longer life LIFE EXPECTANCY AT AGE 25 WOMEN Center on Social Disparities in Health, University of CA, San Francisco

Huge disparities: Children’s health varies by parents’ income % OF CHILDREN, AGE 17 & YOUNGER, IN POOR/FAIR HEALTH Center on Social Disparities in Health, University of CA, San Francisco

Disparities in activity-limiting chronic illness, by income. Similar patterns by education and for diabetes & heart disease % OF ADULTS, AGE 25+, WITH ANY ACTIVITY LIMITATION Center on Social Disparities in Health, University of CA, San Francisco

Racial/ethnic differences are important but do not explain the income/education disparities % OF ADULTS, AGE 25+, IN POOR/FAIR HEALTH Center on Social Disparities in Health, University of CA, San Francisco

Clues? Scarlet fever death rate in children <15: England & Wales Sulpha drugs Penicillin Thomas McKeown, 1974

Measles– mean annual death rate of children under 15: England and Wales Immunization began

Infant mortality rate: England and Wales

Respiratory tuberculosis– mean annual death rate: England and Wales

What influences health? Medical care Genetic makeup Climate & natural physical environment Behaviors, nutrition What else? And what influences these influences?

What affects the factors that affect health? E.g., income Income directly shapes: Medical care Housing Nutrition & physical activity Neighborhood conditions Stress Social support Parents’ income shapes the next generation’s: Education Working conditions, including control Income Center on Social Disparities in Health, University of CA, San Francisco

Poverty Poor Health Poor Health Low Educational Attainment Poor Job Poverty Vicious cycle of poverty and poor health Center on Social Disparities in Health, University of CA, San Francisco

Poor Health Low income  Unhealthy housing Unhealthy neighborhood Poor nutrition Lack of exercise Stress Poor working conditions Low control, helplessness, despair Stress Low Educational Attainment Poor Job How low educational attainment and a poor job lead to poor health Center on Social Disparities in Health, University of CA, San Francisco

Health knowledge, literacy & behaviors Educational attainment Nutrition Exercise Smoking Drugs & alcohol Social standing Exposure to hazards Control / demand imbalance Stress Work-related resources Housing Neighborhood environment Nutrition Stress Work Sense of control Health insurance Sick leave Other benefits Social networks & social support Subjective social status Working conditions Income What influences health? And what influences the influences? L E H T A H

How could your neighborhood affect your health? Physical danger, e.g., crime Safe places to exercise Pollution Access to healthy food Role models, peer pressure Substance abuse Social networks & support Stress, fear, anxiety, despair Blacks & Hispanics of given income level live in different kinds of neighborhoods than whites of similar income level Center on Social Disparities in Health, University of CA, San Francisco

Biological mechanisms Nutrition Exposure to physical hazards, toxins, carcinogens, crime Health-related behaviors lead to different exposures (health-promoting or –damaging) Direct health effects of psychosocial experiences E.g., chronic stress  neuroendocrine, sympathetic nervous system effects  vascular effects, immune suppression, inflammation

CRH AFFECTS MULTIPLE ORGANS & SYSTEMS STRESSOR CORTISOL Hypothalamus Pituitary Gland Adrenal Glands ACTH Stress pathway from brain to body Center on Social Disparities in Health, University of CA, San Francisco

Chronic stress in childhood? Cumulative effects of stress? Poverty/low income is stressful – limited resources to cope with challenges African Americans more likely than whites to have grown up in worse-off households Cumulative stress over lifetime For example, childhood stress or chronic stress could lead to adverse birth outcomes even if pregnancy itself is relatively stress-free via neuro-endocrine dysregulation

Income & stress: Lower income means more stressors during pregnancy, e.g.,: separation or divorce during pregnancy Center on Social Disparities in Health, University of CA, San Francisco % OF WOMEN

Considering income/education is not enough: Racism can harm health in other ways Structural racism tracks people by race into different socioeconomic opportunities Job opportunities Educational opportunities Options for where to live  schools, jobs, housing quality In addition, living in a society with a legacy of discrimination can harm health through pathways involving stress Not only overt incidents Constant vigilance Awareness of racism can undermine self-esteem and confidence even if no clear-cut incident occurs; implications for school/job performance

Economic & Social Opportunities and Resources Living & Working Conditions in Homes and Communities Personal Behavior Medical Care HEALTH Finding solutions: Understanding the importance of social factors Policies to promote healthier homes, neighborhoods, schools and workplaces Policies to promote child and youth development and education, infancy through college Policies to promote economic development and reduce poverty Robert Wood Johnson Foundation Commission to Build a Healthier America www.commissiononhealth.org

Understanding how health is transmitted by social factors across lifetimes and generations Robert Wood Johnson Foundation Commission to Build a Healthier America

The Social Determinants of Health and Health Equity Social factors are crucial influences on health and health disparities The causes of the causes Social factors like education, income, race/ethnicity influence health through many complex pathways The role of racism in health disparities When health data identify race/ethnicity but not other social factors, they can reinforce stereotypes and unfounded assumptions about biology or “culture” It’s not either/or. We need to address both racial/ethnic group and socioeconomic factors

A twin philosophy: Good health requires personal responsibility and a societal commitment to remove the obstacles preventing too many Americans from making healthy decisions The Commission’s Recommendations Building a healthier America is feasible The recommendations focus on people and the places where we spend most of our time: Homes and Communities Schools Workplaces

Starting Early Ensure that all children have high-quality early developmental support (child care, education and other services). This will require committing substantial additional resources to meet the early developmental needs particularly of children in low-income families. Feed children only healthy foods in schools. Require all schools (K-12) to include time for all children to be physically active every day.

Create public-private partnerships to open and sustain full-service grocery stores in communities without access to healthful foods. Fund and design WIC and SNAP (Food Stamps) programs to meet the needs of hungry families with nutritious food. Accessing Healthy Foods

Creating Healthy Communities Become a smoke-free nation. Eliminating smoking remains one of the most important contributions to longer, healthier lives. Integrate safety and wellness into every aspect of community life. Develop a “health impact” rating for housing and infrastructure projects that reflects the projected effects on community health and provides incentives for projects that earn the rating. Create “healthy community” demonstrations to evaluate the effects of a full complement of health-promoting policies and programs.

Decision makers at national, state, and local levels need reliable data on health status, disparities, and the effects of social determinants of health. Better data must be developed for use at the local level, in particular. Fund research to understand the health effects of social factors and promote application of findings by decision makers. Measuring Progress, Building In Accountability

Resources www.commissiononhealth.org Commission’s recommendations Array of reports and tools, including information at state and county levels, intended to be useful to decision-makers Background material, e.g.: State-by-State Chartbooks on Child Health and on Adult Health Overcoming Obstacles to Health. Robert Wood Johnson Foundation, February 2008. www.commissiononhealth.org Overview of key issues and literature on the social determinants of health. Race and Socioeconomic Factors Affect Opportunities for Better Health. Robert Wood Johnson Foundation March 2009. www.commissiononhealth.org Overview and synthesis of literature on how race and socioeconomic factors jointly influence health

Achieving Health Equity Will Require More than Equity in Health Care

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