Why_Health_Disparities_Persist by 05wJCnD

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									  When Good Intentions Fail:
 Why Health Disparities Persist
and what you can do about them


            David R. Williams, PhD, MPH
       Florence & Laura Norman Professor of Public Health
 Professor of African & African American Studies and of Sociology
                        Harvard University
                             There Is a Racial Gap in Health in Early Life:
                                Minority/White Mortality Ratios, 2000

                        3
Minority/White Ratio




                       2.5
                        2                                               B/W ratio
                                                                        AmI/W ratio
                       1.5
                                                                        API/W ratio
                        1                                               Hisp/W ratio
                       0.5
                        0
                                  <1       1-4         5-14   15-24
                                                 Age
                       There Is a Racial Gap in Health in Mid Life:
                          Minority/White Mortality Ratios, 2000

                       2.5
Minority/White Ratio




                        2
                                                                   B/W ratio
                       1.5
                                                                   AmI/W ratio
                        1                                          API/W ratio
                                                                   Hisp/W ratio
                       0.5

                        0
                             25-34   35-44         45-54   55-64
                                             Age
                       There Is a Racial Gap in Health in Late Life:
                             Minority/White Mortality Ratios, 2000


                       1.6
                       1.4
Minority/White Ratio




                       1.2
                       1.0                                           B/W ratio
                                                                     AmI/W ratio
                       0.8
                                                                     API/W ratio
                       0.6
                                                                     Hisp/W ratio
                       0.4
                       0.2
                       0.0
                             65-74         75-84         85+
                                           Age
                                       Age-Adjusted Heart Disease Death Rates
                                          for Blacks and Whites, 1950-2000
                                     700
Death Rates per 100,000 Population




                                                                                     White
                                     600
                                                                                     Black
                                     500


                                     400


                                     300


                                     200


                                     100
                                           1950   1960   1970          1980   1990      2000

                                                                YEAR
                                       Age-Adjusted Cancer Death Rates for
                                          Blacks and Whites, 1950-2000
                                     300

                                                  White
Death Rates per 100,000 Population




                                                  Black
                                     250




                                     200




                                     150




                                     100
                                           1950       1960   1970          1980   1990   2000

                                                                    YEAR
                                Diabetes Death Rates 1955-1995
                                50.0                                                              4.5
                                              White
                                45.0          Am Ind                                       46.4   4.0
Deaths per 100,000 Population




                                40.0          Am Ind/W Ratio                                      3.5
                                35.0




                                                                                                        Am Ind/W Ratio
                                                                                                  3.0
                                30.0
                                                                                                  2.5
                                25.0
                                                             24.3            24.4                 2.0
                                20.0
                                                                                                  1.5
                                15.0           17.0

                                10.0   12.6                                                       1.0
                                                                                    11.7
                                                      10.4
                                                                       8.6                        0.5
                                 5.0
                                 0.0                                                              0.0
                                         1955           1975            1985          1995
                                                                Year
          Source: Indian Health Service; Trends in Indian Health 1998-99
       Life Expectancy at Birth, 1900-2000
      90
      80                                     76.1          77.6
                     69.1          71.7             69.1          71.9
      70
                            60.8      64.1
      60
           47.6
Age




      50                                                                 White
      40                                                                 Black
              33.0
      30
      20
      10
      0
            1900      1950          1970      1990          2000
                                   Year
   The Persistence of Racial Disparities
• We have FAILED!
• In spite of:
     -- a War on Poverty
     -- a Civil Rights revolution
     -- Medicare & Medicaid
     -- the Hill-Burton Act
     -- Major advances in medical research & technology
 We have made little progress in reducing the elevated
  death rates of blacks and American Indians relative to
  whites.
 Understanding Elevated Health Risks

    “Has anyone seen the SPIDER that is
        spinning this complex web of
        causation?”




Krieger, 1994
                       SAT Scores by Income

           Family Income             Median Score
          More than $100,000             1129
          $80,000 to $100,000            1085
           $70,000 to $80,000            1064
           $60,000 to $70,000            1049
           $50,000 to $60,000            1034
           $40,000 to $50,000            1016
           $30,000 to $40,000            992
           $20,000 to $30,000             964
          $10,000 to $20,000              920
          Less than $10,000               873
Source: (ETS) Mantsios; N=898,596
     SES: A Key Determinant of Heath
• Socioeconomic Status (SES) usually measured by
  income, education, or occupation influences health in
  virtually every society.
• SES is one of the most powerful predictors of health,
  more powerful than genetics, exposure to carcinogens,
  and even smoking.
• The gap in all-cause mortality between high and low
  SES persons is larger than the gap between smokers
  and non-smokers.
• Americans who have not graduated from high school
  have a death rate two to three times higher than those
  who have graduated from college.
• Low SES adults have levels of illness in their 30s and
  40s that are not seen in the highest SES group until
  after the ages of 65-75.
                      Percentage of Persons in Poverty
                              Race/Ethnicity
               30


               25                          26.6
                                  25.3
Poverty Rate




               20                                                  21.5

               15
                                                   16.1                     16.8

               10
                                                           10.7
                      9.3
               5


               0
                     White        Black   AmI/AN   NH/PI   Asian   Hisp.   2+ races
                                                                   Any
                                                   Race
               U.S. Census 2006
    Racial/Ethnic Composition of People in
              Poverty in the U.S.
                      2+ races, 2.6%




                           Hisp. Any
                            23.9%

                                         White
     Asian, 3.6%                         46.1%

NH/PI, 0.17%
                                 Black
                                 23.1%
  AmI/AN, 1.6%



   U.S. Census 2006
                Relative Risk of Premature Death by
                        Family Income (U.S.)
                4.0
                3.5
                3.0
                2.5
Relative Risk




                2.0
                1.5
                1.0
                0.5
                0.0
                      <10K      10-19K 20-29K 30-39K 40-49K 50-99K 100+K

                             Family Income in 1980 (adjusted to 1999 dollars)

                  9-year mortality data from the National Longitudinal Mortality Survey
      Added Burden of Race
• Race and SES reflect two related but not
  interchangeable systems of inequality

• SES accounts for a large part of the racial
  differences in health

• BUT, there is an added burden of race, over
  and above SES that is linked to poor health.
           Percent of persons with
      Fair or Poor Health by Race, 1995
                                                     Racial Differences
Race/Ethnicity Percent                             B-W       H-W        B-H

White                        9.1                    8.2              6.0               2.2


Black                        17.3


Hispanic                     15.1
Poor=Below poverty; Near poor+<2x poverty; Middle Income = >2x poverty but <$50,000+
Source: Parmuk et al. 1998
           Percent of Women with
  Fair or Poor Health by Race and Income,
                    1995
Household
                          White             Black           Hispanic
Income
Poor                       30.2              38.2              30.4
Near Poor                  17.9              26.1              24.3
Middle Income               9.2              14.6              13.5
High Income                 5.8              9.2                7.0

SES Difference             24.4              29.0              23.4
Poor=below poverty; Near Poor=<2x poverty; Middle Income=>2x poverty but
<$50,000; High Income=$50,000+
Source: Pamuk et al. 1998
                              Infant Death Rates by Mother’s
                              20
                                      Education, 1995 3
Deaths per 1,000 population



                              18
                              16                                         2.5
                              14                                         2




                                                                               B/W Ratio
                              12                                                           White
                              10                                         1.5               Black
                               8                                                           B/W Ratio
                               6                                         1
                               4                                         0.5
                               2
                               0                                         0
                                   <High High School Some      College
                                   School            College   grad. +
                                               Education
                    Infant Mortality by Mother’s Education,
                                      1995
                   20
                                         NH White                Black           Hispanic          API        AmI/AN
                   18
                              17.3
                   16
                   14                                     14.8
Infant Mortality




                   12                        12.7                                        12.3
                                                                                                                     11.4
                   10
                        9.9
                    8
                                                                           7.9
                    6                               6.5
                                     6 5.7                       5.9 5.5
                    4                                                              5.1          5.4 5.1 5.7
                                                                                                               4.2          4.4 4
                    2
                    0
                                 <12                             12                        13-15                        16+
                                                             Years of Education
           Why Race Still Matters
1. All indicators of SES are non-equivalent across race.
   Compared to whites, blacks receive less income at the
   same levels of education, have less wealth at the
   equivalent income levels, and have less purchasing
   power (at a given level of income) because of higher
   costs of goods and services.
2. Health is affected not only by current SES but by
   exposure to social and economic adversity over the life
   course.
3. Personal experiences of discrimination and institutional
   racism are added pathogenic factors that can affect the
   health of minority group members in multiple ways.
       Race/Ethnicity and Wealth, 2000
             Median Net Worth
Income                        White        Black    Hispanic
All                          $79,400       $7,500    $9,750
 Excl. Hm. Eq.                 22,566       1,166     1,850
Poorest 20%                    24,000         57       500
2nd Quintile                   48,500       5,275     5,670
3rd Quintile                   59,500      11,500    11,200
4th Quintile                   92,842
                                           32,600    36,225
Richest 20%                  208,023       65,141    73,032
Orzechowski & Sepielli 2003, U.S. Census
           Wealth of Whites and of Minorities
                per $1 of Whites, 2000
                                                    White      B/W     Hisp/W
 Household Income                                              Ratio    Ratio

 Total                                             $ 79,400     9¢      12¢
 Poorest 20%                                       $ 24,000     1¢      2¢
 2nd Quintile                                      $ 48,500     11¢     12¢
 3rd Quintile                                      $ 59,500     19¢     19¢
 4th Quintile                                      $ 92,842     35¢     39¢
 Richest 20%                                       $ 208,023    31¢     35¢

Source: Orzechowski & Sepielli 2003, U.S. Census
     Race and Economic Hardship 1995
African Americans were more likely than whites to
experience the following hardships 1:
          1. Unable to meet essential expenses
          2. Unable to pay full rent on mortgage
          3. Unable to pay full utility bill
          4. Had utilities shut off
          5. Had telephone shut off
          6. Evicted from apartment
1 Afteradjustment for income, education, employment status, transfer payments,
home ownership, gender, marital status, children, disability, health insurance and
residential mobility.


   Bauman 1998; SIPP
    Racism: Potential Mechanisms
• Institutional discrimination can restrict economic
  attainment and thus differences in SES and health.
• Segregation creates pathogenic residential
  conditions.
• Discrimination can lead to reduced access to
  desirable goods and services.
• Internalized racism (acceptance of society’s
  negative beliefs) can adversely affect health.
• Racism can lead to increased exposure to
  traditional stressors (e.g. unemployment).
• Experiences of discrimination may be a neglected
  psychosocial stressor.
   Perceived Discrimination:

 Experiences of discrimination
may be a neglected psychosocial
           stressor
            MLK Quote

“..Discrimination is a hellhound that gnaws
at Negroes in every waking moment of
their lives declaring that the lie of their
inferiority is accepted as the truth in the
society dominating them.”

                     Martin Luther King, Jr. [1967]
        Discrimination Persists
• Pairs of young, well-groomed, well-spoken
  college men with identical resumes apply for
  350 advertised entry-level jobs in Milwaukee,
  Wisconsin. Two teams were black and two
  were white. In each team, one said that he had
  served an 18-month prison sentence for cocaine
  possession.

• The study found that it was easier for a white
  male with a felony conviction to get a job than a
  black male whose record was clean.

Source: Devan Pager; NYT March 20, 2004
Percent of Job Applicants Receiving a
              Callback
    Criminal
                                          White   Black
     Record
              No                          34%     14%



             Yes                          17%      5%


Source: Devan Pager; NYT March 20, 2004
             Every Day Discrimination
In your day-to-day life how often do the following things happen to
     you?
•    You are treated with less courtesy than other people.
•    You are treated with less respect than other people.
•    You receive poorer service than other people at restaurants or
     stores.
•    People act as if they think you are not smart.
•    People act as if they are afraid of you.
•    People act as if they think you are dishonest.
•    People act as if they’re better than you are.
•    You are called names or insulted.
•    You are threatened or harassed.
     Everyday Discrimination and
         Subclinical Disease

In the study of Women’s Health Across the Nation
   (SWAN):
-- Everyday Discrimination was positively related to
   subclinical carotid artery disease (IMT; intima-
   media thickness) for black but not white women
-- chronic exposure to discrimination over 5 years
   was positively related to coronary artery
   calcification (CAC)

Troxel et al. 2003; Lewis et al. 2006
   Arab American Birth Outcomes
• Well-documented increase in discrimination and
  harassment of Arab Americans after 9/11/2001
• Arab American women in California had an
  increased risk of low birthweight and preterm
  birth in the 6 months after Sept. 11 compared to
  pre-Sept. 11
• Other women in California had no change in birth
  outcome risk pre-and post-September 11

Lauderdale, 2006
 Determinants of Health in the U.S.

    Environment
       20%
                               Behavior
                                 50%

   Genetics
    20%




        Medical Care
           10%


U.S. Surgeon General, 1979
        Needed Behavioral Changes

• Reducing Smoking
• Improving Nutrition and Reducing Obesity
• Increasing Exercise
• Reducing Alcohol Misuse
• Improving Sexual Health
• Improving Mental Health
            Reducing Inequalities I
      Reducing Negative Health Behaviors?
*Changing health behaviors requires more than just
more health information. “Just say No” is not enough.

*Interventions narrowly focused on health behaviors are
unlikely to be effective.

*The experience of the last 100 years suggests that
interventions on intermediary risk factors will have
limited success in reducing social inequalities in health as
long as the more fundamental social inequalities
themselves remain intact.

House & Williams 2000; Lantz et al. 1998; Lantz et al. 2000
      Changes in Smoking Over Time -I
Successful interventions require a coordinated and
comprehensive approach:

       • The active involvement of professionals and
       volunteers from many organizations (government,
       health professional organizations, community
       agencies and businesses)
       • The use of multiple intervention channels (media,
       workplaces, schools, churches, medical and health
       societies)

Warner 2000
     Changes in Smoking Over Time -2
The use of multiple interventions –
         • Efforts to inform the public about the dangers
         of cigarette smoking (smoking cessation
         programs, warning labels on cigarette packs)
         • Economic inducements to avoid tobacco use
         (excise taxes, differential life insurance rates)
         • Laws and regulations restricting tobacco use
         (clean indoor air laws, restricting smoking in
         public places and restricting sales to minors)
Even with all of these initiatives, success has been only
partial
Warner 2000
       Moving Upstream

Effective Policies to reduce inequalities
 in health must address fundamental
      non-medical determinants.
WHY?

WHY?
Centrality of the Social Environment
An individual’s chances of getting sick are largely
unrelated to the receipt of medical care

Where we live, learn, work, play and worship
determine our opportunities and chances for being
healthy

Social Policies can make it easier or harder to
make healthy choices
          SES and Health Risks
SES is linked to:

*Exposures to health enhancing resources
*Exposures to health damaging factors
*Exposure to particular stressors
*Availability of resources to cope with stress

Health practices (smoking, poor nutrition,
drinking, exercise, etc.) are all socially patterned
      Making Healthy Choices Easier

Factors that facilitate opportunities for health:
• Facilities and Resources in Local
  Neighborhoods
• Socioeconomic Resources
• A Sense of Security and Hope
• Exposure to Physical, Chemical, &
  Psychosocial Stressors
• Psychological, Social & Material Resources
  to Cope with Stress
           Redefining Health Policy

Health Policies include policies in all sectors of
  society that affect opportunities to choose health,
  including, for example,
• Housing Policy
• Employment Policies
• Community Development Policies
• Income Support Policies
• Transportation Policies
• Environmental Policies
         Policy Implications
  Since the socio-political environment
and SES is a key determinant of health,
     improving social and economic
conditions is critical to improving health
     and reducing health disparities
          Policy Area


           Place Matters!
  Geographic location determines
exposure to risk factors and resources
          that affect health.
           Racial Segregation Is              …
1. …"basic" to understanding racial inequality in
    America (Myrdal 1944) .
2. …key to understanding racial inequality (Kenneth
    Clark, 1965) .
3. …the "linchpin" of U.S. race relations and the source
    of the large and growing racial inequality in SES
    (Kerner Commission, 1968) .
4. …"one of the most successful political ideologies" of the
    last century and "the dominant system of racial
    regulation and control" in the U.S (John Cell, 1982).
5. …"the key structural factor for the perpetuation of
    Black poverty in the U.S." and the "missing link" in
    efforts to understand urban poverty (Massey and
    Denton, 1993).
         How Segregation Can Affect Health

      1. Segregation determines quality of education and
         employment opportunities.
      2. Segregation can create pathogenic neighborhood
         and housing conditions.
      3. Conditions linked to segregation can constrain the
         practice of health behaviors and encourage
         unhealthy ones.
      4. Segregation can adversely affect access to high-
         quality medical care.

Source: Williams & Collins , 2001
         Segregation: Distinctive for Blacks
         •      Blacks are more segregated than any other
                racial/ethnic group.
         •      Segregation is inversely related to income for Latinos
                and Asians, but is high at all levels of income for
                blacks.
         •      The most affluent blacks (income over $50,000) are
                more highly segregated than the poorest Latinos and
                Asians (incomes under $15,000).
         •      Thus, middle class blacks live in poorer areas than
                whites of similar SES and poor whites live in much
                better neighborhoods than poor blacks.
         •      African Americans manifest a higher preference for
                residing in integrated areas than any other group.
Source: Massey 2004
    Residential Segregation and SES
A study of the effects of segregation on young
African American adults found that the
elimination of segregation would erase black-
white differences in
     Earnings
     High School Graduation Rate
     Unemployment
And reduce racial differences in single
motherhood by two-thirds

Cutler, Glaeser & Vigdor, 1997
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
Proportion of Black & Latino Children in Poorer
Neighborhoods Than Worst Off White Children

               100
                90
                80                    86%                          Black
                70
  Percentage




                       76%                  74%                    Latino
                60           69%
                50                                   57%
                40
                30                                         44%
                20
                10
                 0
                     All Metro Areas 5 Metro Areas 5 Metro Areas
                                       High Segr.    Low Segr.
                                    Neighborhood
              American Apartheid:
South Africa (de jure) in 1991 & U.S. (de facto) in
                       2000
                     100          90
                      90                          85       82             81        80       80          77
                      80
Segregation Index




                      70                                                                                            66
                      60
                      50
                      40
                      30
                      20
                      10
                       0
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Source: Massey 2004; Iceland et al. 2002; Glaeser & Vigitor 2001
         Reducing Inequalities II
Address Underlying Determinants of Health

• Improve conditions of work, re-design
  workplaces to reduce injuries and job
  stress
• Enrich the quality of neighborhood
  environments and increase economic
  development in poor areas
• Improve housing quality and the safety of
  neighborhood environments
        Neighborhood Renewal and Health - I
   • A 10-year follow-up study of residents in 5 neighborhood
     types in Norway found that changes in neighborhood
     quality were associated with improved health.
   • The neighborhood improvements: a new public school,
     playground extensions, a new shopping center with
     restaurants and a cinema, a subway line extension into the
     neighborhood, a new sports arena & park, and organized
     sports activities for adolescents.
   • Residents of the area that had experienced these dramatic
     improvements in its social environment reported improved
     mental health 10 years later
   • This effect was not explained by selective migration


Dalgard and Tambs 1997
  Neighborhood Renewal and Health - II

• Neighborhood improvement in a poorly functioning area in
  England was linked to improved health and social interaction.
• Improvements: housing was refurbished (made safe & sheltered
  from strangers), traffic regulations improved, improved lighting
  & strengthening of windows, enclosed gardens for apartments,
  closed alleyways, and landscaping. Residents involved in
  planning process.
• One year later:
    – Levels of optimism, belief in the future, identification with
      their neighborhood, trust in other neighbors, and contact
      between the neighbors had all increased.
    – Symptoms of anxiety and depression had declined.
  Neighborhood Change and Health

• The Moving to Opportunity Program
  randomized families with children in high
  poverty neighborhoods to move to less poor
  neighborhoods.
• It found, three years later, that there were
  improvements in the mental health of both
  parents and sons who moved to the low-
  poverty neighborhoods.

Leventhal and Brooks-Gunn, 2003
        Reducing Inequalities III
Address Underlying Determinants of Health

  • Improve living standards for poor persons
    and households
  • Increase access to employment opportunities
  • Increase education and training that provide
    basic skills for the unskilled and better job
    ladders for the least skilled
  • Invest in improved educational quality in the
    early years and reduce educational failure
       Increased Income and Health
  • A study conducted in the early 1970s found that
    mothers in the experimental income group who
    received expanded income support had infants
    with higher birth weight than that of mothers in
    the control group.
  • Neither group experienced any experimental
    manipulation of health services.
  • Improved nutrition, probably a result of the
    income manipulation, appeared to have been the
    key intervening factor.

Kehrer and Wolin, 1979
        Income Change and Health

• A natural experiment assessed the impact of
  an income supplement on the mental health
  of American Indian children.
• It found that increased family income
  (because of the opening of a casino) was
  associated with declining rates of deviant
  and aggressive behavior.


Costello et al. 2003
Economic Policy is Health Policy


In the last 50 years, black-white
differences in health have narrowed
and widened with black-white
differences in income
            Changes in Mortality Rates per
            100,000 Population, Age 35-74,
            Between 1968 and 1978 (Men)
         Year          White        Black

         1968          2,119.7      2,919.8
         1978          1,738.2      2,331.8
         Change         -381.5       -588.0
         % Change         18.0         20.1

Cooper et al., 1981b
      Changes in Life Expectancy at Birth
       Between 1968 and 1978 (Women)
         Year          White     Black

         1968          75.0      67.9
         1978          77.8      73.6
         Change         2.8       5.7
         % Change       3.7       8.4

Cooper et al., 1981b
        Median Family Income of
        Blacks per $1 of Whites
         0.62
         0.61
           0.6
         0.59
Cents    0.58
         0.57
         0.56
         0.55
         0.54
             1978 1980 1982 1984 1986 1988 1990 1992 1994 1996

                                            Year

   Source: Economic Report of the President, 1998
       Health Status Changes, 1980-1991
Indicator                            1980     1991

1.   Excess Deaths (Blacks)          59,000   66,000
2.   Infant Mortality
        Black/White Ratio, Males     1.9      2.1
        Black/White Ratio, Females   2.0      2.3
3.   Life Expectancy
        Black/White Gap, Males       6.9      8.3
        Black/White Gap, Females     5.6      5.8


 Source: NCHS, 1994.
                                U.S. Life Expectancy at Birth, 1984-1992
                         80
                                                                                          White    Black
                                                                                       76.1     76.3   76.5
                               75.3        75.3    75.4     75.6     75.6     75.9
                         75
Life Expectency (Year)




                         70         69.5      69.3     69.1     69.1                       69.1     69.3     69.6
                                                                         68.9     68.8


                         65



                         60
                                1984        1985     1986     1987     1988     1989     1990     1991     1992
                                                                       Year

                              NCHS, 1995
      Policy Area


Reducing Childhood Poverty

Challenges and Opportunities
               Childhood Poverty, U.S., 1996
              Percent of Children Under Age 18
Income                                   Poor    Near Poor Economically
                                                            Vulnerable
All                                      20.5      22.7        43.2

White, non-Hispanic                      11.1      19.7        30.8

Asian or Pacific                         19.5      16.4        35.9
Islander
Black, non-Hispanic                      39.9      28.1        68.0

Hispanic                                 40.3      31.7        72.0
Source: U.S. Census Bureau (Pamuk et al. 1998)
        Family Structure and SES
Compared to children raised by 2 parents those
  raised by a single parent are more likely to:

•   grow up poor
•   drop out of high school
•   be unemployed in young adulthood
•   not enroll in college
•   have an elevated risk of juvenile delinquency and
    participation in violent crime.


McLanahan & Sandefur 1994; Sampson 1987
    Determinants of Family Structure

    • Economic marginalization of males (high
      unemployment & low wage rates) is the central
      determinant of high rates of female-headed
      households.
    • Marriage rates are positively related to average
      male earnings.
    • Marriage rates are inversely related to male
      unemployment.


Bishop 1980; Testa et al. 1993; Wilson & Neckerman 1986
                                          % Children Child Poverty (%)
 Country                                     1 Parent   1 Parent Other
                                               HH
Spain                                             2       32       12
Italy                                             3       22       20
Mexico                                            4       28       26
France                                            8       26       6
Ireland                                           8       48       14
Germany                                          10       51       6
United States                                    19       55       16
United Kingdom                                   20       46       13
Sweden                                           21        7       2
Source: UNICEF (United Nations Children’s Fund), 2000
                             Child Poverty Rates
Country                                       Before Taxes   After Taxes
Netherlands                                          16.0        7.7
Spain                                                21.1       12.3
Sweden                                               23.4        2.6
Canada                                               24.6       15.5
Italy                                                24.6       20.5
United States                                        26.7       22.4
Australia                                            28.1       12.6
France                                               28.7        7.9
United Kingdom                                       36.1       19.8
Poland                                               44.4       15.4
Source: UNICEF (United Nations’ Children’s Fund), 2000
       Policy Matters

 Investments in early childhood
 programs in the U.S. have been
shown to have decisive beneficial
            effects
The High/Scope Perry
 Preschool Study to
       Age 40
             Larry Schweinhart
 High/Scope Educational Research Foundation
             www.highscope.org
     High/Scope Perry Preschool
 123 young African-American children, living in poverty
  and at risk of school failure.
 Randomly assigned to initially similar program and no-
  program groups.
 4 teachers with bachelors’ degrees held a daily class of 20-
  25 three- and four-year-olds and made weekly home visits.
 Children participated in their own education by planning,
  doing, and reviewing their own activities.
                             Results at Age 40
 Those who received the program had better academic
  performance (more likely to graduate from high school)
 Program recipients did better economically (higher
  employment, annual income, savings & home ownership)
 The group who received high-quality early education had
  fewer arrests for violent, property and drug crimes
 The program was cost effective: A return to society of $17
  for every dollar invested in early education
_____________________________________________________________________
Schweinhart & Montie, 2005
Building on Resources
We Need to Better Understand How
Resilience Factors and Processes
Can Affect Health and how to Build
on the Strengths and Capacities of
Communities
Religion & Health: Potential Mechanisms
1.   Religious institutions can provide support, intimacy,
     a sense of connectedness and belonging
2.   Religious beliefs and values can provide systems of
     meaning to interpret and re-interpret stress
3.   Religious beliefs can provide feelings of strength to
     cope with adversity
4.   By encouraging moderation in all things and
     reducing risk taking behavior, religious involvement
     can reduce exposure to stress.
5.   Religious participation can discourage negative
     health behaviors (tobacco, alcohol, drugs, risky
     sexual practices)
6.   Religious institutions can generate stress: time
     demands, role conflicts, social conflicts, criticism
       Religion and Adolescent Risk Behavior
 • Religious high school seniors are less likely than their
   non-religious peers to
    – Carry a weapon (gun, knife, club) to school
    – Get into fights or hurt someone
    – Drive after drinking
    – Ride with driver who had been drinking
    – Smoke cigarettes
    – Engage in binge drinking (5 or more drinks in a
      row)
    – Use marijuana
 • Religious seniors were more likely to
    – Wear seat belts
    – Eat breakfast, green vegetables and fruit
    – Get regular exercise
    – Sleep at least 7 hours per night
Wallace and Forman 1998; Monitoring the Future Study
             U.S. Life Expectancy at Age 20
                by Religious Attendance
      70
                                       63.5          63.4
                           60.1 57.9                        60.1
      60     56.1
                                              52.4
      50            46.4
Age




      40
                                                                   White
                                                                   Black
      30

      20

      10

       0
              Never        <1 week     1/week        > 1/week

  Hummer et al. 1999
       Religious Services as Therapy?
1. Several aspects of some religious services are distinctive
   in the provision of opportunities to articulate and manage
   personal and collective suffering.
2. The expression of emotion and active congregational
   participation can promote ―collective catharsis‖ in ways
   that facilitate the reduction of tension and the release of
   emotional distress.
3. There are parallels between all the key elements of
   formal psychotherapy and the rituals of some religious
   services.

Griffith et al. (1980); Gilkes (1980): Pargament et al. (1983)
RWJF Commission to Build a
   Healthier America
            Overall Goal
The RWJF Commission to Build a Healthier
 America is a national, comprehensive effort
   to raise awareness about the large socio-
 economic status (SES) differences in health
  among Americans and then seek practical,
  common-ground solutions to improve the
                 health of all.
                Key Objectives
• Increase awareness about the relationships
  between social factors and health, and how these
  relationships have produced large inequalities in
  health among Americans
• Generate concern and motivate efforts to address
  the problem of health inequalities based on
  socioeconomic status and race/ethnicity
• Foster and inform constructive public discourse
  about ways to reduce these health inequalities
• Identify and prioritize the adoption of public and
  private policies and interventions to reduce social
  inequalities and thereby improve the health of
  Americans overall
     Commission Infrastructure
• RWJF Foundation Board and Staff
• Central Office: George Washington University,
  Dept. of Health Policy
• Research Arm: Center on Social Disparities in
  Health, UCSF
• Communications Partners:
  – Burness Communications
  – Health 360 Strategies -- a service of Chandler
    Chicco Agency and Mehlman Vogel
    Castagnetti, Inc
                   Approach
Raise awareness and identify areas for action by
   – Targeting decision-makers in public and private
     sector
   – Reaching beyond health care to non-traditional
     allies and advocates
   – Making academic research on social
     inequalities more accessible to policy makers
   – Conducting work in a resolutely nonpartisan
     fashion
   – Designing a plan that is sustainable, flexible
     and relevant
        Commission Activities
•   Commission meetings & Special Events
•   Field Hearings
•   Reports
•   Storybank Development
•   Outreach
•   Website
Commission Meetings & Field Hearings
• Raising awareness across the country
• Taking the message beyond Capitol Hill to
  real communities
• Listening to and learning from real people
  and communities who face the problem of
  social inequalities every day
• Highlighting promising potential solutions
       Commission Timeline
• Two Year life

• February/March 2008 launch

• Ongoing activities in 2008 and 2009

• Culminating in actionable recommendations
  that policy makers can embrace
 Report from RWJF to the Commission

• Presents new evidence of health inequalities across
  income, education, and racial/ethnic groups
• Estimates economic costs of health inequalities
• Reviews literature documenting lasting impact of
  physical and social environments on a child’s health
  and chances of becoming a healthy adult
• Examines roles of personal and societal
  responsibilities for health
• Offers a framework for seeking solutions
A Framework for Seeking Solutions
                Summary
A serious commitment on the part of the RWJ
  Foundation to:
• Explore the factors that influence health
• Raise public awareness of social
  inequalities in health
• Provide meaningful recommendations to
  spur action so that millions of people will
  have a chance to lead healthier lives
www.macses.ucsf.edu
 A 7-part documentary series & public impact campaign
                       www.unnaturalcauses.org

           Produced by California Newsreel with Vital Pictures
 Presented on PBS by the National Minority Consortia of Public Television
Impact Campaign in association with the Joint Center Health Policy Institute
            Unnatural Causes
•   Seven-part documentary series on PBS
•   DVD release
•   Companion Web site and other support tools
•   Ambitious Outreach and Public Impact
    Campaign

…to help reframe the nation’s debate over
 health and what we as a society can—and
 should—do to tackle our health inequities.
             SCHEDULE
• PBS broadcast: Begins March 27, 2008
                    (check local listings)


• DVD release (March, 2008)

• Web site launch: March 15, 2008
  (temporary site now up:
  www.unnaturalcauses.org)
    REFRAMING THE DEBATE
         Society Matters
• Health depends on more than our meds, our
  genes or behaviors…

• Improving the conditions in which we
  are born, live and work can have a
  profound affect on our health
  and well-being
    THE PUBLIC IMPACT CAMPAIGN
    A Broad-Based, Multi-Tiered Effort

•   Press Relations
•   Interactive Companion Web Site
•   Educational Dissemination
•   Outreach Screenings, Forums, Briefings
    & Public Dialogues
    –   Public Health
    –   Non-health sectors
    –   Govt. officials
    –   Community-based organizations
    IMPACT CAMPAIGN GOALS
       Reframing the Debate
• Sound the alarm
• Help introduce the importance of social policies into
  discussions of health
• Inject health consequences into debates over social and
  economic policies
• Health inequities are a societal problem (―we‖), not a
  special interest (―they‖)
• Communicate hopeful solutions
• Build a ―new story‖ connecting individual aspirations for
  better health to a new language of ―social connectedness.‖
    THREE ARENAS FOR USE
          A Tool to…
• Educate
    • Raise awareness of the extent and root causes of health
      inequities and demonstrate that we as a society can make
      different policy choices
• Organize
    • Reach out to and build alliances with other stakeholder
      groups and connect people to health equity initiatives
• Advocate
    • Bring mobilized constituencies together to educate public
      officials and advocate for health equity
          Screening Possibilities
•   Staff training / Leadership development
•   Cross-sectoral dialogues and alliances
•   Civic / labor / business organizations
•   Campus-Community Partnerships
•   Community Dialogs / Town-Hall Meetings
•   Conferences and conventions
•   Policy forums, briefings for govt. officials
•   Contact your PBS station outreach director
   Outreach Campaign Examples
• NACCHO:100 Town-Hall Meetings nationwide
  organized by LPHDs
• Black Women’s Agenda—18 national organizations
   mobilizing members around a racial justice framework for
   infant health
• ISAIAH / Gamaliel central Minnesota interfaith health
   justice coalition-80 congregations-Lent kick-off
• Sonoma County (CA) Board of Supervisors-Health Equity
   Advisory Committee
• HPI ―Place Matters‖ teams—winning buy-in for new
   initiatives in 26 counties
        Campaign Support Tools

•   Community Action “Tool-Kit”
•   Discussion Guides
•   Handouts, Fact Sheets and Backgrounders
•   Viral Marketing: “Myth-buster” video clips
•   Engagement Tools (e.g. “Health Literacy Quiz,”
    “Community Stress Test”)
• “Connect-Up!” Data Base
• Press Kits
• Companion Web site: www.unnaturalcauses.org
   Conditions for HEALTH
H - Housing
E – Education & Environment
A - Access
L - Labor
T – Transportation
H – Hope and Happiness
   CALIFORNIA NEWSREEL
500 Third Street, #505
San Francisco, CA 94103
415-284-7800
www.newsreel.org
www.unnaturalcauses.org

Rachel Poulain
Director of Outreach
rp@newsreel.org
                 Conclusions -I
1. Health officials and organizations cannot
   improve health by themselves
2. Improving health and reducing inequalities in
   health is not just about more health programs, it
   is about a new path to health
3. All policy that affects health is health policy
4. Health officials need to work collaboratively
   with other sectors of society to initiate and
   support social policies that promote health and
   reduce inequalities and health
               Conclusions -II
1. Inequalities in health are created by larger
   inequalities in society.
2. SES and racial/ethnic disparities in health reflect
   the successful implementation of social policies.
3. Eliminating them requires political will for and a
   commitment to new strategies to improve living
   and working conditions.
4. Our great need is to begin in a systematic and
   comprehensive manner, to use all of the current
   knowledge that we have.
5. Now is the time
                   A Call to Action



   ―The only thing necessary for the
   triumph [of evil] is for good men to
              do nothing.‖


Edmund Burke, British Philosopher
www.macses.ucsf.edu

								
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