Health Equity and Social Justice

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					Health Equity and Social
Justice: Community Models,
National Priorities
Adewale Troutman, M.D., M.P.H.
Director, Fulton County Department
of Health and Wellness
Atlanta Georgia
A Review of the Data
Some Selected Data
 278,440 deaths annually in AA community
  estimated 80-90,000 excess deaths in 2000
  – Almost 1 in 3 deaths were excess deaths
 16% of the nation is without health
  insurance, 38% of Latino adults, 26% of
  African American adults, compared with
  14% of white adults (Commonwealth Fund)
Some Selected Data
 Homicide rate for AA is 6x’s that for whites
 Hypertension rate is 4x’s greater for AA
  than for whites
 AA life expectancy is 71.3, 61.5 for AA
  men in Fulton County
  – >78 for the nation
 Infant mortality rate for AA> 2x white rate
   – In some areas >6x white rate
Data (Cont.)
 Breast cancer incidence & mortality
  – Whites 113.2/100,000 & 25.7/100,000
  – African Americans 99.3/100,000 &
    31.4/100,000
  – Latinos 69.4/100,000 & 15.3/100,000
 Latinos almost twice as likely to die from
  diabetes as whites
 Pima Indians have one of the highest
  diabetes rates in the world
Data (Cont.)
 African American men have the highest
  incidence & mortality rates of prostate
  cancer in the world
 Prostate cancer rate AA man > 2x that of
  white men
 African American men 3x more likely to die
  from prostate cancer than white men in
  Georgia
Data (Cont.)
 HIV/AIDS: 56% of the >700,000 AIDS
 cases are either African American or Latino
  – AA 37% but 12 % of population
  – Latino 18% but 13% of population
  – 81% of female cases with & 58% of pediatric
    cases in AA community
 In 1999, AIDS accounted for 50% of all
 African American deaths & 18% of Latino
 deaths
More Data
 African American age adjusted death rates
  exceeded those for whites
  –   By 77% in stroke
  –   By 47% for heart disease
  –   By 34% for cancer
  –   By 655% for HIV infection
Life Expectancy
 Nationally (African American men = 67)
 Fulton County 61.5
 White men 70.7
 White women 79+
Socioeconomic Status
Socioeconomic Status and Health
 Occupation
 Education
 Income
   – Believed to be the biggest contributor to health
     status
 SES as correlate to health outcomes
 PQLI and literacy
Socioeconomic Factors
 Correlate of race
 Must correct for SES when looking at race
 Prevailing measures imperfect proxies
   – Multiple variations within SES
 Standard measures have different meanings
  for different races
  – Purchasing power will differ between races
  – Low SES AA pay more than whites for rent
SES (Cont.)
 At every level, whites have more assets that
  blacks
 Blacks have less valuable homes
 Whites earn 1.5x’s than Blacks, possess 4
  times as much wealth
 Blacks more likely to be first generation
  middle class
 More likely to be supporting poorer
  relatives
SES (Cont.)
 Do not capture effect of lifetime exposure to
  deprivation
 Lack of childhood prevention may have
  long term effects
The World As We Know It
 The reality of the haves and the have nots
 The growth of the gap
  – Concentration of wealth in the hands of a
    shrinking few
  – The immorality and unacceptable nature of a
    permanent underclass
Medical Care
Medical Care
 Persistence in huge variations in quality and
  quantity of care
 AA more than twice as likely to receive
  care in hospital ER’s and clinics where less
  likely to receive continuity of care (different
  provider each visit)
 AA more likely to be dissatisfied with care
Medical Care
 More likely to receive inadequate
  information about care, instructions,
  medication information and information
  about presenting problem
 Increased proportion of AA without health
  insurance (increased from18-25% in 10
  years)
More Data
 Survey of physician attitudes (Van Ryn&
 Burke 2000) after correction for SES
  – AA less intelligent, less educated, more likely
    to be alcoholics and drug abusers, more likely
    to fail to comply
  – Less likely to have social support
  – Less likely to participate in cardiac
    rehabilitation
Let’s Agree on the Terms
Health
 “Not merely the absence of disease but the
  presence of physical, psychological, social
  economic and spiritual well being”
 “The harmonious balance of mind, body
  and spirit”
Equity
 Justice according to natural law or right
 Freedom from bias or favoritism
Justice
 The quality of fairness
 The principle of moral rightness; equity
 Conformity to moral rightness in action or
  attitude
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
Racism
 “An ideology of inferiority that is used to
  justify the unequal treatment of members of
  groups defined as inferior, by both
  individuals and social institutions”
Levels of Racism
 Personally Mediated: Differential
  assumptions and about the abilities, motives
  and intentions of others according to their
  race that may lead to differential actions
  towards members of that race
 Internalized: Acceptance by members of the
  stigmatized race of negative messages about
  their own intrinsic self worth (self
  devaluation, helplessness and hopelessness)
Levels of Racism
 Institutionalized: The differential access to
  goods, services and opportunities of society
  by race. May be manifested through law,
  institutional structure, covert or overt
  privilege & inherited disadvantage
Rights: Claims or entitlements
that are recognized by legal or
moral principles
Human Rights: A higher order
right MORALLY based and
UNIVERSAL. It belongs to all
persons equally because they are
human beings
(Declaration of Independence)
Rights are enforced by legislation
and rules, the force of law
The Right to Health
 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 Right to Health
 The Declaration of Alma Ata,
 International Conference on Primary
 Health Care “The right to health is the
 most important social goal”
The Right to Health
 The International Declaration of Human
 Rights “Everyone has a right to a standard
 of living adequate for the health and well
 being of his family including food, clothing,
 housing and medical care”
The Right to Health
 Affirmed by:
  – The Covenant of the Rights of the Child
  – The Convention on the Elimination of All
    Forms of Racial Discrimination Against
    Women
  – The ICESCR
      • “The right to the enjoyment of the highest
        standard of physical and mental health”
The International Bill of Human
Rights
 The Universal Declaration of Human Rights
  1948
 The International Covenant on Civil and
  Political Rights 1966
 The International Covenant on Economic,
  Social and Cultural Rights ( ICESCR )
“The time has come to herald
human rights as both the
foundation of public health and
the compass of public policy”
JAPHA 2000
The existence of health
disparities concentrated among
specific racial groupings is a
violation of United Nations
covenants, international
principles of human rights and all
principles of universal justice
The Minnesota Model
A Call to Action: Advancing
Health For All Through Social
and Economic Change
 People with higher income enjoy healthier
  longer life
 Disease and death rates are higher in
  populations that have a greater gap in
  income
 People are healthiest when they feel safe
 People are healthiest when they feel their
  job is secure
A Call to Action (Cont.)
 People are healthiest when they feel the
  work they do is important and valued
 Discrimination and racism play a crucial
  role in explaining health status and health
  disparities
Race and Racism
 Health and health care industry suffer same
  history as other sectors of American society
 Examples of access limitation secondary to
  race
  – CABG, angioplasty
  – AIDS medications
  – Referrals for coronary catheterization
  – Anecdotes
Policy Development & Public
Health Leadership

A Core Public Health Function
Policies For Social Justice,
Policies For Health Equity
 Short term and long term solutions
 Short term
   – Attention to symptoms (nutrition, physical
     activity, cholesterol, access)
   – Creating environment to promote health
 Long term
   – Empowerment
   – Redistributive policies
Policies…
 Expand focus on the effects of public policy
  on the health of those suffering inequities
  –   Welfare reform
  –   Housing and development
  –   Job development and health insurance
  –   Literacy and health outcomes
  –   Tax laws
  –   Environmental policies
Policies…
 Measuring progress through “Social Health
  Indexing”
 Living wage
 Educational reform
 Attention to short term only will just create
  a healthier underclass and will not create
  health equity because there is no social
  justice
Some Concluding Thoughts
What Do We Know
 There is a direct relationship between
  poverty and health outcomes
 Disparities in health are linked to disparities
  in wealth
 Health equity and social justice are
  inseparable
 Racism manifests itself in health disparities
What Do We Know
 This is a human rights issue
 The right to health and health care
 The civil rights movement didn’t go far
  enough
 Disproportionate share of uninsured,
  unemployed, undereducated
 Radical gaps in income
What To Do
 The acquisition of the tools of a systematic
  human rights analysis
 Learning the language of human rights
 Determine best practices for evidence based
  health policy
 Balance between promoting and protecting
  human rights and promoting public health
  as a national policy
What To Do
 The integration of human rights education
  into all levels of academic and professional
  training of health professionals
 Partnering with traditional human rights
  activists
 Public policy aimed at economic equity
 Universal coverage and access to high
  quality single standard of care
Transformation
 A new paradigm
 Transformation of self
 Movement from victim to empowered
  position
 Conquer the them vs. us mentality
 The force of self determination
Social Justice
 Health Status inequities are directly related
  to the continued existence of social injustice
 The existence of social injustice typified by
  the continued growth of the gap between the
  haves and the have-nots, lack of access to
  services and care, preventive and curative is
  unethical and immoral
Opportunities for Public Health
Leadership
Leadership Development
 The opportunity to change the world view
  of public health
 The institution in the mirror
 Workforce development for social change
 Healthy People 2010 & health equity
 Core functions, essential services & social
  justice
 MAAP & Social Health Indexing
Leadership Development (Cont.)
 Personal growth and development
 Taking on the challenge of racism
 Cultural competence (consciousness)
 The use of the tools of public health in
  creating health equity through social justice
Social Justice
 The mere concept of a permanent
  “underclass” is inherently unethical
 Public health practice must be manifested
  by a new and unrelenting movement for
  social justice and health equity
 NACCHO initiative
Some Final Thoughts
 The fallacy of improved health for all
 The recognition of social determinants as
  the foundation of health
 SES & racism are key elements of causation
 There are universal principles
 Empowerment vs. victimization
 The students role in understanding &
  change
Moving From Rhetoric to Action
   Definition of Healthy Communities
   Focus on “Social Health & Social Determinants”
   Address race, class & health
   Tool of BRFSS
   Curriculum changes (all levels)
   Policy initiative
    – Incrementalism vs. Radical Change
 A question of quality
 The tool of regulation (Hill-Burton)
What we are willing to turn our
backs on, ignore or deny, is the
measure of our willingness to live
as hypocrites and deny the core
value of ethics in our daily
practice of public health and
more importantly in our very
lives.
We need a social revolution
based on social justice and health
equity & supported by sound,
sweeping policy aimed at
reforming the American system
Adewale Troutman,M.D.,M.P.H.
Nasanan Health Consultants
1208 Clearbrook Drive
Atlanta Georgia 30311
adedrum@aol.com
404 730 1202
404 691 9608

				
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posted:3/29/2008
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