Achieving Health Equity: Framework and Tools for Quality

Camara Phyllis Jones, MD, MPH, PhDSocial Determinants of Health and Equity

Health Equity Grand RoundsMt. Sinai Hospital

Toronto, Ontario, CanadaFebruary 7, 2012

Achieving Health EquityFramework and tools for quality

Office of Surveillance, Epidemiology, and Laboratory ServicesEpidemiology and Analysis Program Office

Achieving Health EquityFramework and tools for quality

The findings and conclusions in this presentationare those of the author,

and do not necessarily represent the official position of theU.S. Centers for Disease Control and Prevention.

Our agenda Levels of health intervention: A Cliff

Analogy The impacts of racism on health

Definition Levels of racism: A Gardener’s Tale Data

Achieving health equity

Levels of health intervention

Medical care and tertiary prevention

Safety net programs and secondary prevention

Primary preventionAddressing thesocial determinants of health

But how do disparities arise? Differences in the quality of care received

within the health care system

Differences in access to health care, including preventive and curative services

Differences in life opportunities, exposures, and stresses that result in differences in underlying health status

eDifferences in exposures and opportunities

Differences in quality of care(ambulance slow or goes the wrong way)

Addressing thesocial determinants of equity:

Why are there differencesin resourcesalong the cliff face?

Why are there differencesin who is foundat different parts of the cliff?

3 dimensions of health intervention

Health services

Addressing social determinants of health

Health services

Addressing social determinants of health

Addressing social determinants of equity

Source: Jones CP et al. J Health Care Poor Underserved 2009.

What is racism?A system

What is racism?A system of structuring opportunity and assigning value

What is racism?A system of structuring opportunity and assigning value based on the social interpretation of how we look (“race”)

Unfairly disadvantages some individuals and communities

Unfairly advantages other individuals and communities

Unfairly advantages other individuals and communities Saps the strength of the whole society through the

waste of human resources

Source: Jones CP. Confronting Institutionalized Racism. Phylon 2003;50(1-2):7-22.

Levels of Racism Institutionalized Personally-mediated Internalized

Source: Jones CP. Levels of Racism: A Theoretic Framework and a Gardener’s Tale. Am J Public Health 2000;90(8):1212-1215.

Institutionalized racism Differential access to the goods, services,

and opportunities of society, by “race”

Examples Housing, education, employment, income Medical facilities Clean environment Information, resources, voice

Explains the association between social class and “race”

Personally-mediated racism Differential assumptions about the abilities,

motives, and intents of others, by “race” Differential actions based on those

assumptions

Prejudice and discrimination Examples

Police brutality Physician disrespect Shopkeeper vigilance Waiter indifference Teacher devaluation

Internalized racism Acceptance by the stigmatized “races” of

negative messages about our own abilities and intrinsic worth

Examples Self-devaluation White man’s ice is colder Resignation, helplessness, hopelessness

Accepting limitations to our full humanity

Source: Jones CP. Levels of Racism: A Theoretic Framework and a Gardener’s Tale. Am J Public Health 2000;90(8):1212-1215.

Levels of Racism: A Gardener’s Tale

Who is the gardener?

Power to decide Power to act Control of resources

Dangerous when Allied with one group Not concerned with

equity

Measuring institutionalized racism Scan for evidence of “racial” disparities

“Could racism be operating here?” Routinely monitor opportunities as well as outcomes by

“race”

Identify mechanisms “How is racism operating here?” Structures: the who?, what?, when?, and where?

of decision-making Policies: the written how? Practices and norms: the unwritten how? Values: the why?

“Reactions to Race” module Six-question optional module on the

Behavioral Risk Factor Surveillance System since 2002

“How do other people usually classify you in this country?”

“How often do you think about your race?” Perceptions of differential treatment at work or when

seeking health care Reports of physical symptoms or emotional upset as a

result of “race”-based treatment

States using the “Reactions to Race” module2002 to 2010 BRFSS

Arkansas, California, Colorado, Delaware, District of Columbia, Florida, Georgia, Indiana, Kentucky, Massachusetts, Michigan, Mississippi, Nebraska, New Hampshire, New Mexico, North Carolina, Ohio, Rhode Island, South Carolina, Tennessee, Vermont, Virginia, Washington, Wisconsin

Arkansas 2004California 2002Colorado 2004Delaware 2002 2004 2005District of Columbia

Florida 2002Georgia 2010Indiana 2009Kentucky 2010Massachusetts 2006

Michigan 2006Mississippi 2004Nebraska 2008 2009New Hampshire 2002New Mexico 2002

North Carolina 2002Ohio 2003 2005Rhode Island 2004 2007 2010South Carolina 2003 2004Tennessee 2005

Vermont 2008Virginia 2008Washington 2004Wisconsin 2004 2005 2006

States using the “Reactions to Race” module

Arkansas 2004California 2002Colorado 2004Delaware 2002 2004 2005District of Columbia

Florida 2002Georgia 2010Indiana 2009Kentucky 2010Massachusetts 2006

Michigan 2006Mississippi 2004Nebraska 2008 2009New Hampshire 2002New Mexico 2002

North Carolina 2002Ohio 2003 2005Rhode Island 2004 2007 2010South Carolina 2003 2004Tennessee 2005

Vermont 2008Virginia 2008Washington 2004Wisconsin 2004 2005 2006

States using the “Reactions to Race” module

Socially-assigned “race” How do other people usually classify you in

this country? Would you say:

White Black or African-American Hispanic or Latino Asian Native Hawaiian or Other Pacific Islander American Indian or Alaska Native Some other group

Socially-assigned “race” On-the-street “race” quickly and routinely

assigned without benefit of queries about self-identification, ancestry, culture, or genetic endowment

Ad hoc racial classification, an influential basis for interactions between individuals and institutions for centuries

Substrate upon which racism operates

Source: Jones CP, Truman BI, Elam-Evans LD, Jones CA, Jones CY, Jiles R, Rumisha SF, Perry GS. Using “socially assigned race” to probe White advantages in health status. Ethn Dis 2008;18(4):496-504.

General health status Would you say that in general your health

Excellent Very good Good Fair Poor

58.3 43.7 41.2 36.1

Report excellent or very good healthWhite Black Hispanic AIAN

General health status by socially-assigned "race", 2004 BRFSS

58.3 43.7 41.2 36.1

13.9 21.5 20.9 22.1

Report fair or poor health

General health status and “race” Being perceived as White is associated with

better health

Self-identified ethnicity Are you Hispanic or Latino?

Yes No

Self-identified “race” Which one or more of the following would

you say is your race?

White Black or African-American Asian Native Hawaiian or Other Pacific Islander American Indian or Alaska Native Other

Which one of these groups would you say best represents your race?

Self-identified “race”/ethnicity Hispanic

“Yes” to Hispanic/Latino ethnicity question Any response to race question

White “No” to Hispanic/Latino ethnicity question Only one response to race question, “White”

Black “No” to Hispanic/Latino ethnicity question Only one response to race question, “Black”

American Indian/Alaska Native “No” to Hispanic/Latino ethnicity question Only one response to race question, “AI/AN”

White Black Hispanic AIAN . . .

White26,373

98.4 0.1 0.3 0.1 1.1

Black5,246

0.4 96.3 0.8 0.3 2.2

fyTwo measures of “race”

How usually classified by others

White26,373

98.4 0.1 0.3 0.1 1.1

Black5,246

0.4 96.3 0.8 0.3 2.2

Hispanic1,528

26.8 3.5 63.0 1.2 5.5

White26,373

98.4 0.1 0.3 0.1 1.1

Black5,246

0.4 96.3 0.8 0.3 2.2

Hispanic1,528

26.8 3.5 63.0 1.2 5.5

53.758.6

Report excellent or very good healthHispanic-Hispanic Hispanic-White White-White

General health status, by self-identified and socially-assigned "race", 2004

Report excellent or very good healthHispanic-Hispanic White-White

Test of H0: That there is no difference in proportions

reporting excellent or very good health

Hispanic-Hispanic versus White-Whitep < 0.0001

Report excellent or very good healthHispanic-Hispanic Hispanic-White

Hispanic-Hispanic versus Hispanic-Whitep = 0.0019

53.758.6

Report excellent or very good healthHispanic-White White-White

Hispanic-White versus White-Whitep = 0.1895

White26,373

98.4 0.1 0.3 0.1 1.1

Black5,246

0.4 96.3 0.8 0.3 2.2

Hispanic1,528

26.8 3.5 63.0 1.2 5.5

AIAN321

47.6 3.4 7.3 35.9 5.8

White26,373

98.4 0.1 0.3 0.1 1.1

Black5,246

0.4 96.3 0.8 0.3 2.2

Hispanic1,528

26.8 3.5 63.0 1.2 5.5

AIAN321

47.6 3.4 7.3 35.9 5.8

Report excellent or very good healthAIAN-AIAN AIAN-White White-White

Report excellent or very good healthAIAN-AIAN White-White

AIAN-AIAN versus White-Whitep < 0.0001

Report excellent or very good healthAIAN-AIAN AIAN-White

AIAN-AIAN versus AIAN-Whitep = 0.0122

Report excellent or very good healthAIAN-White White-White

AIAN-White versus White-Whitep = 0.3070

better health Even within non-White self-identified “race”/ethnic

groups

groups Even within the same educational level

Being perceived as White is associated with higher education

Key questions Why is socially-assigned “race” associated

with self-rated general health status? Even within non-White self-identified “race”/ethnic

Why is socially-assigned “race” associated with educational level?

RacismA system of structuring opportunity and assigning value based on the social interpretation of how we look (“race”), which

Source: Jones CP, Truman BI, Elam-Evans LD, Jones CA, Jones CY, Jiles R, Rumisha SF, Perry GS. Using “socially assigned race” to probe White advantages in health status. Ethn Dis 2008;18(4):496-504.

Could this be true in Canada? Colour Coded Health Care: The Impact of

Race and Racism on Canadians’ HealthSheryl NestelThe Wellesley Institutehttp://www.wellesleyinstitute.com/wp-content/uploads/2012/02/Colour-Coded-Health-Care-Sheryl-Nestel.pdf

Public launch this evening6:00 pm at The 519 Church Street Community CentreFree and open to the public

What is [inequity] ?A system of structuring opportunity and assigning value based on [fill in the blank]

What is [inequity] ?A system of structuring opportunity and assigning value based on [fill in the blank], which

Many axes of inequity “Race” Gender Ethnicity Labor roles and social class markers Nationality, language, and legal status Sexual orientation Disability status Geography Religion

These are risk markers, not risk factors

Achieving health equity “Health equity” is assurance of the

conditions for optimal health for all people

Achieving health equity requires Valuing all individuals and populations equally Recognizing and rectifying historical and contemporary

injustices Providing resources according to need

Health disparities will be eliminated when health equity is achieved

Source: Jones CP 2010, adapted from the National Partnership for Action to End Health Disparities.

ICERD: International Convention on the Elimination of all forms of Racial

Discrimination International anti-racism treaty adopted by

the UN General Assembly in 1965http://www2.ohchr.org/english/law/cerd.htm

Canada signed in 1966 Canada ratified in 1970

19th and 20th periodic report submitted by Canada to the UN Committee on the Elimination of Racial Discrimination (CERD) in 2011http://www2.ohchr.org/english/bodies/cerd/cerds80.htm

CERD Concluding Observations Canada on agenda for the 80th session of

CERD Scheduled for discussion 22 and 23 February 2012

9-page document (25 May 2007) available online http://www2.ohchr.org/english/bodies/cerd/cerds70.htm

Concerns and recommendations include: Paucity of disaggregated data (para 11) Use of term “visible minorities” (para 13) Racial profiling for national security (para 14) Disproportionate use of force and incarceration (para 19) Violence against Aboriginal women (para 20) Dramatic inequality in living standards (para 21)

Health services

Our goal: To expand the conversation

Health services

Social determinantsof health

Health services

Social determinantsof health

Social determinantsof equity

Source: Jones CP et al. J Health Care Poor Underserved 2009.

Our tasks Put racism on the agenda

Name racism as a force determining the other social determinants of health

Routinely monitor for differential exposures and opportunities as well as outcomes by “race”

Our tasks Ask , “How is racism operating here?”

Identify mechanisms in structures, policies, practices, norms, and values

Attend to both what exists and what is lacking

Our tasks Organize and strategize to act

Join in grassroots organizing around the conditions of people’s lives

Identify the structural factors creating and perpetuating those conditions

Link with similar efforts across the country and around the world

For more information please contact Centers for Disease Control and Prevention1600 Clifton Road NE, Atlanta, GA 30333Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: cdcinfo@cdc.gov Web: www.cdc.govThe findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Camara Phyllis Jones, MD, MPH, PhD

1600 Clifton Road NEMailstop E-33Atlanta, Georgia 30333

(404) 498-1128 phone(404) 498-1111 faxcdj9@cdc.gov

Resources Colour Coded Health Care: The Impact of

Race and Racism on Canadians’ HealthSheryl NestelThe Wellesley Institutehttp://www.wellesleyinstitute.com/wp-content/uploads/2012/02/Colour-Coded-Health-Care-Sheryl-Nestel.pdf

Resources Report of the Secretary’s Task Force on

Black and Minority HealthMargaret M. Heckler, SecretaryU.S. Department of Health and Human Serviceshttp://collections.nlm.nih.gov/ext/heckler/8602912V1/PDF/8602912V1.pdf

Resources Unequal Treatment: Confronting Racial and

Ethnic Disparities in Health CareBrian D. Smedley, Adrienne Y. Stith, Alan R. Nelson, EditorsCommittee on Understanding and Eliminating Racial and Ethnic Disparities in Health CareInstitute of Medicine of the National Academieshttp://www.nap.edu/openbook.php?isbn=030908265X

Resources Race: The Power of an Illusion

California Newsreelhttp://www.pbs.org/racehttp://newsreel.org/video/RACE-THE-POWER-OF-AN-ILLUSION

Unnatural Causes: Is Inequality Making Us Sick?California Newsreelhttp://www.unnaturalcauses.org

Resources 3rd World Conference Against Racism, Racial

Discrimination, Xenophobia and Related IntoleranceConvened by the United Nations in Durban, South Africa in 2001http://www.un.org/WCAR/

RACE – Are We So Different? American Anthropological Associationhttp://www.understandingrace.org/home.html

Resources World Conference on Social Determinants of

HealthConvened by the World Health Organization in Rio de Janeiro, Brasil in 2011http://www.who.int/sdhconference/en/

Closing the gap in a generation: Health equity through action on the social determinants of healthWHO Commission on Social Determinants of Healthhttp://www.who.int/social_determinants/thecommission/finalreport/en/index.html

Resources International Convention on the Elimination

of all forms of Racial Discrimination (ICERD)Adopted by the United Nations General Assembly in 1965http://www2.ohchr.org/english/law/cerd.htm

Committee to Eliminate Racial Discrimination (CERD)Office of the United Nations High Commissioner for Human Rightshttp://www2.ohchr.org/english/bodies/cerd/

Resources The Gardener’s Tale podcast

CityMatCH Health Equity and Social Justice Action Grouphttp://www.citymatch.org/UR_tale.php

For more information please contact Centers for Disease Control and Prevention1600 Clifton Road NE, Atlanta, GA 30333Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: cdcinfo@cdc.gov Web: www.cdc.govThe findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Camara Phyllis Jones, MD, MPH, PhD

1600 Clifton Road NEMailstop E-33Atlanta, Georgia 30333

(404) 498-1128 phone(404) 498-1111 faxcdj9@cdc.gov

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