NACCHO-CityMatCHE-MCH Conference Call

January 20, 2005

Social Justice: a matter of (local) Public Health

Magda Peck ScDCEO/Senior Advisor, CityMMatCHCH Professor and Associate Chair for Community Health, Department of Pediatrics

University of Nebraska Medical CenterFounding Director, MPH Program mpeck@unmc.edu 402.561.7500

With thanks to

CityMatCH, NACCHO Families University of Nebraska Medical Center Dennis Raphael @ SDOH Richard Hofrichter (@ NACCHO), plus Nancy

Krieger, Vicente Navarro, John Lynch, Amaryta Sen, and many many others…

“Invisible Heroes”

“Expert” Presenter – MCH and Social Justice: Context and Caveats

Inherently Personal: obligation, choice Historically Professional: public health

values Relatively Intellectual: science vs.

conscience Recently Intensified: intersections,

introspection

"Cowardice asks the question, is it safe? Expediency asks the question, is it politic?

Vanity asks the question, is it popular? But conscience asks the question, is it right?right?

And there comes a time when one must take a position that is neither safe, nor politic,

nor popular, but he must take it because his conscience tells him

that it is right...."

-Martin Luther King, Jr.

“Social Justice” 20 Minute Kickstart

1. Language: definitions, terms

2. Logistics: structures, barriers, pathways

3. Leverage: power/control, (resources/wealth), politics

4. Lessons Learned: invisible heroes

The Language of Optimal “Ends”

Rights: entitlement Equity: fairness Equality: sameness Justice: righted wrongs

Rudolf Virchow (1821-1901)

19th century German pathologist: V. law (Omnis cellula e cella), cell, node, and triad; statesman, public health pioneer

If medicine is to fulfill her great task, then she must enter political and social life

…Constitutional right of the individual citizen to lead a healthful existence

Where after all do universal human rights begin? In small places close to home.

These are the places where every man, woman and child seeks equal justice, equal opportunity, equal dignity.

Eleanor Roosevelt, 1958

A Just Society…

Ensures the development and capabilities of all of its members.

Amaryta Sen

The Language of Disrupted “Means” (to optimal ends)

Discrimination -Isms: race, class, gender… Disparities Ideology

Health and Discrimination

The rationale for studying health consequences of discrimination is to enable a full accounting of what drives population patterns of health, disease and well-being, so as to produce knowledge useful for guiding policies and actions to reduce social inequalities in health and promote well-being.Nancy Krieger, “Discrimination and Health” in Social Epidemiology,

Berkman and Kawachi, 2000.

Race-ism and Public Health

It is impossible to have a frank discussion of inequality…without confronting the continuing blight of racism head on…

long established and growing health disparities are rooted in fundamental social structure inequalities, which are inextricably bound up with the racism that continues to pervade U.S. society.

Cohen and Northridge, AJPH, June 2000, p841

Deeply engrained structural and systemic factors and policies with differential effects on individuals’ health

access to care quality of care scope and relevance of care -

“inaction in the face of need”

Camara Jones, 2000

Institutional Racism, revisited

Health Disparities – United States

Measuring Health

Two overarching goals: Increase quality and

years of healthy life Eliminate health

disparities

Health Disparities – United StatesSelected Mortality Rates by Race - 2000

0

5

10

15

20

25

IMR NNMR PNNMR MMR

White

AA/B

Source: CDC, H Atrash, NCBDDD, 2004

Health Disparities – United StatesMaternal Mortality Rates, US 1920-2000

1

10

100

1000

10000

1920 1930 1940 1950 1960 1970 1980 1990 2000

Year

Lo

g-M

ater

nal

Dea

ths

per

100

,000

Liv

e B

irth

s

White

Other

AA/B

GAP

1.8

3.4

Source: CDC, H Atrash, NCBDDD, 2004

Health Disparities – United StatesInfant Mortality Rates, US 1920-2000

1

10

100

1000

1920 1930 1940 1950 1960 1970 1980 1990 2000

Year

Lo

g-I

nfa

nt

Dea

ths

per

1,0

00 L

ive

Bir

ths White

Other

AA/B

GAP

1.7 2.5

Source: CDC, H Atrash, NCBDDD, 2004

Health Disparities – United StatesNeonatal Mortality Rates, US 1920-2000

1

10

100

1920 1930 1940 1950 1960 1970 1980 1990 2000

Year

Log

Neo

nata

l Dea

ths

per

1,00

0 Li

ve B

irth

s

White

Other

AA/B

Gap

1.42.5

Source: CDC, H Atrash, NCBDDD, 2004

Health Disparities – United StatesPostneonatal Mortality Rates, US 1920-2000

1

10

100

1920 1930 1940 1950 1960 1970 1980 1990 2000

Year

Log

Pos

tneo

nata

l Dea

ths

per

1,00

0 Li

ve B

irth

s White

Other

AA/B

Gap

1.8

2.5

Source: CDC, H Atrash, NCBDDD, 2004

Health Disparities – United StatesLow Birthweight, United States 1981-2002

02468

10121416

Year

Per

cent

Low

Bir

thw

eigh

t

White

AA/B

Hispanic

Source: CDC, H Atrash, NCBDDD, 2004

Health Disparities – United StatesPreterm Delivery, United States 1981-2002

0

5

10

15

20

Year

Per

cent

Pre

term

Bir

ths

White

AA/B

Hispanic

Source: CDC, H Atrash, NCBDDD, 2004

Increasing Diversity – United StatesProjected Population by Race/Ethnicity 2000-2050

0%10%20%30%40%50%60%70%80%90%

100%

2000 2010 2020 2030 2040 2050

Year

All OtherAsianHispanicAA/BWhite

Source: CDC, H Atrash, NCBDDD, 2004

“Tonight, we’re going to let the statistics speak for themselves.”

Ideologic tensions around persistent health inequities

CAUSES individual failure, inevitable consequences of modern

society, random adverse events

OR a complex web of power, politics, and ideology that

shapes social structures and systems

SOLUTIONS

Reformation vs transformation Remedies vs root causes

“Social Justice” 20 Minute Kickstart

1. Language: definitions, terms

2. Logistics: structures, barriers, pathways

Committee on Assuring the Health of the Public in the

21st Century

INSTITUTE OF MEDICINE

OF THE NATIONAL ACADEMIES

THE FUTURE OF

THE PUBLIC’S HEALTH

in the 21st Century

Healthy people in healthy

communities

Health = public good Health = social goal of many sectors

and communities

NOTES: Adapted from Dahlgren and Whitehead, 1991. The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman, 1999).

Over the life span

Living and working conditions may include:

• Psychosocial factors• Employment status and occupational factors • Socioeconomic status (income, education, occupation)• The natural and builtc environments• Public health services• Health care services

Ecological Model for Population Health

Source: Institute of Medicine Report: The Future of the Public’s Health in the 21st Century, November 2002

Racism: Complex interactions between direct, physiologic effects and indirect

pathways

Health Care Disparities: IOM Report 2002

The Institute of Medicine’s Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care concluded that:

A range of patient-level, provider-level, and system-level factors may be involved in racial and ethnic healthcare disparities, beyond access-related factors

Health Disparities in Healthcare: Patient-Level factors

Yes, minority patients are more likely to: Refuse recommended services Adhere poorly to treatment

regimens Delay seeking care

But, these factors are unlikely to be major sources of healthcare disparities

Health Disparities in HealthcareProvider-Level factors

Degree of uncertainty: Information from patients

vs. prior experiences Bias against minorities Beliefs and stereotypes

Health Disparities in HealthcareSystem-Level factors

System organization affects patient care:

Limited access Limited resources Discriminatory management Language barriers Time pressure on physicians Geographic availability

Health Disparities: IOM Recommendations

Multiple approaches are required Most factors are outside the influence

of the health care system: Socioeconomic status Cultural factors Environmental factors Discrimination issues Political systems

“Social Justice” 20 Minute Kickstart

1. Language: definitions, terms

2. Logistics: structures, barriers, pathways

3. Leverage: power, politics

The Public Health SystemThe Public Health System

Assuring the Assuring the Conditions for Conditions for

PopulationPopulationHealthHealth

Employersand

Business

Academia

GovernmentalGovernmentalPublic Health Public Health InfrastructureInfrastructure

The Media

Healthcare

delivery system

Community

What will it really take?

KNOWLEDGE BASE

POLITICAL WILL

SOCIAL STRATEGY

From: Richmond and Kotelchuck

We want the same things.

“Social Justice” 20 Minute Kickstart

1. Language: definitions, terms

2. Logistics: structures, barriers, pathways

3. Leverage: power, politics

4. Lessons Learned: invisible heroes

Dr. William FoegeEmory University/Gates Foundation

Unwarranted optimism: hallmark in (public) health professionals;

Placebo effect in population health? Allows us to go beyond expectations, beyond the boundaries of existing science….

“There is no use trying,” said Alice; “one can’t believe in impossible things.”

“I dare say you haven’t had much practice,” said the Queen.

‘When I was your age, I always did it for a half an hour a day. Why, sometimes I’ve believed as

many as six impossible things before breakfast.”

-Lewis Carroll

When will our consciences When will our consciences grow so tender that we will act grow so tender that we will act to prevent human misery to prevent human misery

rather than avenge it?rather than avenge it? Eleanor Roosevelt

Public Health: a matter of Justice

Social Justice: a matter of

the public’s health

mpeck@unmc.edu

or go to the CityMatCH website: http://www.citymatch.org

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