Aiming for EQUITY in Ohio…a dream deferred

Arthur R. James MD, FACOGAssociate Professor, Dept. of Ob/Gyn

The Ohio State University Wexner Medical CenterNationwide Children’s Hospital

Starting at Home Conference

Goal:

Make the case for why Ohio needs to ELIMINATE the Racial Disparity in Infant

Mortality.

Everyone says “yes”….

But, our actions may not support this response?

Infant MortalityDefinition: The death of any live born baby prior to his/her first birthday.

“The most sensitive index we possess of social welfare . . . ”Julia Lathrop, Children’s Bureau, 1913

Slide prepared by R. Fournier RN, BSNState of Michigan FIMR Director

Dr. Cheryl Lauber

“Infant mortality is a community mirror, reflecting our collective capacity to promote and protect the health and well-being of our very youngest and most vulnerable.”(from City Lights, 9:2, p1)

Infant Mortality:

Infant Mortality is:Multi-factorial. Rates reflect a society’s commitment to the provision of:

1. High quality health care2. *Adequate food and good nutrition3. *Safe and stable housing4. *A healthy psychological and physical environment5. *Sufficient income to prevent impoverishment

“As such, our ability to prevent infant deaths and to address long-standing disparities in infant mortality rates between population groups is a barometer of our society’s commitmentto the health and well-being of all women, children and families.”

SACIM, 1/2013* = non-clinical measure

0

2

4

6

8

10

12

14

OHIO Total IMR: 1980-201512.8

7.2

44% IMPROVEMENT!

SOURCE: ODH

0

5

10

15

20

25

White Black

Ohio White & Black IMR: 1980-2015

Source: ODH

0

5

10

15

20

25

White Black Source: ODH

Non-White Black

0

5

10

15

20

25

White Black

Ohio White & Black IMR: 1980-2015

Source: ODH

“our ability to prevent infant deaths and to address long-standing disparities in infant mortality rates between population groups is a barometer of our society’s commitment to the health and well-being of all women, children and families.”SACIM: January, 2013

0

5

10

15

20

25

White Black

Ohio White & Black IMR: 1980-2015

Source: ODH

1.95

2.75

31% Improvement

51% Improvement

0

5

10

15

20

25

White Black

Ohio White & Black IMR: 1980-2015

Source: ODH

1.95

2.75

“Time Lag” from Survival Gap:

0

5

10

15

20

25

White Black

Ohio White & Black IMR: 1980-2015…Survival Time LAG

Source: ODH

15.05

0

5

10

15

20

25

White Black

Ohio White & Black IMR: 1980-2015…Survival Time LAG

We have to go as far back as 1975 to find a White IMR comparable to our 2015 Black IMR. This suggest a 40-year survival time lag, meaning that unless we change this pattern, Black babies in Ohio have to wait until the year 2055 to experience the same opportunity tosurvive the first year of life as White babies did in 2015. We think this is unfair, unjust and we know that we can do better.

Source: ODH

15.05

11.2

0

5

10

15

20

25

White Black

Ohio White & Black IMR: 1980-2015

We have to go as far back as 1975 to find a White IMR comparable to our 2015 Black IMR. This suggest a 40-year survival time lag, meaning that unless we change this pattern, Black babies in Ohio have to wait until the year 2055 to experience the same opportunity tosurvive the first year of life as White babies did in 2015. We think this is unfair, unjust and we know that we can do better.

Source: ODH

15.05

11.2

X

The BIMR in MA from2011-2013 = 6.9

“Healthy People” History• 1990-Healthy People • 2000-Healthy People • 2010-Healthy People • 2020-Healthy People

0

5

10

15

20

25

White Black

Ohio White & Black IMR: 1980-2015

Source: ODH

ab

8.2

a = HP-1990 Overall IMR Goal of 9b = HP-1990 Black IMR Goal of 12Ohio achieved/exceeded the HP-Overall IMR Goal of “9” for White babies in 1987, 3-yearsin advance of the goal date

Healthy People 1990

0

5

10

15

20

25

White Black

Ohio White & Black IMR: 1980-2015

Source: ODH

c

d

6.37c = HP-2000 Overall IMR Goal of 7d = HP-2000 Black IMR Goal of 11Ohio achieved/exceeded the HP-Overall IMR Goal of “7” for White babies in 1996, 4-yearsin advance of the goal date

Healthy People 2000

0

5

10

15

20

25

White Black

Ohio White & Black IMR: 1980-2015

Source: ODH

e = HP-2010 Goal IMR Goal of 4.5Ohio, like most States, did not achieve the HP-2010 Goal

Healthy People 2010

e

www.cdc.gov/nchs/healthy_people/hp2020.html

0

5

10

15

20

25

White Black

Ohio White & Black IMR: 1980-2015

Source: ODH

f = HP-2020 IMR Goal of 6Ohio achieved this goal for White babies in 2013, 7-years in advance of the goal date.

So, Ohio has achieved HP IMR goals for White babies in advance of the goal dates for 3 of the 4 Healthy People periods.

Healthy People 2020

f

0

5

10

15

20

25

White Black

Ohio White & Black IMR: 1980-2015

Source: ODH

b

Ohio has NEVER accomplished the 1990 HP BIMR Goal, or any otherHP-IMR Goals for Black babies

Patterns/Trends:

As a State, we have a well established, racially determined HP-IMR Goal pattern:

• Achieve HP-White IMR Goals well in advance of the goal dates…

• Simultaneously, we have NEVER achieved any HP-IMR Goals for Black babies.

What if there was EQUITY in Infant Mortality in OHIO?

If the Ohio White IMR and Black IMR were no different…

Why aim for EQUITY?

Ohio 2015 Infant Mortality Rates:

7.2

5.5

15.1

6

Total White Black Hispanic

Ohio 2015 White and Black IMR:

0

2

4

6

8

10

12

14

16

15.1

BlackWhite

5.5

What if Ohio’s Black and White IMRs were the same during 2015?

Of the 367 Black Infant Deaths in 2015…234 would still be alive

• That means that 2 of every 3 Black babies that died in 2015 would still be here!

234Excess Black Infant Deaths

Source: ODH data, HRSA evaluation

If Ohio’s Black IMR had been the same as Ohio’s White IMR since 1990…

5,914Black babies would not have died

Source: ODH data, HRSA evaluation

Why the disparity?

What is it about RACE that accounts for the difference in surviving the 1st year of life?

We pose a similar question regardingthe survival of black babies…would

Ohio tolerate these high rates of infant death if we knew our babies could surviveat a better rate…and the dying babies were

White?

What shall we do? Which “track” shou

Social and Economic Policies

Institutions (including medical care)

Living ConditionsSocial Relationships

Individual Risk FactorsGenetic/Constitutional

Factors

Pathophysiologicpathways

Individual/PopulationHealth

Determinants of Population Health and Health Inequalities

Kaplan, 2002

SDOH:

“While the mother is the environment of the developing fetus, the community is the environment of the mother.”- Dr. Lawrence Wallack, “Going Upstream for the Health of the Next Generation”

"When a flower doesn't bloom, you fix the environment in which it grows, not the flower" -Alexander Den Heijer

Slide used with permission from Mariela Uribe

Eliminate Excuses:

We continue to find excuses to avoid eliminating racial disparities…But, we must muster the courage to go through this door.

Infant MortalityRacial Disparities

Arthur R. James MD

Relationship:

“Inclusion”

EQUITY:

African American Citizenship Status: 1619-2017

Time Span: Status: Years: % U.S. Experience:

1619-1865 Slaves:“Chattel”

246 62%

1865-1964 Jim Crow: virtually noCitizenship

rights

99 25.0%

1964-2017* “Equal” 52 13%

1619-2017 “Struggle”“Unfairness”

398 100%

* USA struggles to transition from segregation & discrimination to integration of AA’s

l l246 yrs.

62% of time

99 yrs.

25% of time

52 yrs.

13% of time

*CRA: Civil Rights Act art james

Time-line of African American Experience:

87% of the AA experience either as Slaves or under Jim Crow

Racial Disparities: we made it this way?We often perceive racial health disparities as consequences of “nature”. As such, we convince ourselves that these differences are “fixed” or “hardwired”; a part of what is different about us as people and therefore cannot be changed.

Similarly, we also often see America as it is instead of an America as it should be…and we accept the difference between the two as “normal”.

However, these disparities are differences that we created, differences that occur as a consequence of systems that we put into place. Therefore, we know they can be changed and would suggest that their persistence is in part because of our unwillingness to “undo” what we have done.

A R James

The Real Narrative About What Creates Health Inequities

• Disparities are not just because of lack of access to health care or to poor individual choices.

• Disparities are mostly the result of policy decisions that systematically disadvantage some populations over others.

• Especially, populations of color and low income

• Structural Racism

Thank You

Contact Information:

arthur.james2@osumc.edu614.293.4929

HOME & HEALTHBridging Housing & Health for Sustainable Healthy Communities

Ohio Housing Finance Agency – Starting at Home ConferencePanel Presentation – Healthy Places, Healthy PeopleApril 29th 2015

Jason Reece – Reece.35@osu.eduDirector of Research, The Kirwan Institute for The Study of Race & EthnicityLecturer, City & Regional Planning – Knowlton School of ArchitectureThe Ohio State UniversityKirwaninstitute.osu.edu

A CONCEPTUAL MODEL OF HOUSING & HEALTH

Habitability• Exposure• Toxicity

Security & Finances

• Stress• Resources

Neighborhood & Environment

• Stress• Exposure

HABITABILITY & HEALTH RISK

Issues Mold Asbestos Lead Pests Unsafe structures

Outcomes Lead poisoning Asthma Injury

HABITABILITY & HEALTH RISKS

Households Trapped in Substandard Housing

Neglected and occupied rental property on Hilltop 2013

Image from “legacy of neglect” The Columbus Dispatch, 2013

http://www.dispatch.com/content/stories/local/2013/11/10/1-legacy-of-neglect.html

HOUSING SECURITY, STABILITY & FINANCES

Housing stressed families spent 30% less on food, 50% less on clothing, and 70% less on health care (Joint Center for Housing Studies)

Housing is a primary cost pressure contributing to food insecurity

The psychological impacts of housing instability can be profound and can be a significant cause of trauma

PLACE (NEIGHBORHOOD) & HEALTH RISK

INFANT & MATERNAL HEALTH & HOUSING

WPA Informational Posters for the NYC Housing

Authority (1930’s).

Source: Library of Congress

INFANT & MATERNAL HEALTH & HOUSING

Housing is a tremendous stressor which can contribute to poor infant and maternal health outcomes Cost burden stress Housing instability stress Homelessness Neighborhood condition impacts Direct environmental conditions

77.0%69.5%

55.5% 56.5% 58.0%

48.5%

73.0%

59.1%

49.3%

% of Renters Cost Burdened by Housing for Infant Mortality Hot Spot Areas

THE FINANCIAL ARGUMENT: HOUSING & HEALTH

Health Care Spending

The U.S. has the most expensive health care system in the world

$2.9 trillion in 2013 for health care spending in the US

Medicaid and Medicare expenditures would account for more than $1 trillion in 2013

3% of health care spending went to public health (prevention)

National health care expenses are expected to $5.2 trillion in 2023

The Role of Social Determinants in Health Care Costs & Outcomes

Social determinants of health (such as neighborhood impacts and housing) account for 60% of premature deaths

Social determinants are major contributors to chronic diseases

Approximately 75% of health care costs are treating chronic disease

HOUSING INTERVENTIONS COULD BE A CRITICAL INVESTMENT TO REDUCE HEALTH CARE COSTS & IMPROVE OUTCOMES

THE FINANCIAL ARGUMENT: HOUSING & HEALTHFederal Support for Housing & Community Development has Dwindled

The average Community Development Block Grant entitlement community disbursement has declined 44% since 2000

Housing vouchers have decreased since sequestration

The majority of federal funds for housing go to high income households

LOCALLY LED INTERVENTIONS: HEALTH STAKEHOLDERS INVESTING IN HOUSING & COMMUNITY DEVELOPMENT

Join the conversation.@CradleCincy

Infant mortality 101

• Deaths per 1,000 live births in a specific geographic location

• “Live birth” in Ohio includes any baby who is born and either:has a pulse OR takes a breath OR shows movement of voluntary muscles

• Counted until first birthday

• Counted at Mom’s home address

What is “infant mortality rate”?

Source: Ohio Revised Code, section 3705.01

Why infant mortality is so important

• Every life is significant.

• Ohio has unacceptably high rates

• It is an indicator of the overall health of the community

• It reveals inequalities in our community

• It is extremely expensive and that cost affects us all

Our Crisis

Where we are today

5.82 7.21 8.96

Deaths per 1,000 live births

Source: US is 2014 CDC data; Ohio is 2015 CDC data; County is 2012-2016 vital records data compiled by Hamilton County Public Health and confirmed with Cincinnati Health Department.

*Source: Fetal and Infant Mortality Review (FIMR)

Source: 2012-2016 vital records data compiled by Hamilton County Public Health

Barriers to Accessing Affordable Housing

Michelle Smith Wojnowski, C-CHWClinical Community Linkages Specialist

Affordable Housing in Lucas County

• There are 153 low income housing apartment complexes which contain 13,183 subsidized apartments for rent.o Many of these rental apartments are income based housing with about 4,498 apartments

that set rent based on your income.

• There are 3,581 Project-Based Section 8 subsidized apartments (“HUD Apartments”) in Lucas County.

• There are 6,167 other low income apartments that don't have rental assistance but are still considered to be affordable housing for low income families.

Affordable Housing Snapshot-Lucas County

Total Affordable Apartment Properties 153

Total Low Income Apartments 13,183

Total Rent Assisted Apartments 4,498

Percentage of Housing Units Occupied By Renters 37.01%

Average Renter Household Size 2.12

Total Population 441,815

Housing Units 180,267

Average Household Size 2.36

Median Household Income $41,751 ±$657

Median Rent $664 ±$7

Percentage Of Renters Overburdened 49.35% ± 1.66pp

*Data derived from 2010 Census and 2014 5-Year American Community Survey

Barriers to Accessing Housing

• Emergency Housing Assistance• Requirements for Affordable Housing• Availability of Safe & Affordable Housing

Emergency Housing

• HUD’s definition of “homeless”• “Hoops” to jump through to get into a shelter• Who is allowed to stay in a shelter

The most direct way to access long term housing is to go through the shelter system.

Shelter systems are difficult to get into and are not a permanent solution.

Barriers to accessing emergency housing include:

Requirements for Affordable Housing

• Birth Certificate and/or Driver’s License• Credit Check• Background Check • Application Fee and deposit

To be eligible for housing, you must provide the following :

Availability of Housing

• Limited availability of safe & affordable housing due to:oLeadoGang violenceoDrugsoInfestationso“Slum Lords”

Case Study

Contact Information:

Michelle Smith- Wojnowski, C-CHWCommunity-Clinical Linkages SpecialistHospital Council of Northwest Ohio

(419) 842-0800mwojnowski@hcno.org