how inequality kills - royal college of physicians and ... · income inequality income inequality...

David Ansell, MD, MPH Michael E. Kelley Professor of Internal Medicine

SVP and Associate Provost for Community Health Equity

Rush University Medical Center

How Inequality Kills: Social Medicine as a Core Med Ed Competency

I have no disclosures

A Talk in 3 Parts • Part 1: Why Social Medicine?

• Part 2: How Inequality Kills: Structural Violence

• Part 3: Social Medicine as a Core Competency for Med Education

Part 1: Why Social Medicine?

If Health is a Human Right

Then what are the implications for Medical Education?

One street, two worlds

“Doctors within Borders”

Part 2: How Inequality Kills: Equity and Structural Violence

Healthy Chicago 2.0 Map of Communities with Hardship

Z

Source: Healthy Chicago 2.0 Plan, http://www.cityofchicago.org/content/dam/city/depts/cdph/CDPH/HC2.0Plan_3252016.pdf

Chance of a 16 year Black teen on the South Side of Chicago living to 65?

50%

Chicago Black Women 62% More Likely To Die Of Breast Cancer

Age-Adjusted Female Breast Cancer Mortality for

Chicago, Per 100,000 Population.

Prepared by The Sinai Urban Health Institute

De

ath

s p

er

10

0,0

00

wo

me

n

1981-

1983

1984-

1986

1987-

1989

1990-

1992

1993-

1995

1996-

1998

1999-

2001

2002-

2004

50

40

30

20

10

0

38

24

35

39

Black

White

38 per 100,000 is

62% more deaths than 24 per 100,000

2005-

2007

Geography Of the Death Gap Chicago Community Areas with the

Highest Annual Breast Cancer Mortality Rates

2000 - 2005

Predominately African American Communities

Non- African American Communities

Hospitals with American College of Surgeons

Approved Cancer Programs

6 Ways Structural Racism Kills • Concentration of Black Disadvantage (White

Advantage)- location effect

• Structural racism: police, incarceration, schools, housing, jobs, food

• Embodiment of Racism (Embodiment of Privilege)

• Bias (Implicit and Explicit)

• Inequality in quality of health care delivery

• Inequity in health outcomes

Equity and Equality: The social, structural and political determinants of health

Worldwide life expectancy growing

20 year life expectancy gap between rich and poor

Average life expectancies hide large societal death gaps

©2003 RUSH University Medical Center

Global Income Inequality

©2003 RUSH University Medical Center

National Income Inequality Gaps

Income Inequality

Income inequality in OECD countries is at its highest level for the past half century. The average income of the richest 10% of the population is about nine times that of the poorest 10% across the OECD, up from seven times 25 years ago.

60

65

70

75

80

1950 1960 1970 1980 1990 2000 2005

Canada USA

How Does Health Care Influence Life Expectancy?

Lifespan Growing Faster for Canadians than Americans

48

55

51

57

53

59

54

59

55

60

20

30

40

50

60

1991 2006

Poorest Q2 Q3 Q4 Richest

Remaining life

expectancy at age 25

Mortality Gap by Income is Shrinking in Canada

Growing Gap in Life Expectancy by Income

National Academy of Sciences, 2015

The gap is growing in the US Dramatic gains for the wealthy; losses for lower income

Remaining life

expectancy at

age 50

32.3

28.3

31.4 29.7

32.4 32.4 33.4 33.1

36.2

41.9

20

25

30

35

40

45

Turned 50 in 1980 Turned 50 in 2010

Poorest Q2 Q3 Q4 Richest

It is not just about spending

Public includes benefit costs for govt. employees & tax subsidies

for private insurance

Data are for 2014 or most recent year

Sources: OECD 2015; NCHS; Health Affairs 2002 21(4)88

$3,240 $3,710

$4,120 $4,430

$4,720 $5,000 $5,220

$6,470 $6,292

$3,398

$-

$2,000

$4,000

$6,000

$8,000

$10,000

UK JAP FRA CAN GER SWE HOL SWI USA

Total US Public US Private

20

13

he

alt

hca

re s

pe

nd

ing p

er

ca

pit

a

$9,160

29

23 33

41

18

60

42

56

37

47

17

45 40 37

22

54 53 61

39 46 46

15

0

20

40

60

80

100

AUS CAN FR GERNETH NZ NOR SWE SWIZ UK US

2009 2012

Percent

Physician Views of their Health Systems “System Works Well, Only Minor Changes Needed”

Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

Part 3. Social Medicine as a Core Competency

“I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as

well as the infirm.” Hippocratic Oath

“The physicians are the natural

attorneys of the poor, and social

problems fall to a large extent within their jurisdiction.”

Narrative + Data+ Public Action= Change

White Coats for Black Lives

7 Social Medicine Competencies

• Respect for History/ Cultural Humility/Privilege

• Narrative as a tool for “seeing the invisible”

• Improvement skills for mitigating health inequities

• Skills to conduct a structural inequity analysis- social, structural and political determinants of health-”how does structural racism work here?”

• Structured mentored clinical experiences with marginalized populations with reflection

• Advocacy and activism training- “teach speech”

• Tools to manage “empathetic distress”

Differential Incentives leads to Inequality

Health care is a human right