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COMMUNITY ISSUES FORUMPORTLAND OREGON
OCTOBER 8, 2009
ADEWALE TROUTMAN, M.D., M.P.H., M.A.THE TROUTMAN GROUP
Creating Health Equity; Social Justice, Human Rights and the Social Determinants of Health
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The Troutman Group
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A Case Study; But Why
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The Troutman Group
Vital Statistics:
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Reframing
The Troutman Group
Health vs. HealthcareIndividual vs. Population HealthMarket Justice vs. Social JusticeRights vs. Privileges Biological/Behavioral Determinants vs Social
DeterminantsCreating Health Equity vs. eliminating Health
Disparities
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TRADITIONAL SOCIAL JUSTICE
How can we address risky behavior and target
vulnerable populations?
How can we target the health depriving conditions and
policies that make people vulnerable?
Why do people smoke? What economic policies and social conditions predispose
people to the stress that encourages smoking?
How can we create more green space, bike
paths, and farmers’ markets in disadvantaged
neighborhoods?
What policies and institutional practices by government and
corporations discourage access to transportation,
recreational resources, and access to nutritious foods in
neighborhoods where population is poorest?
How can we promote greater personal
responsibility for health?
How can we create social responsibility and public
accountability to protect the public good?
How do we treat the consequences of health
inequity?
How does the prioritization of profit over human need and
ecological sustainability affect health inequity?
Overarching social justice questions: Why do those who make decisions that negatively affect
health make those decisions? Why do they have that
power?
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Let’s get on the same page.
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The Troutman Group
Health
“The presence of physical, psychological, social, economic and spiritual well being not merely the absence of disease or infirmity”
“The maintenance of a harmonious balance of mind, body and spirit” Community and individual
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Health Equity
“Health equity is the realization by ALL people of the highest attainable level of health. Achieving health equity requires valuing all individuals and populations equally, and entails focused and ongoing societal efforts to address avoidable inequalities by assuring the conditions for optimal health for all groups, particularly for those who have experienced historical or contemporary injustices or socioeconomic disadvantage.”
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The Troutman Group
Health Equity
“The absence of unfair and avoidable or remediable differences in health among social groups” ( The Commission )
A value position supported by an evidence base
There is and will be political opposition to the core value of health equity
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Health Inequities
The Troutman Group
Systemic, avoidable, unfair and unjust differences in health status and mortality rates and in the distribution of disease and illness across population groups. They are sustained over time and generations and beyond the control of individuals
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The development of society can be judged by:
• the quality of its populations’ health
• the fairness in distribution of health, and
• the degree of protection provided from disadvantage due to ill-health
Marmot 2006 Harveian Oration
Health equity as a development outcome
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The Troutman Group
Justice
The quality of fairnessThe principle of moral rightness; equityConformity to moral rightness in action or
attitude
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The Troutman Group
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
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Rights
The Troutman Group
Claims or entitlements that are recognized by legal or moral principles
Enforced by legislation and rules, the force of law
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Human Rights
The Troutman Group
A higher order right MORALLY based and UNIVERSAL. It belongs to all persons equally because they are human beings(Declaration of Independence)
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The Troutman Group
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
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Market Justice vs. Social Justice
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Market Justice
The Troutman Group
Emphasizes personal responsibility as the basis for distributing burdens and benefits
Individuals assume prime responsibility for their own health
Little expectation that society should act to protect or promote the health of its members
Social Darwinism
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Social Justice
The Troutman Group
Significant factors within society impede fair distribution of benefits and burdens
Social class distinctions, heredity, racism, ethnism play significant roles
Collective action necessary to neutralize or overcome forces
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www.who.int/social_determinants
Social justice is a matter of life and death. It affects the way people live, their consequent chance of illness, and their risk of premature death…
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The Case for Action
The Troutman Group
The moral, ethical, this is the right thing to do because it is case
The pragmatic, this is costing the system countless dollars and self interest in the financial crisis around health inequities make it a must do.
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The Economic Burden of Health Inequities in the United States
THomas LaViest et al John Hopkins,University of Maryland
Direct medical costs of health inequalities
Indirect cost of health inequalities
Cost of premature death
( The pragmatic case )
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Economic Burden Findings
THomas LaViest et al John Hopkins,University of Maryland
Between 2003 and 2006 combined cost of health inequalities and premature death was $1.24 trillion
Eliminating health disparities for minorities would have reduced direct medical care expenditures by $229.4 billion
Between 2003 and 2006, 30.6% of direct medical care expenditures for African Americans, Asians and Latinos were excess costs due to health inequalities
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Findings ( Cont )
THomas LaViest et al John Hopkins,University of Maryland
Eliminating health inequalities for minorities would have reduces indirect costs associated with illness and premature death by more than one trillion dollars between 2003 and 2006
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A New Direction
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Looking upstream, finding the causes of he causes.
The Troutman Group
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Socioeconomic StatusSocioeconomic Status WHOWHO
The Troutman Group
OccupationEducationIncome
Income gaps
Racism & discrimination
HousingPolitical power
• Early Life• Social Exclusion• Work• Unemployment• Social Support• Addiction• Food• Transport• The Social Gradient• Stress
Social Determinants
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Stress
The Troutman Group
Continuing existence of anxiety, insecurity, low self esteem and social isolation
Lack of control over home and work lifeProfound effect on healthCumulative
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The Power of Poverty
The Troutman Group
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Income Inequities
The Troutman Group
1995 study Kennedy, Kawachi and Prothrow-Stith
282 cities in the U.S.Death from income inequities “ is comparable
to the combined loss of life from lung cancer, diabetes, motor vehicle crashes, HIV infection and homicide”
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The Troutman Group
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The Troutman Group
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The Elephant in the Room: Racism
The Troutman Group
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What is racism?
The Troutman Group
A system
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What is racism?
The Troutman Group
A system of structuring opportunity and assigning value
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What is racism?
The Troutman Group
A system of structuring opportunity and assigning value based on the social interpretation of how one looks (“race”)
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What is racism?
The Troutman Group
A system of structuring opportunity and assigning value based on the social interpretation of how one looks (“race”) Unfairly disadvantages some individuals and
communities
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What is racism?
The Troutman Group
A system of structuring opportunity and assigning value based on the social interpretation of how one looks (“race”) Unfairly disadvantages some individuals and
communities Unfairly advantages other individuals and
communities
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What is racism?
The Troutman Group
A system of structuring opportunity and assigning value based on the social interpretation of how one looks (“race”) Unfairly disadvantages some 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, Phylon 2003
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Levels of Racism
The Troutman Group
Individually Mediated People make assumptions about one abilities based on
their race and act differently towards them ( discrimination)
Institutionalized Differential access to goods and services, access to
power, economic and social mobility based on race. May be supported by law or institutional structure and practice.
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Levels of Racism
The Troutman Group
Internalized Acceptance by members of the racial or ethnic group
of the negative beliefs of their own abilities and value. May lead to depression, hopelessness, helplessness and
living as victim
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“Patients” experiencing symptoms of heart disease, from Schulman et al. (1999)
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“Patients” experiencing symptoms of heart disease, from Schulman et al. (1999)
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Place Matters
The Troutman Group
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Tell me how a man died and I’ll tell you where he lived
Aristotle
The Troutman Group
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The role of residential segregation;“The metropolitan areas with the
highest segregation levels have the most unequal geographies of
opportunity”Delores Acevedo-Garcia et al
The Troutman Group
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Opportunity Neighborhoods
The Troutman Group
Sustainable employmentHigh performing schoolsAccess to high quality healthcareAdequate transportationHigh quality childcareNeighborhood safetyInstitutions that facilitate civic engagement
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Housing
The Troutman Group
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Built Environment Issues
The Troutman Group
Hope sixWhere did all the poor people go?The segregation of povertyGrids, green space and gentrificationRural infrastructure
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Cotter Lane
The Troutman Group
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Park DuValle
The Troutman Group
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Park DuValle
The Troutman Group
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Education
The Troutman Group
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In El Salvador, if mothers had no education their babies have 100
chances in 1000 of dying in their first year of life; if mothers have at least
secondary education the infant death rate is a quarter of that (World Bank
2006)
The Troutman Group
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How Does Education Influence Health
Education can improve health by increasing health knowledge
Leads to greater employment opportunitiesLinked with social and psychological factors
that affect health
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Takin’ it to a Higher Level
Power
Policy
Place
Advocacy
The Troutman Group
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www.who.int/social_determinants
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CSDH three overarching recommendations:
1. Improve daily living conditions
2. Tackle the unequal distribution of power, money and resources
3. Measure and understand the problem and assess the impact of action
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The Center for Health Equity
The Troutman Group
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The Troutman Group
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The Importance of Leadership and Political Will
The Troutman Group
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The Troutman Group
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The CHE is dedicated to a civic process that builds social engagement, autonomy and
movement to strengthen communities and influence public policy in an effort to
Create Health Equity
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The Center focuses its work to eliminate health inequities due to race, ethnicity
and socioeconomic status
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Current Work
Framing researchHealth Equity Community Hearings Civic capacity building mini grantsHealth Equity Speaker SeriesWeb based learningRetraining workforce ( Dialogue process )
Outreach workers as community organizers
Undoing Racism workshops ( community wide)Health Equity Summit
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Current Work ( Cont )
Photo voiceCommunity dialoguesOperationalizing Health Equity within the
departmentCHI projectHIA-Shepard Square ( Hope 6 )The cabinet dialogueFood justice
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Food Justice
The Troutman Group
Individual choice vs structure and systemsFood access, transportation and qualityDecreased access to healthy foods, increased
access to unhealthy foods ( Food Security Task Force )
Economic development and community health
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Strategy 3: Expand access to and distribution of healthy food.
The Troutman Group
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Increased Neighborhood Access
The Troutman Group
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From the Dinner Table to the Policy Table
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Health Policy Is Health Policy Is Social PolicySocial Policy
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Policies For Social Justice, Policies For Health Equity
Short term and long term solutionsShort term
Attention to symptoms( nutrition, physical activity, cholesterol, access)
Creating environment to promote healthLong term
Empowerment Redistributive policies Poverty Elimination
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Policies ( Cont )
Environmental changeHousing reformJob creation tied to insuranceNational Health Program to Insure Universal
Access and Universal CoverageLand UseHealth Impact Assessment
The Troutman Group
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Policies ( Cont )
Zoning policies ( Concentration of business types)
Nutrition School meals Trans fat Restaurant labeling
Physical education in schoolsBuilt environment with attention to
gentrification Smoking
The Troutman Group
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Policies…
Measuring progress through “Social Health Indexing”
Living wageEducational reform
Class size Teacher experience Funding mechanisms
Attention to short term only ,will just create a healthier underclass and will not create health equity because there is no social justice
The Troutman Group
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The Troutman Group
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The Troutman Group
A fragmented non system of sick care where inequity is common, prevention and wellness are after thoughts and outcomes correlate to societal status
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Universal access to a single standard of high quality care
National Health Insurance
Single Payer
The Troutman Group
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Health in All Policies addresses the effects on health across all policies such as agriculture, education, the environment, fiscal policies, housing, and transport. It seeks to improve health and at the same time contribute to the well-being and the wealth of the nations through structures, mechanisms and actions planned and managed mainly by sectors other than health. Thus HiAP is not confined to the health sector and to the public health community, but is a complementary strategy with a high potential towards improving a population’s health, with health determinants as the bridge between policies and health outcomes.
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Phillis Wheatley Students present
Photo-voice Exhibits on
Health Policy Issues
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Photo Voice
Youth empowerment through engagementCommunity health and barriersYouth as creators, producers, interpretersRaise awareness about the policy processPresentation to policy makers ( Mayor Metro
Council, Board of Health, Business Community
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If my community were healthy it would look like, no people littering, people riding bikes, no people dealing drugs, kids playing at the park, no gunshots, parents and kids walking their dogs, no people smoking, parents taking their baby’s in a stroller to the park to walk them around the park. Denzel: age 10
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My neighborhood has many train
tracks and a really big
factory that does
something, I don’t know
what. There is a church, a community center but there is no
store close to where I live.
D’coreyan: age 10
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Every day I go to the community center on the side of it, they are selling drugs or showing off their guns and sometimes I am scared to walk pass because I
think they will shoot me. Michael: age 10
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From Theory to Practice
Cross discipline collaboration based on social determinants
Public awareness of determinants of health and health equity
Civic capacity buildingCommunity assessmentPolicy process and community engagementCurriculum changeStaff reorientationThink holistically ( Housing and HIA’s etc.)
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Taking a Personal Inventory
Commitment to honestyCommitment to honestyExploration of beliefs, practices. Internal Exploration of beliefs, practices. Internal
messagingmessaging
The person and The person and the organizationthe organization in the mirrorin the mirror
Are you happy with what you see?Are you happy with what you see?Where do I get to make changesWhere do I get to make changes
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Building a Social Movement
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The Troutman Group
Social Movements • A type of group action• Large informal groupings of individuals
and/or organizations focused on specific political or social issue
• Based on coalitions and alliances• It’s about social change• The United Farm Workers movement• The Anti-Apartheid Movement • The Civil Rights movement• Women’s liberation movement
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The Troutman Group
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Are You Willing to Take the Risk?
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Adewale Troutman, M.D.,M.P.H.The Troutman Group
5109 Forrest Grove PlaceLouisville, KY [email protected]
502 544 8570www.thetroutmangroup.org
The Troutman Group
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