Creating a Culture of Health Equity

KC Community Conversation

November 14, 2014 Rex Archer, MD MPH

Saving Lives, Protecting People from Health Threats,

Saving Money through Prevention

"The reason we have government is to solve

problems collectively that we can not solve

individually." Dr. Thomas Farley, NYC Health Commissioner (from

the HBO May, 2012 Documentary, "Weight of the Nation"

Saving Lives, Protecting People from Health Threats,

Saving Money through Prevention

“Public health is what we, as a society, do collectively through organized actions to assure the conditions in which all people

can be healthy.”

-Institute of Medicine (1988), Future of Public Health

79.1  

74.6   73.8  

65.7  

80.3  

77.1  75.2  

68.7  

60  

65  

70  

75  

80  

85  

White  female   Black  female   White  male   Black  male  

Life  expectancy  (year)  

Life  expectancy,  KCMO  1999-­‐2003  vs.  2009-­‐2013  1999-­‐2003   2009-­‐2013  

*Non-­‐Hispanic  white  male  and  female  and  non-­‐Hispanic  black  male  and  female.  

+1.2  years  +2.5  years  

+3.0  years  +1.4  years  

14.6  

12.1  

6.8  5.5  

11.2  

7.2  6.4  

4.0  

0  

2  

4  

6  

8  

10  

12  

14  

16  

Black  male     Black  female   White  male     White  female  

No.  of  infan

t  deaths  p

er  1,000  births)  

Infant  mortality  rate,  KCMO  1999-­‐2003  vs.  2009-­‐2013  1999-­‐2003   2009-­‐2013  

*Non-­‐Hispanic  white  male  and  female  and  non-­‐Hispanic  black  male  and  female.  

-­‐27.2%  

-­‐40.6%  

-­‐23.4%  

-­‐5.9%  

POPULATION APPROACH VS. INDIVIDUAL APPROACH

Life  expectancy  by  zip  code,    Kansas  City,  MO  2008-­‐2012  

Life  expectancy   Nonwhite  

Below  poverty@    

Median  family@  

(year)   %   %   income  ($)  81-­‐83  years   11.3   8.0   92,258  73-­‐79  years   35.6   21.3   53,264  70-­‐72  years   82.4   37.4   27,899  

*Too  small  popula+on  to  calculate  life  expectancy  

64153 64154 64156

64163

64155

6411964151

64134

64129

64120

64157

64161

64132

64138

64149

64131

64116

64130

64137

64117

64136

64118

64160

64164

64139

64133

64127

64165

64133

64108

64133

64128

64147

64111

64158

64109

64126

64118

64112

64124

64114

6414664145

64110

64113

64152

64079

64106

64166

6412364125

64012

64152

6410564101

64102

64167

64030

64079

64081

64079

64152

Life expectancy

80-83 years

73-79 years

70-72 years

Too small pop.*

@ 2008-2012 American Community Survey 5-Year Estimates

240  226  

66   58   53   52   51   46   41   37  

126  108  

3  28   24   29   34   28  

12   10  0  

50  

100  

150  

200  

250  

Rate  per  100,000  pop

ulaQ

on   Shortest  life  expectancy   Longest  life  expectancy  

Leading  Causes  Crude  Mortality  Rates  in  Two  Areas,    KCMO  2008-­‐2012    

6zipcodes include zip code 64109, 64126, 64127, 64128, 64130, and 64132, which are the shortest life expectancy; 11zipcodes include zip code 64112, 64113, 64116, 64118, 64151, 64152, 64153, 64154, 64156, 64157, and 64158, which are the longest life expectancy.

EsSmated  Deaths  AVributable  to  Social  Factors              U.S*          KCMO**  

•  Less  than  High  School  graduaSon  245,000  234  •  Racial  segregaSon      176,000  561  •  Low  social  support      162,000  232  •  Individual  level  poverty      133,000  236  •  Income  inequality        119,000  222  •  Community  level  poverty        39,000  349  

               _____________________________  

~47%  of  annual  KCMO  deaths  (41-­‐53%)    Total  1,834***                              

*Galea,  et.al.,  American  Journal  of  Public  Health  August  2011,  Vol  101  no.  8  **ConservaSve  esSmate  for  Kansas  City,  MO  based  on  Galea,  et.al.  ***ConservaSve  esSmates  that  assume  factors  are  not  synergisSc    

Social and Economic

Factors 40%

Health Behaviors 30%

Clinical Care 10%

Physical Environment

10%

Genes and Biology

10%

What Creates Health? What are the Determinants of Health?

Tarlov AR. Public policy frameworks for improving population health. Ann N Y Acad Sci 1999; 896: 281-93.

Through inequities H

ow d

o di

spar

ities

aris

e?

Access to care

Quality of care

Exposures

and opportunities

Achieving  Health  Equity  by  Addressing  the  Social  Determinants  of  Health    

 

•  It  is  Sme  to  stop  thinking  of  health  as  something  we  get  at  the  doctor’s  office    

 

•  Health  starts—long  before  illness-­‐-­‐  in  our  homes,  neighborhoods,  schools  and  jobs.  

 

•  All  residents  should  have  the  opportunity  to  make  the  choices  that  allow  them  to  live  a  long,  healthy  life,  regardless  of  their  income,  educaSon  or  ethnic  background.  

 

•  Your  neighborhood  or  job  shouldn’t  be  hazardous  to  your  health.  

 

•  The  more  we  see  the  problem  of  health  this  way,  the  more  opportuniSes  we  have  to  improve  it.      

 

12  

The Cost of a Long Life 13 Japan

We  need  to  restructure  our  investments  

Hospitalization

Chronic Disease Care

Public Health KC-CHIP Our goal is to

work upstream to keep Kansas Citians from falling in the river of medical care and going over the waterfall of hospitalization.

Healthy Communities Healthy Living

Medical System

We Have to Change! •  The “System” is broken • We need to address inequities/injustices • How can we do things differently?

Refocusing Upstream

Fam

ily &

C

ultu

re

Fam

ily &

C

ultu

re

Health

Inequities

Health

Disparities

Fam

ily &

C

ultu

re

Place Policy Narrative

Examples Condoms, eat healthy, be physically active

Rx for high blood pressure, high cholesterol

Poverty, education, housing, inequality

Immunizations, brief intervention, cessation treatment, colonoscopy

Fluoridation, 0g trans fat, iodization, smoke-free laws, tobacco tax

Religious, moral teachings, beliefs

Largest Impact

Smallest Impact

Contributory/Distributive (Social) Justice

Changing the Context to make individuals’ default

decisions healthy

Long-lasting Protective Interventions

Clinical Interventions

Counseling & Education

Socioeconomic Factors

Factors that Affect Health

Frieden, Archer

Social Structure

Power and Wealth Imbalance LABOR

MARKETS

GLOBALIZATION &

DEREGULATION HOUSING POLICY

EDUCATION SYSTEMS

TAX POLICY

Social Determinants of Health

Disparity in the Distribution of Disease, Illness, and Wellbeing

Institutional Racism

Class Oppression

Gender Discrimination

and Exploitation

SOCIAL NETWORKS

SOCIAL SAFETY

NET

Safe Affordable Housing

Social Connection

& Safety

Quality Education

Job Security

Living Wage

Transportation Availability of Food

Psychosocial Stress / Unhealthy Behaviors

Definitions

Social Justice Health Equity

The absence of unfair, unjust advantage or privilege based on race, class, gender, or other forms of difference.

A fair, just distribution of the social resources and social opportunities needed to achieve well-being.

Health Disparity

“A disproportionate difference in health between groups of people.”

By itself, disparity does not address the chain of events that produces it.

Health Inequity “Differences in population health status and mortality rates that are systemic, patterned, unfair, unjust, and actionable, as opposed to random or caused by those who become ill.” Margaret Whitehead

Deaths Prevented And Change In Health Care Costs Plus Program Spending, Three Intervention Scenarios, At Year 10 And Year 25.

Milstein B et al. Health Aff 2011;30:823-832

WE KNOW HOW TO

REVERSE EPIDEMICS

Your Kansas City, MO

Health Department

87  

20  

9  

62  

3  0  10  20  30  40  50  60  70  80  90  

100  

City   Aim4Peace  target  area  

Num

ber  o

f  hom

icides  

Number  of  homicides  between  city  and  Aim4Peace  target  area,  YTD  October  17,    2014  

YTD2013  

2010-­‐2012*  

2013  

YTD2014  

*2010-­‐2012  in  target  area  means  average  number  of  homicides  among  2010-­‐2012  

-­‐29%  reducSon  

-­‐85%  reducSon  

Seeing a Wider Set of Relationships

Centers for Disease Control and Prevention, Bobby Milstein

Public Health As A Social Justice Enterprise

JUSTICE = TRUTH + POWER

Public Health Practice Research + Data

Community Organizing

=  

Aligned Campaigns (PH&CO) • 2012: Cap the Rate, Raise the Wage

• 2013: Ban the Box • 2013-2014: Low Wage Worker Actions/

Living Wage • 2014: Ban the Ban • 2014: Raising of America Kansas City • 2014: Advance KC Development Scoring • Other Ongoing: Medicaid Expansion, Early

Voting, Violence/Homicide Prevention

Questions?

Your Nationally Accredited

Kansas City, Mo., Health Department

Improving Service. Protecting People. Saving Lives.

Rex Archer, MD, MPH

Director of Health

Prepared by: T.Cole

We are focused on prevention of gun-related violence that is primarily related to arguments and

retaliation in targeted areas of East Patrol, but we seek to expand to the entire Metro Area.

A4P Current Target Zone: KCMO Police Sector 330, parts of 320 & 340

KCPD Beats

2010 (Jan-Dec)

2011 (Jan-Dec)

2012 (Jan-Dec)

2013 (Jan-Dec)

diff % change

2014 (Jan-

Oct. 16)

diff % change

331 4 4 3 3 0 0% 1 -2 -67% 332 3 3 7 1 -6 -86% 0 -1 -100% 333 0 5 2 0 -2 -100% 1 1 0% 334 6 3 4 3 -1 -25% 1 -2 -67%

Total 330

13 15 16 7 -9 -56% 3 -4 -57%

324 4 7 4 2 -2 -50% 0 -2 -100%

Total 17 22 20 9 -11 -55% 3 -6 -67%

To Achieve the Vision Participants Reached Consensus on Six KC-CHIP Strategic

Issues/Goals  

 

 

 

Safe  and  Healthy  Community   Encourage  

AcQve  Living    and  Healthy  

EaQng  

Reduce  health  dispariQes/social  determinants  of  

health  

 

Ensure  Every    Child  has  a    Healthy  Start  

Access  to  Clinical    

PrevenQve    Services,  

 Illness  Care,    &  Public  Health  

Services  &  IntervenQons  

Live  Tobacco  Free  in  KC   Thriving

people living, learning and working in a

healthy, active, vibrant, and safe community,

where there is equitable access to jobs, quality health, education and

social services

34  

Develop  and  Sustain  a    High  Performing  OrganizaQon  

Increase  Public  Health  EffecQveness  and      Promote  PrevenQon  Strategies  that  Reduce    Health  InequiQes    

and  Improve  the  Health  of  the  Community  

Increase Stakeholder Awareness, and Support of Mission & Activities

Updated  as  of  5/16/13  

Kansas  City,  Missouri  Health  Department  Strategic  Map:  2013-­‐2016  

Enrich  and  Support  Community  Partnerships  

Lead  Policy  and  Advocacy  

Development  

Review  Current  Programs,    Services  And  IdenSfy    

Gaps  

Implement  QI  Focus  into  

 All  Programs  

Incorporate  an  EvaluaSon  Component  into  All  Programs  

Align  Partnerships  with    Emerging  Changes  in  Public  Health  Issues  

Leverage  CommunicaSons  To  AcSvate  Partners  and  

Improve  Efficiency  

Ensure  ConSnuing  Face-­‐to-­‐Face  (1  on  1s)  

InteracSons  

Assure  Quality  of  Services  Delivered  or  Contracted  For  

Develop  Departmental  Capacity  and  

Technical  ExperSse  

Determine  Framework  for  Policy  and  

Advocacy  Issues  

IdenSfy  &  PrioriSze  Department  &  Community  

   Health  PrioriSes  

Develop  Public  and  Private  Strategic  

Alliances  to  Advocate  for  RecommendaSons  

Develop  &  Enforce  Agency  CommunicaSon  Plan    Including  an  Integrated  Brand  Framework  

IdenSfy  &  Respond  to  CommuniSes’  Perceived    

Value  of  KCHD  

Increase  Visibility  Of  KCHD  Services  

 Engage  &  Inform  Key  Decision-­‐  

Makers  &  Influencers    on  Policy  RecommendaSons  

 

Strengthen  Internal  ProgrammaSc  awareness    

And  Linkages  

 Pursue    and  Maintain  NaSonal  Public    Health    

AccreditaSon      

Update  and  &  Implement  a  Staff  Training  Plan  

IdenSfy  &  OpSmize    Technology  to  Innovate    

Public  Health  

Recruit,    Retain,  and  Invest  in  Quality  Staff  

Strengthen  the  Impact    of  Programs  and  

Services  

Assure  RecogniSon  of    KCHD/KCMO  for  all  Funded    AcSviSes  (Co-­‐Branding)  

Use  Data,  and  Evidence-­‐Based  PracQces  as  Tools  to  Drive  Decision-­‐Making  

Communicate  the  Meaning    and  Importance  of  

Public  Health  

1

2

3

4

5

6

F

A B DC E

Tracks  of  Work  for  Year  2:  ProgrammaSc  Linkages  (Yellow),  Performance  Management  (Pink),  IntegraSng  Technology  (Orange),  Workforce  Development    (Green),  Stakeholder  Awareness  (Blue),  Cultural  Competency  (Purple)  will  be  added  as  TA  progresses  

Work  with  Community    Organizing  Agencies  to  address    

health  inequiSes  

Become  an  Academic    Health  Department  

Cultural  Competency  

Expand  and  Sustain  Funding  and  Investment  

Arenas of Power

Power is the ability to act or produce an effect •  Directly impacting decisions makers •  Developing deeper relationships and

aligning interests •  Consciously shifting the narrative

Working with Faith-based Organizations

We believe: •  Everyone has a story •  In the potential of transformation

(individual, community, society at large) •  Power is a product of relationships •  We get as much justice as we have

power to compel

Three Principles of Community Organizing

v Win concrete improvements in people's lives

v Make people aware of their own power

v Alter the relations of power: §  Build strong organizations §  Pass new laws and regulations §  Elect good people who recognize

your power