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

The Troutman Group

A Case Study; But Why

The Troutman Group

Vital Statistics:

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

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?

Let’s get on the same page.

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

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.”

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

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

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

The Troutman Group

Justice

The quality of fairnessThe principle of moral rightness; equityConformity to moral rightness in action or

attitude

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

Rights

The Troutman Group

Claims or entitlements that are recognized by legal or moral principles

Enforced by legislation and rules, the force of law

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)

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

Market Justice vs. Social Justice

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

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

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…

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.

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 )

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

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

A New Direction

Looking upstream, finding the causes of he causes.

The Troutman Group

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

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

The Power of Poverty

The Troutman Group

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”

The Troutman Group

The Troutman Group

The Elephant in the Room: Racism

The Troutman Group

What is racism?

The Troutman Group

A system

What is racism?

The Troutman Group

A system of structuring opportunity and assigning value

What is racism?

The Troutman Group

A system of structuring opportunity and assigning value based on the social interpretation of how one looks (“race”)

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

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

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

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.

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

“Patients” experiencing symptoms of heart disease, from Schulman et al. (1999)

“Patients” experiencing symptoms of heart disease, from Schulman et al. (1999)

Place Matters

The Troutman Group

Tell me how a man died and I’ll tell you where he lived

Aristotle

The Troutman Group

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

Opportunity Neighborhoods

The Troutman Group

Sustainable employmentHigh performing schoolsAccess to high quality healthcareAdequate transportationHigh quality childcareNeighborhood safetyInstitutions that facilitate civic engagement

Housing

The Troutman Group

Built Environment Issues

The Troutman Group

Hope sixWhere did all the poor people go?The segregation of povertyGrids, green space and gentrificationRural infrastructure

Cotter Lane

The Troutman Group

Park DuValle

The Troutman Group

Park DuValle

The Troutman Group

Education

The Troutman Group

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

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

Takin’ it to a Higher Level

Power

Policy

Place

Advocacy

The Troutman Group

www.who.int/social_determinants

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

The Center for Health Equity

The Troutman Group

The Troutman Group

The Importance of Leadership and Political Will

The Troutman Group

The Troutman Group

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

The Center focuses its work to eliminate health inequities due to race, ethnicity

and socioeconomic status

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

Current Work ( Cont )

Photo voiceCommunity dialoguesOperationalizing Health Equity within the

departmentCHI projectHIA-Shepard Square ( Hope 6 )The cabinet dialogueFood justice

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

Strategy 3: Expand access to and distribution of healthy food.

The Troutman Group

Increased Neighborhood Access

The Troutman Group

From the Dinner Table to the Policy Table

Health Policy Is Health Policy Is Social PolicySocial Policy

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

Policies ( Cont )

Environmental changeHousing reformJob creation tied to insuranceNational Health Program to Insure Universal

Access and Universal CoverageLand UseHealth Impact Assessment

The Troutman Group

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

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

The Troutman Group

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

Universal access to a single standard of high quality care

National Health Insurance

Single Payer

The Troutman Group

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.

Phillis Wheatley Students present

Photo-voice Exhibits on

Health Policy Issues

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

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

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

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

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.)

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

Building a Social Movement

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

The Troutman Group

Are You Willing to Take the Risk?

Adewale Troutman, M.D.,M.P.H.The Troutman Group

5109 Forrest Grove PlaceLouisville, KY 40059denzibell@aol.com

502 544 8570www.thetroutmangroup.org

The Troutman Group