Understanding Health Inequities in Boston
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Transcript of Understanding Health Inequities in Boston
Understanding Health Inequities in Boston
Barbara Ferrer, PH.D., MPH, M.ED
Executive Director
Boston Public Health Commission
Health Indicator Black WhiteAsthma (< 5, hosp) 11.4 per 1000 3.4Birth Weight (Less than 3.3lbs) 3.0% of births 1.6%Body Weight (Overweight or Obese) 68% 41%Breast Cancer (Morality) 29.7 per 100,000 25.9Cervical Cancer (Mortality) 5.6 per 100,000 2.3Death Rate (Mortality) 1116.8 per 100,000 919.6Diabetes (Mortality) 41.8 per 100,000 16.6Drug Related Mortality 15.7 per 100,000 19Heart Disease (Mortality) 239.6 per 100,000 238.1High Blood Pressure 30.4% 17.2%HIV / AIDS (Mortality) 28.1 per 100,000 6.8Homicide 27.2 per 100,000 2.2Hospitalization 163.8 per 1000 108.9Infant Mortality (Mortality) 8.7 per 1000 4.1Lung Cancer (Mortality) 61.6 per 100,000 66.2Prostate Cancer (Mortality) 68.3 per 100,000 31.2Smoking during pregnancy 6.3% 5.1%Suicide (Mortality) 3.6 6.2Teen Birth Rate (15 - 17) 14.1 per 1,000 6Uninsured 9.2% 6.5%
Racial Disparities in Boston
Life Expectancy of Black and White Boston Residents, 2004-2006
74.881.1
69.6
77.475.581.6
0
10
20
30
40
50
60
70
80
90
100
Males Female
Life
Exp
ect
an
cy in
Ye
ars
Boston
Black
White
DATA SOURCE: Boston resident deaths and live births, Massachusetts Department of Public HealthData ANALYSIS: Boston Public Health Commission Research Office
Infant Mortality Rates by Race/Ethnicity and Year, Boston, 1993-2005
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
Dea
ths
per
1,00
0 Li
ve B
irths
W
ithin
Rac
e/E
thni
city
Black 15.0 12.5 11.9 9.9 12.8 12.0 13.5 13.6 13.5 12.4 14.2 12.1 8.7
Latino 8.9 8.2 3.0 5.2 3.6 4.5 4.1 5.1 5.6 6.5 4.0 9.4 3.1
White 5.9 7.2 4.7 6.7 9.5 4.0 5.6 2.8 5.1 4.6 3.1 4.1
Boston 9.8 9.2 6.8 7.0 8.4 6.3 7.4 6.7 7.4 7.0 6.3 6.0 5.2
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
NOTE: Rates for Asians and Others are not presented because each group had less than 5 deaths per year for most of the years shown.DATA SOURCE: Boston resident deaths, Massachusetts Department of Public HealthDATA ANALYSIS: Boston Public Health Commission Research Office
n<5
Cumulative Birthweight Distribution by Race/Ethnicity, Boston: 2000-2005
<500g <750g <1,000g <1,500g <2,000g <2,500g 2,500g+
Asian 0.08% 0.19% 0.49% 0.90% 2.04% 6.69% 93.31%
Black 0.54% 1.41% 2.02% 3.46% 5.97% 13.25% 86.75%
Latino 0.18% 0.51% 0.80% 1.54% 3.05% 7.94% 92.06%
White 0.09% 0.28% 0.58% 1.26% 2.79% 6.93% 93.07%
Other 0.23% 0.77% 1.17% 2.03% 4.06% 9.15% 90.85%
DATA SOURCE: Boston Resident live births, Massachusetts Department of Public HealthDATA ANALYSIS: Boston Public Health Commission Research Office
Birthweight-Specific Infant Mortality Rates by Race/Ethnicity, Boston, 2002-2004
0.0
150.0
300.0
450.0
600.0
750.0
900.0
Dea
ths
per
1,00
0 Li
ve B
irths
in B
irthw
eigh
t C
ateg
ory
White 714.3 90.9 0.7
Black 780.5 131.6 2.2
Latino 923.1 149.3 14.9 1.7
ELBW VLBW LBW NBW
* Count is 0; therefore rate not calculated.NOTE: ELBW is <500g, VLBW is <1,500g, LBW is <2,500g, NBW is 2,500g+.DATA SOURCE: Boston resident live births and infant deaths, Massachusetts Department of Public HealthDATA ANALYSIS: Boston Public Health Commission Research Office
n<5*
IS IT ABOUT EDUCATION OR INCOME?
Racial & Ethnic DisparitiesInfant Mortality & Education
African Americans
16+ years of
schooling
White Americans <9
years of schooling
Per 1,000 Live BirthsNCHS 2002
10.2
6.8
Racial & Ethnic DisparitiesInfant Mortality & Household Income
African Americans
with Household
Income $35,000+
White Americans
with Household
Income <$10,000
Per 1,000 Live Births
16.6
11.2
IS IT ABOUT HEALTH BEHAVIOR?
Racial & Ethnic DisparitiesInfant Mortality & Cigarette Smoking
African American
Non-Smokers
White American
Smokers
Per 1,000 Live Births NCHS 2002
13.2
9.2
Low Birthweight by Smoking Status and Race/Ethnicity, Boston, 2005
17.9%
13.4%
17.9%
25.5%
9.3%
6.8%
7.9%
13.7%
5.7%
0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0%
BOSTON
White
Latino
Black
Asian Nonsmoker
Smoker
Percentage of Births Within Race/Ethnicity and Smoking Group
NOTE: LBW for Asian smokers not shown because n<5DATA SOURCE: Boston resident live births, Massachusetts Department of Public HealthDATA ANALYSIS: Boston Public Health Commission
Racial & Ethnic DisparitiesInfant Mortality & Prenatal Care
African Americans
First Trimester
Prenatal Care
White Americans
Prenatal Care
After 1st
Trimester or None
Per 1,000 Live Births NCHS 2002
12.7
7.1
0%
5%
10%
15%
20%
25%
30%
Per
cent
age
of B
irth
s W
ithin
R
ace/
Eth
nici
ty a
nd P
NC
Ade
uqac
y G
roup
Adequate-Intensive 9% 26% 18% 25% 15% 19%
Adequate-Basic 4% 6% 3% 4% 2% 3%
Intermediate 8% 4% 3% 3% 5%
Inadequate/None 10% 16% 9% 13% 8% 12%
Asian Black Latino Other White Boston
NOTE: LBW percentage are not shown where n<5. PNC adequacy was assessed by the Kotelchuck Index (APNCU Index).DATA SOURCE: Boston resident live births, Massachusetts Department of Public HealthDATA ANALYSIS: Boston Public Health Commission Research Office
Low Birthweight by Adequacy of Prenatal Care and Race/Ethnicity,
Boston, 2005
n<5
Is It About Race?
Race has no clear biologic or genetic basis…”there are no characteristics, no traits, not even one gene that turns up in all members of one so-called race, yet is absent from others” (L. Adelman. Race and Gene Studies)
The meanings of racial designations- White, Black, Asian- are subject to historical, cultural and political forces; “race justified social inequalities as natural”.
Racial & Ethnic DisparitiesInfant Mortality & Nativity
0
2
4
6
8
10
12
14
16
Foreign Born United States Born
Black Women
9.2
14.2
Per 1,000 Live Births
NCHS 2002
Low Birthweight by Maternal Birthplace, Boston, 2004
8.1% 7.3%
4.9%
12.5%
10.0%
12.3%
6.8%
15.1%
10.5%
13.8%
7.2%8.1%
0.0%
4.0%
8.0%
12.0%
16.0%
20.0%
China
Domin
ican
Rep.
El Sal
vado
rHai
ti
Jam
aica
Puerto
Rico
US - Asia
n
US - Bla
ck
US - L
atin
o
US - O
ther
US - W
hite
Vietn
am
Pe
rce
nta
ge
of B
irth
s W
ithin
Birt
hp
lace
SOURCE: Boston resident live births, Massachusetts Department of Public HealthANALYSIS: Boston Public Health Commission Research Office
WHAT ABOUT RACISM ?
How Can Racism Affect Health Status?
Differences in socio-economic status and environmental conditions
Differences in exposure to “stress” Differences in access to health care services Differences in diagnostic testing, treatment, and the
quality of care received within the health care system Differences in health behaviors
Socio-Economic Conditions
Legacy of slavery, segregation and discrimination created social and economic inequities
Institutional structures and social relations can serve to maintain these disparities
Model of Social Determinants of Health Disparities
Racism
SocioeconomicStatus
EnvironmentalExposure
Stress
Access To HealthServices
Access to Testingand Screening
HealthOutcomesHealth Behaviors
24%
5% 4% 4% 3%8%
39%
14%
84%
44%
2%
14%
53%
3%
48%
15%
6%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
BOSTON
Allsto
n/Brig
hton
Back
Bay
Charle
stown
East B
osto
n
Fenway
Hyde
Park
Jam
aica
Plain
Mat
tapa
n
North
Dor
ches
ter
North
End
Roslin
dale
Roxbu
ry
South
Bos
ton
South
Dor
ches
ter
South
End
Wes
t Rox
bury
Pe
rce
nta
ge
of
To
tal P
op
ula
tion
Of
Ne
igh
bo
rho
od
DATA SOURCE: US Department of Commerce, Bureau of the Census, American Fact Finder, Census 2000DATA ANALYSIS: Boston Public Health Commission, Research Office
Black Resident Population by NeighborhoodBoston, 2000
Environmental Exposures
Exposure to waste disposal sites Exposure to air pollutants Exposure to “unregulated” job sites (housecleaning,
sweat shops, farms) Exposure to sub-standard housing (quality, density,
location) Exposure to alcohol and tobacco products
Low Birthweight by Neighborhood Boston, 2005
5.7%
8.5%
7.0%
5.5%
7.2%
11.5%
13.4%
7.8%
12.8%
8.0%
11.5%
9.3%
6.1%
9.5%9.0%
7.6%
9.6%
0%
5%
10%
15%
BOSTON
Allsto
n/Brig
hton
Back B
ay**
Charle
stown
East B
osto
n
Fenway
Hyde
Park
Jam
aica
Plain
Mat
tapa
n
North
Dorch
este
r
North
End
Roslin
dale
Roxbu
ry
South
Bos
ton
South
Dor
ches
ter
South
End
Wes
t Rox
bury
Pe
rce
nta
ge
of B
irth
s W
ithin
Ne
igh
bo
rho
od
NOTE: Back Bay includes the North End/DATA SOURCE: Boston resident live births, Massachusetts Department of Public HealthDATA ANALYSIS: Boston Public Health Commission Research Office
Asthma Hospitalizations of Children Under Age 5 by Neighborhood, Boston, 2004-2006
3.7
7.4
9.7
7.9
12.9
5.8
11.511.6
7.86.9
7.8
5.04.03.7
2.5
8.1
0.0
3.0
6.0
9.0
12.0
15.0
BOSTON
Allsto
n/Brig
hton
Back
Bay*
Charle
stown
East B
osto
n
Fenway
Hyde
Park
Jam
aica
Plain
Mat
tapa
n
North
Dor
ches
ter
Roslin
dale
Roxbu
ry
South
Bos
ton
South
Dor
ches
ter
South
End
Wes
t Rox
bury
Hos
pita
lizat
ions
per
1,0
00 P
opul
atio
n
*Includes the North EndDATA SOURCE: Acute Care Hospital Case Mix files, Massachusetts Division of Health Care Finance and PolicyDATA ANALYSIS: Boston Public Health Commission Research Office
Health Behaviors
Individual behavior exists within a social context
Internalized racism can affect health behavior Health behavior alone does not account for
unequal burden of disease and death
48 6283 88 88 103 107 117 126
158 175
230
347
050
100150200250300350400
Charle
stow
n
South
Bos
ton
Allsto
n/Brig
hton
Jam
aica P
lain
Wes
t Rox
bury
Combi
ned
Centra
l Are
a*
Hyde
Park
Roxbur
y
East B
osto
n
South
Dor
ches
ter
Mat
tapa
n
Roslinda
le
North D
orch
este
r
Yo
uth
Pe
r F
aci
lity
Number of Youth Per Facility Across Boston Neighborhoods 1999-2000
* Combined Central Area includes Beacon Hill/Back Bay, Central, Fenway/Kenmore, and South End.
DATA SOURCE: Play Across Boston: Summary Report, December 2002
The Contextual Effect of the Local Food Environment on Residents’ Diets
Study by Moreland et al. AJPH. 11/2002
Findings: Only 8% of Black Americans lived in a census tract
with at least one supermarket compared to 31% of White respondents
Presence of supermarkets was associated with meeting dietary recommendations among Black Americans
Stress
Understanding the biologic impacts of social stress (Wadhwa et al. 2001., Culhane et al. 2001., Kramer et al. 2001 )
Theory of allostatic load (Michael Lu. 2002, Rich-Edwards. 2001)
“ ..a woman’s chronic exposure to racism creates an allostatic load ..altering the endocrine milieu in which the placenta is established….” (Rich-Edwards. 2001)
Racial and Ethnic Disparities Stress & Preterm Birth
Mother Placenta FetusStress
Hypothalamus
Pituitary
Adrenal
CRH
CRH
ACTH
CortisolNorepineprhine
++
Hypothalamus
Pituitary
Adrenal
Liver
CRH
ACTH
CortisolDS
16 alpha OH DS
Estriol
+
+
Adapted from Hobel 1998
Racial & Ethnic DisparitiesLow Birth Weight & Racism
0
2
4
6
8
10
12
14
16
18
20
Per
cent
Wom
en R
epor
ting
D
iscr
imin
atio
n
<1,500 g > 2,500 g
Birthweight
Collins 2000
12%
20%
P < 0.01
The Provision of Health Care
Differences in access to and types of health insurance/health plans
Differences in access to pharmaceutical drugs
Differences in provision of diagnostic tests, therapeutic procedures, transplants, and preventive services
Evidence of Racial and Ethnic Disparities in Healthcare
Disparities consistently found across a wide range of disease areas and clinical services
Disparities are found even when clinical factors, such as stage of disease presentation, co-morbidities, age, and severity of disease are taken into account
Disparities are found across a range of clinical settings, including public and private hospitals, teaching and non-teaching hospitals, etc.
Disparities in care are associated with higher mortality among minorities (e.g., Bach et al., 1999; Peterson et al., 1997; Bennett et al., 1995)
“If racism was constructed, it can be undone.
It can be undone if people understand when it was constructed, why it was constructed, how it functions, and how it is maintained.”
---People’s Institute For Survival and Beyond
What Next?
Need for Institutional ResponsibilityUnderstanding the nature of the
problemIdentifying opportunities for alternativeroles
Need for Institutional ResponseChanging policies and proceduresMobilizing for action