naccho-citymatch e-mch conference call january 20, 2005 social justice: a matter of (local) public...
TRANSCRIPT
NACCHO-CityMatCHE-MCH Conference Call
January 20, 2005
Social Justice: a matter of (local) Public Health
Magda Peck ScDCEO/Senior Advisor, CityMMatCHCH Professor and Associate Chair for Community Health, Department of Pediatrics
University of Nebraska Medical CenterFounding Director, MPH Program [email protected] 402.561.7500
With thanks to
CityMatCH, NACCHO Families University of Nebraska Medical Center Dennis Raphael @ SDOH Richard Hofrichter (@ NACCHO), plus Nancy
Krieger, Vicente Navarro, John Lynch, Amaryta Sen, and many many others…
“Invisible Heroes”
“Expert” Presenter – MCH and Social Justice: Context and Caveats
Inherently Personal: obligation, choice Historically Professional: public health
values Relatively Intellectual: science vs.
conscience Recently Intensified: intersections,
introspection
"Cowardice asks the question, is it safe? Expediency asks the question, is it politic?
Vanity asks the question, is it popular? But conscience asks the question, is it right?right?
And there comes a time when one must take a position that is neither safe, nor politic,
nor popular, but he must take it because his conscience tells him
that it is right...."
-Martin Luther King, Jr.
“Social Justice” 20 Minute Kickstart
1. Language: definitions, terms
2. Logistics: structures, barriers, pathways
3. Leverage: power/control, (resources/wealth), politics
4. Lessons Learned: invisible heroes
The Language of Optimal “Ends”
Rights: entitlement Equity: fairness Equality: sameness Justice: righted wrongs
Rudolf Virchow (1821-1901)
19th century German pathologist: V. law (Omnis cellula e cella), cell, node, and triad; statesman, public health pioneer
If medicine is to fulfill her great task, then she must enter political and social life
…Constitutional right of the individual citizen to lead a healthful existence
Where after all do universal human rights begin? In small places close to home.
These are the places where every man, woman and child seeks equal justice, equal opportunity, equal dignity.
Eleanor Roosevelt, 1958
A Just Society…
Ensures the development and capabilities of all of its members.
Amaryta Sen
The Language of Disrupted “Means” (to optimal ends)
Discrimination -Isms: race, class, gender… Disparities Ideology
Health and Discrimination
The rationale for studying health consequences of discrimination is to enable a full accounting of what drives population patterns of health, disease and well-being, so as to produce knowledge useful for guiding policies and actions to reduce social inequalities in health and promote well-being.Nancy Krieger, “Discrimination and Health” in Social Epidemiology,
Berkman and Kawachi, 2000.
Race-ism and Public Health
It is impossible to have a frank discussion of inequality…without confronting the continuing blight of racism head on…
long established and growing health disparities are rooted in fundamental social structure inequalities, which are inextricably bound up with the racism that continues to pervade U.S. society.
Cohen and Northridge, AJPH, June 2000, p841
Deeply engrained structural and systemic factors and policies with differential effects on individuals’ health
access to care quality of care scope and relevance of care -
“inaction in the face of need”
Camara Jones, 2000
Institutional Racism, revisited
Health Disparities – United States
Measuring Health
Two overarching goals: Increase quality and
years of healthy life Eliminate health
disparities
Health Disparities – United StatesSelected Mortality Rates by Race - 2000
0
5
10
15
20
25
IMR NNMR PNNMR MMR
White
AA/B
Source: CDC, H Atrash, NCBDDD, 2004
Health Disparities – United StatesMaternal Mortality Rates, US 1920-2000
1
10
100
1000
10000
1920 1930 1940 1950 1960 1970 1980 1990 2000
Year
Lo
g-M
ater
nal
Dea
ths
per
100
,000
Liv
e B
irth
s
White
Other
AA/B
GAP
1.8
3.4
Source: CDC, H Atrash, NCBDDD, 2004
Health Disparities – United StatesInfant Mortality Rates, US 1920-2000
1
10
100
1000
1920 1930 1940 1950 1960 1970 1980 1990 2000
Year
Lo
g-I
nfa
nt
Dea
ths
per
1,0
00 L
ive
Bir
ths White
Other
AA/B
GAP
1.7 2.5
Source: CDC, H Atrash, NCBDDD, 2004
Health Disparities – United StatesNeonatal Mortality Rates, US 1920-2000
1
10
100
1920 1930 1940 1950 1960 1970 1980 1990 2000
Year
Log
Neo
nata
l Dea
ths
per
1,00
0 Li
ve B
irth
s
White
Other
AA/B
Gap
1.42.5
Source: CDC, H Atrash, NCBDDD, 2004
Health Disparities – United StatesPostneonatal Mortality Rates, US 1920-2000
1
10
100
1920 1930 1940 1950 1960 1970 1980 1990 2000
Year
Log
Pos
tneo
nata
l Dea
ths
per
1,00
0 Li
ve B
irth
s White
Other
AA/B
Gap
1.8
2.5
Source: CDC, H Atrash, NCBDDD, 2004
Health Disparities – United StatesLow Birthweight, United States 1981-2002
02468
10121416
Year
Per
cent
Low
Bir
thw
eigh
t
White
AA/B
Hispanic
Source: CDC, H Atrash, NCBDDD, 2004
Health Disparities – United StatesPreterm Delivery, United States 1981-2002
0
5
10
15
20
Year
Per
cent
Pre
term
Bir
ths
White
AA/B
Hispanic
Source: CDC, H Atrash, NCBDDD, 2004
Increasing Diversity – United StatesProjected Population by Race/Ethnicity 2000-2050
0%10%20%30%40%50%60%70%80%90%
100%
2000 2010 2020 2030 2040 2050
Year
All OtherAsianHispanicAA/BWhite
Source: CDC, H Atrash, NCBDDD, 2004
“Tonight, we’re going to let the statistics speak for themselves.”
Ideologic tensions around persistent health inequities
CAUSES individual failure, inevitable consequences of modern
society, random adverse events
OR a complex web of power, politics, and ideology that
shapes social structures and systems
SOLUTIONS
Reformation vs transformation Remedies vs root causes
“Social Justice” 20 Minute Kickstart
1. Language: definitions, terms
2. Logistics: structures, barriers, pathways
Committee on Assuring the Health of the Public in the
21st Century
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
THE FUTURE OF
THE PUBLIC’S HEALTH
in the 21st Century
Healthy people in healthy
communities
Health = public good Health = social goal of many sectors
and communities
NOTES: Adapted from Dahlgren and Whitehead, 1991. The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman, 1999).
Over the life span
Living and working conditions may include:
• Psychosocial factors• Employment status and occupational factors • Socioeconomic status (income, education, occupation)• The natural and builtc environments• Public health services• Health care services
Ecological Model for Population Health
Source: Institute of Medicine Report: The Future of the Public’s Health in the 21st Century, November 2002
Racism: Complex interactions between direct, physiologic effects and indirect
pathways
Health Care Disparities: IOM Report 2002
The Institute of Medicine’s Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care concluded that:
A range of patient-level, provider-level, and system-level factors may be involved in racial and ethnic healthcare disparities, beyond access-related factors
Health Disparities in Healthcare: Patient-Level factors
Yes, minority patients are more likely to: Refuse recommended services Adhere poorly to treatment
regimens Delay seeking care
But, these factors are unlikely to be major sources of healthcare disparities
Health Disparities in HealthcareProvider-Level factors
Degree of uncertainty: Information from patients
vs. prior experiences Bias against minorities Beliefs and stereotypes
Health Disparities in HealthcareSystem-Level factors
System organization affects patient care:
Limited access Limited resources Discriminatory management Language barriers Time pressure on physicians Geographic availability
Health Disparities: IOM Recommendations
Multiple approaches are required Most factors are outside the influence
of the health care system: Socioeconomic status Cultural factors Environmental factors Discrimination issues Political systems
“Social Justice” 20 Minute Kickstart
1. Language: definitions, terms
2. Logistics: structures, barriers, pathways
3. Leverage: power, politics
The Public Health SystemThe Public Health System
Assuring the Assuring the Conditions for Conditions for
PopulationPopulationHealthHealth
Employersand
Business
Academia
GovernmentalGovernmentalPublic Health Public Health InfrastructureInfrastructure
The Media
Healthcare
delivery system
Community
What will it really take?
KNOWLEDGE BASE
POLITICAL WILL
SOCIAL STRATEGY
From: Richmond and Kotelchuck
We want the same things.
“Social Justice” 20 Minute Kickstart
1. Language: definitions, terms
2. Logistics: structures, barriers, pathways
3. Leverage: power, politics
4. Lessons Learned: invisible heroes
Dr. William FoegeEmory University/Gates Foundation
Unwarranted optimism: hallmark in (public) health professionals;
Placebo effect in population health? Allows us to go beyond expectations, beyond the boundaries of existing science….
“There is no use trying,” said Alice; “one can’t believe in impossible things.”
“I dare say you haven’t had much practice,” said the Queen.
‘When I was your age, I always did it for a half an hour a day. Why, sometimes I’ve believed as
many as six impossible things before breakfast.”
-Lewis Carroll
When will our consciences When will our consciences grow so tender that we will act grow so tender that we will act to prevent human misery to prevent human misery
rather than avenge it?rather than avenge it? Eleanor Roosevelt
Public Health: a matter of Justice
Social Justice: a matter of
the public’s health
or go to the CityMatCH website: http://www.citymatch.org
Want to follow up with me?