CENTER ON SOCIAL DISPARITIES IN HEALTH
University of California, San Francisco
What is health equity -­‐-­‐ And how will more data help us achieve it? Human Rights and Health Equity Department Annual Symposium Mt. Sinai Hospital, Toronto, Canada May 13, 2014 Paula Braveman, MD, MPH University of California, San Francisco Professor of Family & Community Medicine Director, Center on Social DispariOes in Health “The poor are ge+ng poorer, but with the rich ge+ng richer it all averages out in the long run.” ©2000 The New Yorker Collec1on from cartoonbank.com. All rights reserved CENTER ON SOCIAL DISPARITIES IN HEALTH
University of Califor nia, San Francisco
What are “health dispariOes/inequaliOes”? §  Differences, variaOons §  Subtle implicaOon of potenOal concern §  Most official U.S.A. definiOons refer only to differences between unspecified groups §  But we really mean: Health differences that are unfair in a parOcular way §  Whitehead: unfair, avoidable, unjust §  But noOons of fairness, jusOce, and avoidability vary CENTER ON SOCIAL DISPARITIES IN HEALTH
University of Califor nia, San Francisco
Are these health differences in Canada unfair? •  Infant mortality 60% higher among poorest v richest income quinOle & 4 Omes higher among Inuit vs general Canadian populaOon •  Disabled Canadians o\en have delayed Ca detecOon due to providers a]ribuOng symptoms to pre-­‐exisOng condiOons •  So. Asian Canadians have 3-­‐5 Omes the CVD mortality risk as White Canadians •  Trans people experience high levels of mental & emoOonal distress due to marginalizaOon/rejecOon CENTER ON SOCIAL DISPARITIES IN HEALTH
University of Califor nia, San Francisco
Are all health differences unfair? §  Skiers have more leg fractures than non-­‐skiers §  Younger adults healthier than elderly §  White women have more breast Ca §  Wealthy people in Toronto have higher rates of an illness than wealthy people in Montreal §  Some middle-­‐class communiOes lack adequate supply of denOsts §  Who decides what’s fair? Source: Google Images hDp://
an1ques.lovetoknow.com/an1que-­‐balance-­‐scales CENTER ON SOCIAL DISPARITIES IN HEALTH
University of Califor nia, San Francisco
Can we call it unfair if the causes are unknown? §  Compared with European-­‐American (“White”) newborns, African-­‐American (“Black”) newborns are 2 to 3 Omes as likely to have: §  low birth weight §  preterm birth §  which predict infant mortality, childhood disability & development, and adult chronic disease §  Unknown causes A human rights-­‐based definiOon of health inequality §  A health difference closely linked with social (including economic) disadvantage §  Adversely affects groups who have experienced greater obstacles to health based on: §  racial or ethnic group, religion, socioeconomic status/posiOon, disability, sexual orientaOon, gender, gender idenOty, or other characterisOcs historically linked to discriminaOon or exclusion Not all health differences are health inequali:es §  Not all health differences – or even all health differences warranOng acOon §  A parOcular subset of health differences §  Plausibly avoidable, systemaOc §  Adversely affect socially disadvantaged groups §  May or may not be caused by social disadvantage §  Unfair because they put already socially disadvantaged groups at further disadvantage with respect to their health Equity is jusOce Equity is the goal of eliminaOng inequaliOes InequaliOes: the metric to assess progress toward equity Equity versus equality: Equal rights vs. equal resources ObligaOon to focus on those with the greatest social/
economic obstacles to fulfilling their rights §  Health equity requires jusOce in medical care and the social factors that shape opportuniOes to be healthy § 
§ 
§ 
§ 
Infant mortality rate: England and Wales 160
140
120
Penicillin
100
80
NICU’s
60
40
20
0
1842
1860
1873
1888
1903
1915
1932
1946
1962
Source: T. McKeown, 1974. How could income (or wealth) affect health? Income can shape: •  Medical care •  NutriOon & physical acOvity opOons •  Housing & neighborhood condiOons •  Services Which can affect: •  Stress •  Family stability Parents’ income shapes offspring’s: •  EducaOon •  OccupaOon •  Income •  Work condiOons EducaOon can shape health behaviors by determining knowledge and skills EducaOonal a]ainment • Health knowledge • Literacy • Problem-­‐
solving •  Coping skills • Diet • Exercise • Smoking • Health/disease management Other plausible pathways from education to
health, e.g., via work & income
Income EducaOonal a]ainment Work § Neighborhood/ school environment § Diet & exercise opOons § Stress Work-­‐
related resources §  Health insurance § Sick leave § Stress Working condiOons §  Control / demand imbalance § Stress HEALTH Psychosocial pathways from educaOon to health EducaOonal a]ainment Social standing § Social & economic resources § Perceived status § Stress Social networks § Social & economic resources § Norms § Social support § Stress Control beliefs (powerlessness, sense/locus of control, fatalism, mastery) § Coping § Response to stressors HEALTH CENTER ON SOCIAL DISPARITIES IN HEALTH
University of Califor nia, San Francisco
How could discriminaOon harm health? §  By constraining social and economic opportuniOes à  e.g., ins1tu1onal/structural racism à racial segrega1on à deep, concentrated, inter-­‐genera1onal poverty with liDle chance to escape à health-­‐damaging vs health-­‐promo1ng exposures and experiences (nutri1on, housing, neighborhood condi1ons, stress of economic hardship…) §  AddiOonal psychological effects, e.g., on self-­‐esteem; stress of being the “out” group, threatened, vigilance §  Racial inequality could diminish social cohesion, affecOng everyone CENTER ON SOCIAL DISPARITIES IN HEALTH
University of Califor nia, San Francisco
Is the stress-­‐health link biologically plausible? •  Advances in neuroscience help elucidate how social factors “get into the body” •  HPA axis, sympatheOc nervous system, and immune/
inflammatory mechanisms have been demonstrated as responses to stress –  Mediators include corOsol, other stress hormones, cytokines, telomerase •  Chronic stress is a plausible and likely major contributor to both socioeconomic and racial/ethnic inequaliOes in health What creates & perpetuates health inequiOes across the life course and across generaOons? SOCIETY Social Context INDIVIDUAL Influencing social inequity 1. Social straOficaOon Social posiOon, e.g. by race & class Decreasing harmful exposures 2. DifferenOal exposure Specific exposure Decreasing vulnerability 3. DifferenOal vulnerability Disease PrevenOng unequal consequences Policy Context 5. More social inequity Adapted from Finn Diderichsen, U. Copenhagen 4. DifferenOal consequences Social consequences of ill health 17 Pursuing health equity requires understanding and addressing the role of social factors Policies to promote economic
development, reduce poverty,
and reduce racial segregation
Economic & Social
Opportunities and Resources
Policies to promote child
and youth development
and education, infancy
through college
Living & Working Conditions
in Homes and Communities
Policies to promote healthier
homes, neighborhoods,
schools and workplaces
Behaviors
Medical Care
Interactions between genes and experiences
HEALTH Adapted from Robert Wood Johnson Foundation Commission to Build a Healthier America |
www.commissiononhealth.org
CENTER ON SOCIAL DISPARITIES IN HEALTH
University of Califor nia, San Francisco
What can medical care providers and insOtuOons do about health equity? §  So much we do not know. Great complexity. §  An interven1on that works in one seUng or popula1on may fail miserably in another §  Health effects oXen don’t manifest for decades §  Weigh risks of acOng on less-­‐than-­‐certain knowledge against risks of conOnued inequitable status quo §  Act on the best available knowledge. We know enough to act. §  Health equity requires addressing the social determinants of health. CENTER ON SOCIAL DISPARITIES IN HEALTH
University of Califor nia, San Francisco
What can medical care providers and insOtuOons do about health equity? §  Collect and use data on social factors to guide pracOce and policy (see RacializaOon & Health in Toronto, October 2013) §  More effecOve Rx plans §  Strategically posiOoned to idenOfy needs for social services and collaborate with appropriate agencies to address these needs §  AdvocaOng policies likely to reduce health dispariOes –  Policies on poverty, child care, educa1on, transporta1on, housing… –  Moral and scien1fic authority – speaking to health effects