Envisioning Health Equity Peter A. Gorski, M.D., M.P.A. Children’s Board of Hillsborough County and University of South Florida

Social Determinants of Health and Wealth Your neighborhood Physical, social, economic, educational qualities Your skin color Race, ethnicity Who’s your daddy Parents’ education, income, health, social capital

Poverty Sickens Strong connections between child health and adult health Between child wealth and adult wealth Between child wealth and adult health Regardless of child’s health condition Regardless if social class changes from childhood to adulthood Childhood poverty gets biologically embedded

Epigenetics Life Course Perspective Balance of stresses and supports across life course exert cumulative influence on health Especially during sensitive periods of development, powerful experience gets embedded into our biology Reforming DNA structure, gene expression and brain chemistry Consequences to BMI, blood pressure, immune function, memory, learning, attention and mental health

Racial and Ethnic Disparities in Birth Outcomes: A Life Course Perspective This may be particularly important for MCH, where one developmental stage often gets disconnected from another. In perinatal health, we focus so much on events occurring in the 9 months of pregnancy we forget that there are a great deal of life course influences on perinatal outcomes, and a great deal of perinatal influences on life course outcomes. For example, in explaining the Black-White gap in infant mortality, for decades we searched for maternal risk factors during pregnancy rather than looking at the mothers’ cumulative life course experiences. The danger of focusing solely on risk factors during pregnancy is not only that it doesn’t adequately explain the disparities, but more importantly it can misguide public health interventions and policies. For two decades we thought if we could get women universal access to good quality prenatal care, then we can do something about reducing infant mortality and racial disparities in this country. Many of us recognize now that to expect prenatal care, in less than nine months, to reverse all the cumulative disadvantages and inequities over the life course of the woman, may be expecting too much of prenatal care. If we as are serious as a nation about improving birth outcomes and reducing disparities, we have to start taking care of women not only during pregnancy, but before pregnancy and between pregnancies and indeed, across the entire life course of women and families. Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective. Maternal Child Health J. 2003;7:13-30.

School Readiness Trajectories Strategies to Improve School Readiness Trajectories Poverty Lack of health services Toxic Stress Age 6 mo 12 mo 18 mo 24 mo 3 yrs 5 yrs Ready to learn Pre-school “Healthy” Trajectory Health Services Appropriate Discipline Reading to child “At Risk” Trajectory Parent education Emotional Health Literacy “Delayed/Disordered ” Trajectory Birth Early Infancy Late Infancy Early Toddler Late Toddler Early Preschool Late Preschool

Race is Not a Proxy for Poverty or Wealth

Beyond (or Underneath) SES African American infant mortality higher in more segregated cities even when controlling for SES

SES? – Ask the Professionals 10.2 6.8 And that African American women with more than 16 years of schooling still have higher infant mortality than White women with less than nine years of schooling. Think about this. These are African American women who have graduated from college, and gone on to graduate schools, medical schools, law schools, business schools to get their MD’s and JD’s, and MBA’s. We are talking about African American doctors and lawyers and business executives. And they still have higher infant mortality than White women who never went to high school in the first place. NCHS 2002

SES? – Ask the Africans Birth weight distribution of African-born blacks is more closely related to US-born whites than to US-born blacks David RJ, Collins JW. Differing birth weight among infants of U.S.-born blacks, African-born blacks, and U.S.-born whites. N Engl J Med. 1997 Oct 23;337(17):1209-14.

Pathogenesis (and Salutogenesis): Complex Interaction between Biology and Environment This explains why many, if not all, of the chief public health killers have common root causes. Degradation of personal dignity, social justice and community I can only be as healthy as my neighbors

Enhancing Public Health – A Provocative Perspective Single disease prevention approach rarely works Treating symptoms rather than root causes Since inequities are at root of health disparities, we must work for the equitable distribution of conditions that promote health and healthy development – Social, educational, economic and environmental capital healthcare

Even More Provocative Compensatory or Disparities Model (Affirmative Health Action) flawed See next slide Equity Framework Health is a human right Every human being has intrinsic worth. Policies should be directed to what every person needs and deserves to thrive and contribute

Why Target Whole Communities? Health and well-being of each person depends on condition of all (see next slide) Cannot predict individual course based on group risk factors Cost burden of case-finding and treatment too high Moral weakness of accepting unequal outcomes

Post-neonatal Infant Mortality (per 100,000 live births,1986) Wilkinson RG. Income distribution and life expectancy. BMJ. 1992;304:165-168.

My Vision-Dream for the Health Equity Coalition Expand public understanding of health equity framework Forge strategic partnerships across the county’s public and private sectors – every decision impacts health Document and demonstrate the correlation and causal association between social, economic, educational, environmental and healthcare equity and population health outcomes Advocate for policies and practices that promote and create advantage for all citizens