Health Equity Ron Chapman, MD, MPH Director and State Health Officer California Department of Public Health

What causes health inequities? “The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries. The structural roots of health inequities lie within education, taxation, labor and housing markets, urban planning, government regulation, health care systems, all of which are powerful determinants of health, and ones over which individuals have little or no direct personal control but can only be altered through social and economic policies and political processes.” WHO Commission on the Social Determinants of Health

“Social Determinants of Health”  Social-Physical-Economic-Services Determinants Income & income inequality Education Race/ethnicity/gender & related discrimination Built Environment Stress Social support Early child experiences Employment Housing Transportation Food Environment Social standing

What is the role of health care?  Public Health Agency of Canada: “there is mounting evidence that the contribution of medicine and health care is quite limited, and that spending more on health care will not result in significant further improvements in population health. On the other hand, there are strong and growing indications that other factors such as living and working conditions are crucially important for a healthy population.”

Estimated Deaths Attributable to Social Factors in the US  Low education: 245,000  Racial segregation: 176,000  Low social support: 162,000  Individual level poverty: 133,000  Income inequality: 119,000  Area level poverty: 39,000  In comparison: Acute MI: 192,898 Cerebrovascular disease: 167,661 Lung cancer: 155,521 Estimated Deaths Attributable to Social Factors in the US. Galea S et.al. AJPH:June 16,2011;eprint.

Oakland, CA  People who live in West Oakland can expect to live on average 10 years less than those who live in the Berkeley Hills.  People who live in Bayview/Hunters Point can expect to live on average 14 years less than their counterparts on Russian Hill  Residents of Bay Point can expect to live on average 11 years less than people in Orinda Life Expectancy in the Bay Area

Compared to a white child born in the Oakland hills, a black child born in West Oakland is:  Likely to die almost 15 years earlier  5x more likely to be hospitalized with diabetes  2x as likely to die of heart disease  3x more likely to die of stroke  2x more likely to die of cancer  7x more likely to be born into poverty  4x less likely to read at grade level by grade 4  4 x as likely to live in a neighborhood with high density of fast food and liquor outlets  5.6x more likely to drop out of school Alameda County Department of Public Health

Inequities in Contra Costa County  Hospitalization rate for asthma for African American children 5x that of White children  Latinas have a rate of births to teens more than twice that of the county overall  Most of the homicide deaths in Contra Costa occurred among African Americans  People living in San Pablo, Oakley, Richmond, Antioch, Brentwood and Pittsburg, as well as African Americans and men overall, are more likely to die from heart disease

Health Equity in California  Lowest Infant Mortality African Americans double  Lowest Teenage Pregnancy Hispanic teens double  Lowest Tobacco Use Low income population double

How could income effect health? Income directly shapes:  Nutrition & physical activity options  Housing quality  Neighborhood conditions  Social networks & support  Stress due to inadequate resources to face daily challenges  Medical care Parents’ income shapes the next generation’s:  Education, which shapes their  Working conditions (physical & psychosocial) &  Income Center on Social Disparities in Health, UCSF

Children Raised in Poverty  Have lower levels of educational attainment more likely to score lower on standardized tests, be held back a grade, drop out of high school, less likely to get a college degree attend schools with fewer resources suffer from poor nutrition, chronic stress, and other health problems that interfere with their school work change residences and schools frequently as their families struggle to find affordable housing  Have lower earnings and are more likely to live in poverty as adults

* BARHII The Social Gradient in Health

Across racial and ethnic groups, higher income*, more physically active adults NHIS Age-adjusted * Similar by education

 U.S. California  6.1 million Californians (16.3%) incomes <FPL  2.2 million Ca children (nearly ¼) in families <FPL

Health Impact of Resolving Racial Disparities  1991 to 2000 Medical advances averted 176,633 deaths Equalizing the mortality rates of Whites and African Americans would have averted 886,202 deaths  “The prudence of investing billions in the development of new drugs and technologies while investing only a fraction of that amount in the correction of disparities deserves reconsideration. It is an imbalance that may claim more lives than it saves.” Wolff S. Satcher D., et.al. The Health Impact of Resolving Racial Disparities: An Analysis of US Mortality Data. Am J Public Health. 2004;94:2078–2081

How could a neighborhood affect health?  Safe places to exercise  Access to healthy food  Exposure to targeted advertising of harmful substances  Social networks & support  Norms, role models, peer pressure  Fear, anxiety, stress, despair  Violence and fear  Quality of schools

INSTITUTIONAL POWER Corporations & businesses Government agencies Schools Laws & regulations Not-for-profit organizations RISK BEHAVIORS Risk Behaviors Smoking Poor nutrition Low physical activity Violence Alcohol & other Drugs Sexual behavior LIVING CONDITIONS Physical environment Land use Transportation Housing Residential segregation Exposure to toxins Social environment Experience of class, racism, gender, immigration Culture, incl. media Violence Economic & Work Environment Employment Income Retail businesses Occupational hazards Service environment Health care Education Social services DISEASE & INJURY Communicable disease Chronic disease Injury (intentional & &unintentional) MORTALITY Infant mortality Life expectancy SOCIAL INEQUITIES Class Race/ethnicity Immigration status Gender Sexual orientation UPSTREAMDOWNSTREAM Community capacity building Community organizing Civic engagement Strategic partnerships Advocacy Individual health education Health care Emerging Public Health Practice Current Public Health Practice POLICY Case management A PUBLIC HEALTH FRAMEWORK FOR REDUCING HEALTH INEQUITIES BAY AREA REGIONAL HEALTH INEQUITIES INITIATIVE

Go Before You Show Prenatal Campaign  First trimester prenatal care is key to healthy birth outcomes.  In Solano County, 1 st trimester prenatal care was much higher for women on commercial insurance vs. Medi-Cal.  Go Before You Show campaign created to increase 1 st trimester prenatal care in Medi-Cal.  Results…

Office of Health Equity  Office of Multicultural Health  Office of Multicultural Services  Office of Women’s Health  Health in All Policies  Healthy Place Team