Community Health and Health Disparities: A Shared Responsibility Saint Louis University School of Public Health Greater St. Louis Community Health Speaker Series Thursday, January 14, 2010 Deborah Prothrow-Stith, MD Consultant, SpencerStuart Adjunct Professor, Harvard School of Public Health

2 There Are Many Indicators of Poor Health Outcomes Among U.S. Minorities Incidence rate of hypertension is 11 % higher for African Americans as for whites Black infant mortality is more than twice white infant mortality: 14 per 1,000 vs. 6 per 1,000 births Life expectancy for black men (67.8 yrs) is seven years less than that for white men (74.6) Blacks, Hispanics, and Asian Americans are also more likely to be uninsured Approximately 39% of blacks, 46% of Hispanics, compared with 26% of whites do not have a regular doctor Approximately 45% of Hispanics, 41% of Asians, 35% of blacks report difficulty paying for medical care, vs. 26% of whites National Center for Health Statistics

3 MLK Quote “Of all the forms of inequality, injustice in health is the most shocking and the most inhuman.” Martin Luther King Jr. March 25, 1966 Chicago

4 Effective Strategies for Community Health Require I.Increasing the knowledge base Example: race and racism II.Eliminating turf wars Example: Medicine and Public Health III.Thinking outside the box Example: CBPR IV. Yielding decision-making power Example: Boxing Out the Violence

5 I. Increasing Knowledge Example: Racism and Health “Race” is not a biological construct that reflects innate differences, but a social construct capturing the social classification of people in our race-conscious society. Race-associated differences in health outcomes may in fact be due to the impacts of racism.

6 Census Irregularities 1790 to 1850, the only categories recorded were White and Black (Negro), with Black designated as free and slave to 1870, 1890, 1910, and 1920, enumerators were instructed to identify Mulattoes (and Quadroons and Octoroons in 1890) among the Black population. 1860, with much of the West region of the United States being counted, American Indians (excluding those not taxed) and Chinese (in California only) were identified separately. Japanese were identified separately starting in census, Asian and Pacific Islander categories other than Chinese and Japanese were identified for the first time in decennial census reports, including, for example, Filipino, Hindu, and Korean.

7 Census Irregularities 1930 census only, there was a separate race category for Mexican. The race category of Mexican was eliminated in 1940, and 1930 race data were revised to include the Mexican population with the White population. 1950, an attempt was made for the first time (and with limited success) to identify individuals of mixed American Indian, Black, and White ancestry living in certain communities in the eastern United States Other individuals who were Asian and Pacific Islanders and individuals of mixed American Indian, Black, and White ancestry were grouped together as "Other race.“ Koreans were identified in tabulations for the conterminous United States and Hawaii, and Eskimos and Aleut were again identified only in Alaska.

8 Three Levels of Racism Institutionalized: Differential access by race to goods, services, and opportunities of society. –inherited disadvantage –material conditions, access to power Interpersonal or Personally mediated: Prejudice and discrimination. Internalized: Acceptance by members of stigmatized races of negative messages about our own abilities and intrinsic worth.

9 TIME SPAN CITIZENSHIP STATUS -YRS PERCENT U.S. EXPERIENCE STATUSHEALTH & HEALTH SYSTEM EXPERIENCE % Chattel slavery Disparate/inequitable treatment; poor health status & outcomes. “ Slave health deficit ” & “ Slave health sub-system ” in effect % Virtually no citizenship rights Absent or inferior treatment and facilities. De jure segregation/ discrimination in South, de facto throughout most of health system. “ Slave health deficit ” uncorrected % Most citizenship rights Southern medical school desegregation [1948], Imhotep Hospital Integration Conferences [ ], hospital desegregation in federal courts [1964]. Disparate health status, outcomes, and services with apartheid, discrimination, institutional racism and bias in effect % The struggle continues HEALTH DISPARITIES/ INEQUITIES AFRICAN AMERICAN CITIZENSHIP STATUS & HEALTH EXPERIENCE FROM 1619 TO 2010 Source: Byrd, WM, Clayton, LA. An American Health Dilemma, Volume 1, A Medical History of African Americans and the Problem of Race: Beginnings to 1900, New York, NY: Routledge

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11 Anti-Racism Curriculum

12 II. Eliminating the Turf Wars Example: Medicine and Public Health

13 Medicine Anatomy Histology Biochemistry Physiology Pathophysiology Pharmacology Establishing a Relationship Building Trust Taking a History Patient Education Developing a Rx plan Receiving Feedback Soliciting Cooperation Excellence in clinical care requires merging the “art” and “science” medicine

14 Public Health Epidemiology Biological Sciences Biostatistics Behavioral Science Political Science Economics Environmental Science Assessment Policy development Assurance Program Development Design Implementation Management Evaluation Communication Leadership Cultural competency Excellence in public health practice requires merging of the “art” and “science” of public health

15 Proposed Relationship Between Public Health and Medicine Primary PreventionSecondary PreventionTertiary Prevention Education & Policy Risk Reduction Treatment Medicine Public Health Type of Intervention Degree of Discipline Involvement in Interventions

16 III.Thinking outside the box Example: Community Based Participatory Research CBPR is a collaborative approach to research that equitably involves all partners in the research process and recognizes the unique strengths that each brings. W. K. Kellogg Foundation Community Health Scholars Program (2001) “participatory research fundamentally is about who has the right to speak, to analyze, and to act.” Budd Hall, 1992

17 Similar Activities and Labels PR –Participatory Research PAR Participatory Action Research Collaborative Action Research Action Research – now a more overarching term describing participatory inquiry and PRACTICE Mutual Inquiry FPR –Feminist Participatory Research

18 What Created the CBPR Movement 21 st century’s problems (e.g.HIV, Homelessness, environmental injustice, violence) are too complex for a traditional “outside expert” approach. Greater community and political demands for accountability within the research arena. Considerable community and funder disappointment with traditional research paradigms. Scholars of color and feminist scholars paying attention to issues of race, class, culture as these influence research enterprises.

19 Fundamental Characteristics of CBPR It is participatory (from beginning to end). It is cooperative, engaging community members and researchers in a joint process in which both contribute equally. It is a co-learning process. It involves systems development and local community capacity building. It is an empowering process through which participants can increase control over their lives. It achieves a balance between research and action (a shift in the power equation). * Barbara Israel et al (1998)

20 CBPR Guiding Principles CBPR begins with a research topic of importance to the community with the aim of combining knowledge and action for social change to improve community health and eliminate health disparities. Community Benefit Mutual Benefit Mutual Investment Career Development Can Research become an organizing theme for a social change movement in a community that has been abused by research in the past?

21 IV: Yielding Power Example: Boxing Out the Violence

22 Optimism is a MUST I.Increasing the knowledge base Example: race and racism II.Eliminating turf wars Example: Medicine and Public Health III.Thinking outside the box Example: CBPR IV. Yielding decision-making power Example: Boxing Out the Violence

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