Making Health Equity a Reality: Approaches to Transforming Public Health Practice Nicolas Freudenberg ACHIEVE Action Institute April 24, 2012

Advancing Health Equity Nicholas Freudenberg Distinguished Professor of Public Health City University of New York School of Public Health CDC ACHIEVE Meeting 24 April

Today’s Questions 1. What is health equity and why is it important? 2. What are the obstacles to health equity? 3. What strategies can public health staff, health advocates and local policy makers use to advance health equity? 4. What are the assets local health departments, community organizations and local elected officials can leverage to promote health equity? 5. How can we get started in making equity a priority in our work? 3

Health equity is achieved when every person has the opportunity to achieve their full potential for health. Amartya Sen 4

In an equitable society, everyone has opportunity to Complete education needed to support themselves and families Find food that sustains health Live in safe housing Breathe clean air and drink clean water Participate in making decisions that affect well-being What else? 5

Some Examples of Health Inequalities Mortality rate for infants of mothers with less than 12 years of education was 1.5 times higher than for those of mothers with 13 + years of education. Native Hawaiians or other Pacific Islanders, American Indians/Alaska Natives, African Americans, Hispanics/Latinos all significantly more likely to have been diagnosed with diabetes compared to White counterparts. More than twice as many children (2–5 years) from poor families experienced a greater number of untreated dental caries than children from non-poor families 25 year old with less than 9 years of school had average life expectancy 8 years shorter than those who had finished high school, and 12 years shorter than those who had finished at least a year of college. 6

Trends Driving Inequalities in Health Increasing poverty and unemployment rates Cuts in safety net programs for children, poor people and others Decline of US manufacturing jobs that provided road out of poverty Shift of health care costs from employer to employee Reductions in state and local support for education, health care, and child care 7

Changes in Income Equality 8

Racial/Ethnic Differences in School Completion 9

Source : / / Changes in Incarceration Rates by Race/Ethnicity 10

Strategies for Advancing Health Equity 1. Improve the living conditions that are fundamental determinants of health 2. Protect populations against disease promoting forces 3.Support policies that create health promoting communities 4.Bring evidence to those who have the power to change policy 11

1. Improve the living conditions that are fundamental determinants of health. 12

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Deaths Attributable to Social Circumstances, US, ,000 adult deaths attributable to low education, defined as lack of a high school degree; 176,000 to racial segregation, 162,000 death to low social support, not being connected to people can support health, 133,000 to individual-level poverty, defined as an income of less than $10,000, 119,000 deaths to income inequality, and 39,000 to area-level poverty. Source: Galea S, Tracy M, Hoggatt KJ, Dimaggio C, Karpati AAm J Public Health ;101(8):

Improved school achievement Better health Improved school achievement Better lifetime health 15

How education improves health More education contributes to: Higher incomes (and the purchase of better food and housing, more health care, etc.) More skills, knowledge and resources to protect health More social support and stronger social networks Lower rates of unhealthy behavior Having family members, peers or neighbors with more education also associated with better health 16

What are the health problems that interfere with school achievement? Teen pregnancy Chronic illnesses such as asthma and diabetes Vision and hearing problems Learning disorders Psychological and emotional problems Substance use Family health problems Violence and bullying Hunger and obesity Social isolation 17

Components of a Comprehensive School Health Program School based health center with primary care, mental health and reproductive health services Comprehensive health and sexuality education Substance abuse prevention and treatment Healthy school environment Safety and violence prevention programs Family health services Food services and access to healthy food Physical activity program 18

What are roles for health professionals in improving school completion rates? Educate public and policy makers on education and health virtuous circle Develop and advocate for health and other policies and programs that reduce health-related school drop out Participate in multi-issue coalitions to improve public schools Create an evidence base that can guide policy What else? 19

Other areas where evidence shows improved living conditions can reduce inequalities Support paid sick leave and living wage campaigns End foreclosures and make affordable housing a policy priority Reduce institutional racism and the residential segregation that worsens education, employment and food inequalities 20

2. Protect populations against disease promoting forces 21

US Deaths Related to Products of Key Industries IndustryHealth outcomes related to products Estimated Annual Deaths US AlcoholAccidents, homicides, liver cancer, cirrhosis 100,000 AutomobilesRespiratory diseases including lung cancer, heart disease, injuries; obesity and its associated conditions 43,000 FirearmsHomicide, suicide, injuries35,000 Food and BeveragesObesity, diabetes, heart disease, cancer 365,000 (includes deaths attributed to inactivity) PharmaceuticalsOver and under medication100,000 TobaccoHeart disease, lung and other cancers, respiratory diseases 435,000 22

Communities fight Big Tobacco 23

3. Support strategies that create health promoting communities Increase opportunities for safe physical activity Increase access to healthy foods Decrease promotion of unhealthy food Use public space to promote democratic participation 24

Why focus on policy? Two approaches to improving health 25

4. Bring evidence to those who have power to change policy 26 27

Your homework assignment Who are the constituencies in your community who can support your efforts to change conditions that allow health inequality to persist? What are the messages that will bring these groups together ? What are the strategies that will mobilize communities to act to reduce health inequalities? 27

What assets are available to support campaigns to advance health equity? Scientific and health evidence History of successful efforts Social Movements and community organizations America’s Second Language Capacity for critical self-reflection 28

Getting started Look for deeper causes Focus on equity Find your partners Just do it 29

Stay in touch Nicholas Freudenberg CUNY School of Public Health CUNY Doctor of Public Health Program Corporations and Health Watch 30