1. Health Equity March 21, 2016

2. What is health? “Health is a state of complete physical, social and mental well- being, and not merely the absence of disease or infirmity.” World Health Organization 1948

3. Public Health “Public health is what we, as a society, do collectively to assure the conditions in which (all) people can be healthy.” Institute of Medicine (1988), Future of Public Health

4. Factors that determine health Tarlov AR. Public policy frameworks for improving population health. Ann N Y Acad Sci 1999; 896: 281-93.

5. Necessary conditions for health Peace Shelter Education Food Income Stable eco-system Sustainable resources Social justice and equity World Health Organization. Ottawa charter for health promotion. International Conference on Health Promotion: The Move Towards a New Public Health, November 17-21, 1986 Ottawa, Ontario, Canada, 1986. Accessed July 12, 2002 at.

6. Social Determinants of Health External environments and conditions that contribute to health or lack of health.

7. Health Equity Attainment of the highest level of health possible for all people. Achieving health equity requires valuing everyone with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health disparities and health care disparities

8. Health Equity: Diabetes by Income Level, Minnesota 2010

9. Health Inequity Health Inequity—Differences in health status between more and less socially and economically advantaged groups, caused by systematic differences in social conditions and processes that effectively determine health. Health inequities are avoidable, unjust, and therefore actionable.

10. Health Equity: Diabetes by Income Level, Minnesota 2010 Source: CDC Behavioral Risk Factor Surveillance System Percentages are weighted to population characteristics.

11. Structural inequities Structures or systems of society — such as finance, housing, transportation, education, social opportunities, etc. — that are structured in such a way that they benefit one population unfairly (whether intended or not).

12. Who’s affected by structural inequities in Minnesota? American Indians African Americans Children Persons with mental health challenges LGBTQ Immigrants Refugees Asian-Pacific Islanders Hispanics/Latinos Rural Minnesotans Women Older Minnesotans Persons with disabilities And more…

13. Health equity and structural racism: Structural racism is the normalization of an array of dynamics — historical, cultural, institutional and interpersonal — that routinely advantage white people while producing cumulative and chronic adverse outcomes for people of color and American Indians.

14. Health inequities in Minnesota are significant and persistent, especially by race: In Minnesota, an African American or Native American infant has more than twice the chance of dying in the first year of life as a white baby.

15. Appendix D: Redlining and Infant Mortality in Minneapolis, MN

16. Infant mortality rates in Minneapolis by neighborhood, 2001-2010

17. Comparison: Redlining and Infant Mortality in Minneapolis “Color-coded maps indicated which neighborhoods were considered lesser (green=best; blue=still desirable) or greater (yellow=declining; and red=hazardous), investment risks,…”

18. Low Birth Weight (singletons) by Race, 2011 Bloomington, Richfield 7% Minnesota Department of Health Vital Records, 2010 White Black/African American White Black/African American

19. Preterm Births (singletons) by Race, 2011 Edina 6% Minnesota Department of Health Vital Records, 2010

20. What is Structural Inequity? Systematic or Structural elements of society that benefit one population unfairly. Finance Housing Transportation Education Social Opportunities ETC… From Minnesota Department of Health Office of Health Statistics, Advancing Health Equity in Minnesota, 2014

21. Who graduates on time?

22. Structural Inequity Employment Financial Security Ability to pay high property tax Access to Quality School System Education

23. Structural Inequity Employment Financial Security Ability to pay high property tax Access to Quality School System Lower Education

24. Structural Inequity Unemployment Financial Security Ability to pay high property tax Access to Quality School System Lower Education

25. Structural Inequity Unemployment Financial Insecurity Ability to pay high property tax Access to Quality School System Lower Education

26. Structural Inequity Unemployment Financial Insecurity Inability to pay high property tax Access to Quality School System Lower Education

27. Structural Inequity Unemployment Financial Insecurity Inability to pay high property tax Lack of Access to Quality School System Lower Education

28. Structural Inequity Unemployment Financial Insecurity Inability to pay high property tax Lack of Access to Quality School System Lower Education Is this Systematic?

29. Bloomington Unemployment American Community Survey: 2010-2014 (5-year estimates) Employment Status

30. Edina Unemployment American Community Survey: 2010-2014 (5-year estimates) Employment Status

31. Richfield Unemployment American Community Survey: 2010-2014 (5-year estimates) Employment Status

32. How could education affect health? Braveman P, Gottlieb L. Public Health Rep. 2014 Jan-Feb;129 Suppl 2:19-31. The social determinants of health: it's time to consider the causes of the causes.

33. Lets look at obesity and health equity

34. Overweight and Obesity Leads to… Coronary Heart Disease High Blood Pressure Stroke Type 2 Diabetes Abnormal Body Fats Metabolic Syndrome Hold on there’s more…

35. Overweight and Obesity Leads to… Cancer Osteoarthritis Sleep Apnea Obesity Hypoventilation Syndrome Reproductive problems Gallstones Overweight and Obese children are more likely to be so as adults

36. Ok, who’s obese in Bloomington, Edina and Richfield?

37. Bloomington Overweight by Race/Ethnicity 18.3% Minnesota Student Survey, 2013 Dark bars differ significantly from White (p<0.05)

38. Edina Overweight by Race/Ethnicity 23.6% Minnesota Student Survey, 2013 Dark bars differ significantly from White (p<0.05)

39. Richfield Overweight by Race/Ethnicity 17.5% Minnesota Student Survey, 2013 Dark bars differ significantly from White (p<0.05)

40. Chronic Disease by Income Adults Bloomington, Edina, Richfield and Eden Prairie Hennepin County Adult SHAPE, 2010 Dark bars and light bars differ significantly from each other (p<0.05) 3.7% 6.5%

41. Interconnectedness If we are not all healthy together, none of us is as healthy as we could be.

42. Public Health “Public health is what we, as a society, do collectively to assure the conditions in which (all) people can be healthy.” Institute of Medicine (1988), Future of Public Health

43. A community effort Health – and health equity - are created in the community by people working together to create just economic, social and environmental conditions that promote health.

44. Everyone needs: Access to economic and educational opportunities (high school graduation, access to jobs, transportation, etc.)… The capacity to make decisions and effect change for ourselves, our families and our communities (empowerment of women, community self- governance, opportunities for civic participation, etc.)…

45. Everyone needs (cont’d)… Social and environmental safety in the places we live, learn, work, worship and play (housing conditions, crime rates, school climate, social norms and attitudes, etc.) and Culturally-competent and appropriate services when the need arises (access to health care, mental health care, financial assistance, etc.)

46. What needs to be done Achieving health equity and eliminating health disparities requires valuing everyone and making intentional, consistent efforts to address avoidable systematic inequalities, historical and contemporary injustices.

47. To create change Public understanding – of what creates health Public agenda – create expectation that we can and will address these conditions Public/political will – to make tough choices- accountability for policies, programs

48. Our Approach Continue to support BER’s work to factor in health in all policies Building the capacity of our staff to understand and address health equity Management team taking the Intercultural Development Inventory Breaking down silos and asking questions Thinking creatively on funding Health equity work does not fit the traditional public health funding model Collaborating Expanding our collaborative work within BER to address health equity Developing new relationship in the community Strengthening existing relationships Sharing data on health equity Acknowledging solution will be collaboratively developed and implemented Being patient Source: Advancing health equity: Case studies of health equity practice in four award-winning California health departments.

49. Questions