1. CENTER ON SOCIAL DISPARITIES IN HEALTH University of California, San Francisco What is health equity -- And how will more data help us achieve it? Human Rights and Health Equity Department Annual Symposium Mt. Sinai Hospital, Toronto, Canada May 13, 2014 Paula Braveman, MD, MPH University of California, San Francisco Professor of Family & Community Medicine Director, Center on Social Disparities in Health

2. “The poor are getting poorer, but with the rich getting richer it all averages out in the long run.” ©2000 The New Yorker Collection from cartoonbank.com. All rights reserved

3. CENTER ON SOCIAL DISPARITIES IN HEALTH University of California, San Francisco What are “health disparities/inequalities”?  Differences, variations  Subtle implication of potential concern  Most official U.S.A. definitions refer only to differences between unspecified groups  But we really mean: Health differences that are unfair in a particular way  Whitehead: unfair, avoidable, unjust  But notions of fairness, justice, and avoidability vary

4. CENTER ON SOCIAL DISPARITIES IN HEALTH University of California, San Francisco Are these health differences in Canada unfair? Infant mortality 60% higher among poorest v richest income quintile & 4 times higher among Inuit vs general Canadian population Disabled Canadians often have delayed Ca detection due to providers attributing symptoms to pre-existing conditions So. Asian Canadians have 3-5 times the CVD mortality risk as White Canadians Trans people experience high levels of mental & emotional distress due to marginalization/rejection

5. CENTER ON SOCIAL DISPARITIES IN HEALTH University of California, San Francisco Are all health differences unfair?  Skiers have more leg fractures than non-skiers  Younger adults healthier than elderly  White women have more breast Ca  Wealthy people in Toronto have higher rates of an illness than wealthy people in Montreal  Some middle-class communities lack adequate supply of dentists  Who decides what’s fair? Source: Google Images http://antiques.lovetoknow.com/antique-balance-scales

6. CENTER ON SOCIAL DISPARITIES IN HEALTH University of California, San Francisco Can we call it unfair if the causes are unknown?  low birth weight  preterm birth  which predict infant mortality, childhood disability & development, and adult chronic disease  Unknown causes  Compared with European-American (“White”) newborns, African-American (“Black”) newborns are 2 to 3 times as likely to have:

7. A human rights-based definition of health inequality  A health difference closely linked with social (including economic) disadvantage  Adversely affects groups who have experienced greater obstacles to health based on:  racial or ethnic group, religion, socioeconomic status/position, disability, sexual orientation, gender, gender identity, or other characteristics historically linked to discrimination or exclusion

8. Not all health differences are health inequalities  Not all health differences – or even all health differences warranting action  A particular subset of health differences  Plausibly avoidable, systematic  Adversely affect socially disadvantaged groups  May or may not be caused by social disadvantage  Unfair because they put already socially disadvantaged groups at further disadvantage with respect to their health

9. Equity is justice  Equity is the goal of eliminating inequalities  Inequalities: the metric to assess progress toward equity  Equity versus equality: Equal rights vs. equal resources  Obligation to focus on those with the greatest social/economic obstacles to fulfilling their rights  Health equity requires justice in medical care and the social factors that shape opportunities to be healthy

10. Infant mortality rate: England and Wales Source: T. McKeown, 1974. NICU’s Penicillin

11. How could income (or wealth) affect health? Income can shape: Medical care Nutrition & physical activity options Housing & neighborhood conditions Services Which can affect: Stress Family stability Parents’ income shapes offspring’s: Education Occupation Income Work conditions

12. Diet Exercise Smoking Health/disease management Education can shape health behaviors by determining knowledge and skills Health knowledge Literacy Problem- solving Coping skills Educational attainment

13. Other plausible pathways from education to health, e.g., via work & income HEALTH Educational attainment  Health insurance  Sick leave  Stress  Neighborhood/ school environment  Diet & exercise options  Stress Working conditions Work- related resources Income Work  Control / demand imbalance  Stress

14. Psychosocial pathways from education to health Educational attainment  Social & economic resources  Norms  Social support  Stress HEALTH  Social & economic resources  Perceived status  Stress Control beliefs (powerlessness, sense/locus of control, fatalism, mastery) Social standing Social networks  Coping  Response to stressors

15. CENTER ON SOCIAL DISPARITIES IN HEALTH University of California, San Francisco How could discrimination harm health?  By constraining social and economic opportunities  e.g., institutional/structural racism  racial segregation  deep, concentrated, inter-generational poverty with little chance to escape  health-damaging vs health-promoting exposures and experiences (nutrition, housing, neighborhood conditions, stress of economic hardship…)  Additional psychological effects, e.g., on self-esteem; stress of being the “out” group, threatened, vigilance  Racial inequality could diminish social cohesion, affecting everyone

16. CENTER ON SOCIAL DISPARITIES IN HEALTH University of California, San Francisco Is the stress-health link biologically plausible? Advances in neuroscience help elucidate how social factors “get into the body” HPA axis, sympathetic nervous system, and immune/inflammatory mechanisms have been demonstrated as responses to stress – Mediators include cortisol, other stress hormones, cytokines, telomerase Chronic stress is a plausible and likely major contributor to both socioeconomic and racial/ethnic inequalities in health

17. Social position, e.g. by race & class Social consequences of ill health Disease 1. Social stratification SOCIETY INDIVIDUAL Specific exposure 5. More social inequity 3. Differentialvulnerability 2. Differential exposure 4. Differentialconsequences Social Context Policy Context What creates & perpetuates health inequities across the life course and across generations? Adapted from Finn Diderichsen, U. Copenhagen 17 Preventing unequal consequences Decreasing harmful exposures Decreasing vulnerability Influencing social inequity

18. HEALTH Behaviors Medical Care Living & Working Conditions in Homes and Communities Economic & Social Opportunities and Resources Policies to promote child and youth development and education, infancy through college Policies to promote healthier homes, neighborhoods, schools and workplaces Policies to promote economic development, reduce poverty, and reduce racial segregation Pursuing health equity requires understanding and addressing the role of social factors Adapted from Robert Wood Johnson Foundation Commission to Build a Healthier America | www.commissiononhealth.org Interactions between genes and experiences

19. CENTER ON SOCIAL DISPARITIES IN HEALTH University of California, San Francisco What can medical care providers and institutions do about health equity?  So much we do not know. Great complexity.  An intervention that works in one setting or population may fail miserably in another  Health effects often don’t manifest for decades  Weigh risks of acting on less-than-certain knowledge against risks of continued inequitable status quo  Act on the best available knowledge. We know enough to act.  Health equity requires addressing the social determinants of health.

20. CENTER ON SOCIAL DISPARITIES IN HEALTH University of California, San Francisco What can medical care providers and institutions do about health equity?  Collect and use data on social factors to guide practice and policy (see Racialization & Health in Toronto, October 2013)  More effective Rx plans  Strategically positioned to identify needs for social services and collaborate with appropriate agencies to address these needs  Advocating policies likely to reduce health disparities – Policies on poverty, child care, education, transportation, housing… – Moral and scientific authority – speaking to health effects