graphic above from nam; later icons from the...

[Beyond]Social Determinants of HealthWilliam B. Jordan, MD, MPHSeptember 2019

Graphic above from NAM; Later icons from the Noun Project

Disclosures: None

Image from Public Domain Picturesvia Smithsonian Magazine

Learning Objectives• Define social

determinants of health

• Identify major impacts of context

• Describe a public health approach

• Generate a next step

Agenda1. What are

we saying?2. What are

we mapping?

3. What are we doing?

4. What will we do next?

Prologue

http://www.refugees1956.org/2017/01/21/assisting-1956-hungarian-student-refugees-gary-l-filerman/

1. What are we saying?

How We See Ourselves Changes over Time"The single story creates stereotypes, and the problem with stereotypes is not that they are untrue, but that they are incomplete. They make one story become the only story.“-Chimamanda Ngozi Adichie

People Take Shortcuts in Judging Others“All of us, despite the best of all possible intentions, are affected by unconscious processes. It affects what we see, how we react, how we feel, how we behave. If we’re not aware of it and taking measures to counter it, it affects quality of care.”-Michelle van Ryn

Headwinds & Tailwinds: Invisible & Powerful“In my class and place, I did not recognize myself as a racist because I was taught to see racism only in individual acts of meanness by members of my group, never in invisible systems conferring unsought racial dominance on my group from birth…”-Peggy McIntosh

Racism = Prejudice + Power“Racism is a system of power and oppression that structures opportunities and assigns value based on race, unfairly disadvantaging people of color (racial oppression), while unfairly advantaging whites (racial privilege & supremacy)”-Aletha Maybank

Credit: Benjamin Jancewicz

Racism Works across 4 Levels

INTERNALIZED INTERPERSONAL INSTITUTIONAL STRUCTURAL

Race Is a Social Construct with Real Consequences

Transit Housing Services

Incarceration Education Health

Trauma is Perpetuated by Institutional Betrayal“trusted and powerful institutions… acting in ways that visit harm upon those dependent on them for safety and wellbeing… is institutional betrayal…. Institutional betrayal may contribute to the range of deleterious health effects associated with… trauma through incomplete access to health care services.”-Smith and Freyd

https://www.cdc.gov/tuskegee/index.html

Healthcare Can Be Desegregated through Advocacy“when he signed [Medicare] into law, President Lyndon Johnson made a point of not inviting the AMA to the ceremony. He did invite the National Medical Association. That was the organization for black doctors. They'd long supported the bill. They saw the potential for Medicare to help desegregate health care for patients and professionals.”-Edith Mitchell

https://www.blbfilmproductions.com/

Healthcare Needs a Diverse & Structurally Competent Workforce“The trained ability to discern how a host of issues defined clinically as symptoms, attitudes, or diseases also represent the downstream implications of a number of upstream decisions”-Johnathan Metzl & Helena Hansen

Closing Gaps Requires Moving Upstream

http://barhii.org/framework/

Social Determinants of Health Are Midstream““…conflating the social determinants of health and the social processes that shape these determinants’ unequal distribution can seriously mislead policy.” [WHO] Simply accommodating people in systems that were never designed for their survival is inherently inequitable.”-Nashira Baril

Discrimination and stressors Food security and

access to healthy foods

Stable income and job security

Environmental quality

Neighborhood conditionsQuality affordable healthcare

Educationalopportunities

Housing

Health is affected by

America: Equity and Equality in Health 3 – Raising a Voice in the LANCET

“Structural racism and health inequities in the USA: evidence and interventions”Zinzi D Bailey, Nancy Krieger, Madina Agénor, Jasmine Graves, Natalia Linos, Mary T Bassett

HEALTHPeople with fair or poor health outcomes (2014)

14.1% 12.2% 7.3% 8.3% 8.9%

WORKPeople of color face discrimination in the workplace

LIVING CONDITIONSPeople of color are more likely to experience neighborhoods with:

Native American or Alaskan Native

BlackNon-Hispanic

Hispanicor Latino

Asian Whitenon-Hispanic

Nationwideaverage

Poor quality housing

Aggressive surveillance

Concentrated pollution

Resource starved education

13.6%

Social Determinants & Racism Intersect

Historical, Political, and Cultural Contexts Intersect

https://ajph.aphapublications.org/doi/10.2105/AJPH.2007.111278

Defining the Problem Frames the Solutions“Differences in health based on racism and class oppression may be eliminated, but will require exploration of which population groups are made vulnerable by social injustice, particularly powerlessness. Confronting these injustices demands organizing strategies aimed at transforming political power and more broadly addressing the networks of well-resourced interests that generate poor living and working conditions.”-Richard Hofrichter

https://health.ny.gov/prevention/prevention_agenda/health_across_all_policies/

NYC Blueprint for Equity, Sustainability, and Health“The actions we take now will ensure we have a dynamic, inclusive economy, a healthier environment, more affordable housing, and more reliable and resilient infrastructure.”-Bill de Blasio

Health Department Shifted to a Health Equity Framework“Inequities in health are unfair, unnecessary and avoidable. New York City is the most unequal city in the United States and one of the most segregated. It is no surprise that these everyday realities are reflected in our health. A more deliberate effort to name and address these disparities will frame all that we do.”-Mary T. Bassett

2. What are we mapping?

Basic questions to ask ourselves when mapping

1) Who, or what, is being mapped? 2) How is the problem defined? How does this shape the solution?3) What is not on the map? 4) How will resources be distributed based on how the problem is

described?

More Illness & Early Death in Some Neighborhoods

https://www1.nyc.gov/site/doh/health/neighborhood-health/nyc-neighborhood-health-atlas.page

Context Differs by Neighborhood

https://www1.nyc.gov/site/doh/health/neighborhood-health/nyc-neighborhood-health-atlas.page

Addressing Income Inequality Could Prevent Early Death

Estimating Potential Reductions in Premature Mortalityin NYC From Raising the Minimum Wage to $15

Tsao T-Y, Konty KJ, Van Wye G, et al. Estimating Potential Reductions in Premature Mortality in New York City From Raising the Minimum Wage to $15. American Journal of Public Health. 2016;106(6):1036-1041. doi:10.2105/AJPH.2016.303188.

Neighborhood Gaps Persistent but Narrowing

Source: NYC DOHMH Bureau of Vital Statistics, 2000-2016

Premature Mortality

2002-2004 2005-2007 2008-2010 2011-2013 2014-2016

3-Year Averages

Infant Mortality

Housing Policy Drove Segregation & Access to Resources

D1

A1

Segregation Casts a Long Shadow on Health Outcomes

Non-White PopulationPercent

15-4344-7273-9192-99Unpopulated

Source: NYC DOHMH population estimates, matched from US Census Bureau intercensal population estimates, 2010-2013, updated June 2014. U.S. Census Bureau; American Community Survey, 2013 3-year Estimates, Table S1701; generated using American Fact Finder (http://factfinder2.census.gov/)

2a. Mapping Maternal Child Health

Severe Maternal Morbidity Driven by Racism + Poverty

New York City Department of Health and Mental Hygiene (2016). Severe Maternal Morbidity in New York City, 2008–2012. New York, NY.

Toxic Stress Drives Preterm Births

Original study: Krieger N, Huynh M, Li W, Waterman PD, Van Wye G. Severe sociopolitical stressors and preterm births in New York City: September 1, 2015-August 31, 2017.Journal of Epidemiology and Community Health2018 Oct 17.

Look for Uncommon & Better Solutions

USA TODAY Childbirth complication rates at maternity hospitals

2b. Mapping Chronic Illness

Rising Burden of Disease Varies by Geography & Demographics

Gaps in Diabetes Outcomes Driven by Social Determinants

Using Hotspot Data to Target Services

3. What are we doing?

Signing of Equity LegislationLocal laws enacted to require assessment, training, and work around racial and gender equity

Make a Plan: Take Care New York (TCNY)

Develop a Framework: Center for Health Equity

VisionEvery New Yorker has the opportunity to live in a thriving,

resourced, and equitable neighborhood.MissionTo prioritize the elimination of healthinequities, which are rooted in historical and contemporary injustices and discrimination, including racism and other intersecting systems of oppression.

Transform Name Focus Change Mobilize

Approaches & Theory of Change

DISMANTLING TARGETED UNIVERSALISM

FOCUS ON WHERE VARIABLE INVESTMENT IS GREATEST

MEANINGFUL COMMUNITY ENGAGEMENT

MOVING UPSTREAM

CAPACITY BUILDING

Prevention TreatmentExclusiveExclusionary Institution

Passive“Club”

Institution

Symbolic ChangeCompliance organization

Identity Change

Affirming institution

Structural ChangeTransforming

institution

Fully InclusiveMulticultural organization

MONOCULTURAL MULTICULTURAL ANT-RACIST ANTI-RACIST MULTICULTURAL

Continuum on Becoming and Anti-Racist Multicultural Organization

Source: Crossroad Ministry, Jackson, Hardiman

Transform: Make a Long-Term Commitment to System Level Changes

Transform: Use Standard Tools to Be Explicit about Racism

1• Desired results

2• Analysis of data

3• Community engagement

4• Strategies for racial equity

5• Implementation plan

6• Communications and accountability

Transform: Develop a Theory of Change

1) Policies2)Programs and Services 3)Research and Evaluation

That:

• Contribute to the understanding of and advance health equity

• Address structural racism and its impact

• Address the root causes of health inequities

Measurable reduction of

health inequities

Internal and External

Communications

Budgets and Contracts

Data Collection and Metrics

Community Engagement and

Partnerships

Organizational Commitment and

Leadership

Workforce Equity and

Competencies

Organizational Alignment & Capacity Outcomes around

Racial Equity and Social Justice Reflected in:Practice Outcomes Community-

Level Impact

Transform: Embrace a Process of Internal Reform

Normalize

Build Shared AnalysisOperate with Urgency

Organize

Internal InfrastructurePartner with Others

Operationalize

Use Racial Equity ToolsUse Data & Metrics

Visualize

National Best Practice From Center for Social Inclusion (CSI) and Government Alliance on Race and Equity (GARE)

Action Planning Areas

1. Organizational Identity & Communications2. Workforce Equity & Competencies3. Community Engagement 4. Budgets and Contracts

Transform: Create Structures & Set Goals

CommunicationsWorkforce Equity

& InclusionCommunity Engagement

Finance EquityStaff Learning &

Development

Workgroups

Alignment, Management, Coordination, &

Evaluation

Review & Approval

Planning & Development

Implementation & Accountability Cabinet

Steering Committee

Workgroups

Divisional Action Teams

Race to Justice Staff (mgmt team)

Multidirectional communication flow

Core Team

Transform: Create & Adopt a Community Engagement Framework

Transform: Train Staff

AGENCY TOTAL: >7,500(includes DOHMH, non-DOHMH, and remote employees)

82% of staff completed the gender identity and expression awareness module 70% of staff completed the introduction to health equity learning module 27% of staff have completed Race to Justice Core Workshop 12 Undoing Racism Workshops have occurred

Name: Make Injustice Visible through Stories & Data

- Community health profiles- Neighborhood reports- Epi Data Briefs - Journal articles- Opinion editorials - Press events - Blogs

Name: Use Data to Promote Social Change

East Harlem(RANKS 12th)

FinancialDistrict

(RANKS 59th)

Manhattan NYC

4.029.0 18.0 20.0

Elementary school absenteeism

(Per of students missing 20+ or more school days)

East Harlem(RANKS 14th)

FinancialDistrict

(RANKS 59th)

Manhattan NYC

1.1

31.7 16.0 23.6Teen Births(Per 1,000 girls ages 15-19)

East Harlem(RANKS 19th)

Midtown(RANKS 59th)

Manhattan NYC

10.0 5.7 8.1 9.0Preterm Births(Percent of all live births)

East Harlem(RANKS 21st) 13%

Stuyvesant Town andTurtle Bay(RANKS 59th)

3%

Manhattan 7%

NYC 10%

Diabetes (percent of adults)

Focus: Choose a Geography

Focus: Learn from History“Team-work has brought the power to increase efficiency and to prevent duplication of effort, to discover gaps in the local health program, and to provide the service needed.”-Ten-Year Report of the East Harlem Health Center, 1932

Focus: Action CentersDevelop a Neighborhood Strategy

UPSTREAM

DOWNSTREAM

Community Engagement

and Collective Action

Innovation in Programs and

Policy

Co-location and Referrals

Identify and address immediate health and social needs, especially through:

• Capacity building• Resource provision• Service delivery

Identify and elevate barriers in systems, policies, and practices that address living conditions, such as the following:

• Food environment• Violence• Asthma triggers• Birth equity

Address structural determinants of health:

• Larger community organizing and mobilizing

• Policies with health equity impact

Focus: Action CentersActivate Spaces, Welcome Residents, & Provide Services

Focus: Friendship BenchesPeers Create Safe, Non-traditional Public Space to Talk about Mental Health

https://abcnews.go.com/GMA/Wellness/city-benches-encouraging-conversations-mental-health/story?id=64774855

Focus: Healthy Start BrooklynSupporting Women & Families around Children

Infant MoralityRate per 1,000 live births

1.0-2.8

2.9-4.4

4.5-6.0

6.1-9.0

UnpopulatedInterpret with caution due to small number of events

Focus: Healthy Start Brooklyn Support Includes Doulas and Groups

Direct Services through Contracted Partners• Home Visiting and Case

Management• Health Education Classes

Doula Support

Fatherhood Support

Community Action Network

CenteringPregnancy Parenting Education Classes

Exercise Classes

Childbirth Education Classes

Bereavement Support

Focus: Harlem Health Advocacy PartnersCHWs Deliver Services & Organize in Public Housing

“I’m diabetic … I learned about my A1C, and now I am to the point where I no longer take insulin.”

6.7

6.8

6.9

7

7.1

7.2

7.3

1 6 12 18

A1C

Leve

l

Months from Consent to Specimen Collection

18 Month A1C Trajectory ofHHAP Year 1 & 2 ParticipantsVersus Comparison Group

Cohort 1Cohort 2Comparison

Analysis prepared by NYU School of Medicine

Change: Capacity-Building for CBOs & CHWs around Social Determinants

Change: Advancing a Sustainable CBO & CHW Payment ModelPreliminary DSMP results:

• Cost: $743.85 per participant

• Savings: $1,061-$2,228 per participant (hospitalizations)

Change: Shop Healthy NYC! Technical Assistance to the Food Sector & Consumers

Change: Shop Healthy NYC!

Corner Stores Are Promoting Healthier Foods

Change: Health Equity in All Planning

Working across Public Sectors on Neighborhood Plans Centering Health Equity

NACCHO: Local Health Department Strategies for Implementing Health in all Policies

Develop & Structure Agency

Relationships

Incorporate Health into

Decision-Making Process

Build Capacity

Implement Accountability

Structures

Integrate Research Data, and Evaluation

SystemsCoordinate

Funding and Investments

SynchronizeCommunications &

Messaging

Change: Health Equity in All Planning

Neighborhood Plans Center Equitable Health Outcomes and Food Access

Mobilize: Meaningful Community Engagement through Collective Impact

Backbone Support: The frame

Continuous Communication: All parts knowing what is being done at all times

Mutually Reinforcing Activities: Pedaling

Common Agenda: Getting there together or not at all

Shared Measurement: Gears and crank

Mobilize: Increasing Biking and Walking in Brownsville and East New York

“THE STREETS NEED TO BE SAFER.”

Mobilize: Increasing Access to Support through Doulas

4. What will we do next?

What Are We Saying?Are we talking about context (not just each person’s choices)?

What Are We Mapping?Are we holding ourselves accountable to closing gaps for those with the highest burden?

What Are We Doing?Are we reforming our institutions, lifting the voices of those most affected, and working across sectors to improve health?

What Will We Do Next?How will we plan for and make sustainable community investments that close gaps in health?

Thank You! Contact:William B. Jordan, MD, MPH

Center for Health Equity

wjordan@health.nyc.gov