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