NACCHO-CityMatCH
E-MCH Conference Call
January 20, 2005
Social Justice: a matter
of (local) Public Health
Magda Peck ScD
CEO/Senior Advisor, CityMatCH
Professor and Associate Chair for
Community Health, Department of Pediatrics
University of Nebraska Medical Center
Founding Director, MPH Program
[email protected]
402.561.7500
With thanks to
 CityMatCH, NACCHO Families
 University of Nebraska Medical Center
 Dennis Raphael @ SDOH
 Richard Hofrichter (@ NACCHO), plus Nancy
Krieger, Vicente Navarro, John Lynch,
Amaryta Sen, and many many others…
 “Invisible Heroes”
“Expert” Presenter – MCH and
Social Justice: Context and Caveats
 Inherently Personal: obligation, choice
 Historically Professional: public health
values
 Relatively Intellectual: science vs.
conscience
 Recently Intensified: intersections,
introspection
-Martin Luther King, Jr.
"Cowardice asks the question, is it safe?
Expediency asks the question, is it politic?
Vanity asks the question, is it popular?
But conscience asks the question, is it right?
And there comes a time when one must take a
position that is neither safe, nor politic,
nor popular, but he must take it
because his conscience tells him
that it is right...."
“Social Justice” 20 Minute Kickstart
1. Language: definitions, terms
2. Logistics: structures, barriers,
pathways
3. Leverage: power/control,
(resources/wealth), politics
4. Lessons Learned: invisible
heroes
The Language of Optimal “Ends”
 Rights: entitlement
 Equity: fairness
 Equality: sameness
 Justice: righted wrongs
Rudolf Virchow (1821-1901)
19th century German pathologist: V. law
(Omnis cellula e cella), cell, node, and
triad; statesman, public health pioneer
 If medicine is to fulfill her great task, then
she must enter political and social life
 …Constitutional right of the individual
citizen to lead a healthful existence
Eleanor Roosevelt, 1958
Where after all do universal
human rights begin? In small
places close to home.
These are the places where
every man, woman and child
seeks equal justice,
equal opportunity,
equal dignity.
A Just Society…
Ensures the development and
capabilities of all of its members.
Amaryta Sen
The Language of Disrupted
“Means” (to optimal ends)
 Discrimination
 -Isms: race, class, gender…
 Disparities
 Ideology
Health and Discrimination
The rationale for studying health
consequences of discrimination is to
enable a full accounting of what drives
population patterns of health, disease and
well-being, so as to produce knowledge
useful for guiding policies and actions to
reduce social inequalities in health and
promote well-being.
Nancy Krieger, “Discrimination and Health” in Social Epidemiology,
Berkman and Kawachi, 2000.
Race-ism and Public Health
It is impossible to have a frank discussion of
inequality…without confronting the continuing
blight of racism head on…
long established and growing health disparities
are rooted in fundamental social structure
inequalities, which are inextricably bound up
with the racism that continues to pervade
U.S. society.
Cohen and Northridge, AJPH, June 2000, p841
Institutional Racism, revisited
Deeply engrained structural and systemic
factors and policies with differential effects
on individuals’ health
 access to care
 quality of care
 scope and relevance of care “inaction in the face of need”
Camara Jones, 2000
Health Disparities – United States
Measuring Health
 Two overarching
goals:
 Increase
quality and
years of healthy life
 Eliminate health
disparities
Health Disparities – United States
Selected Mortality Rates by Race - 2000
25
20
15
White
AA/B
10
5
0
IMR
NNMR
PNNMR
Source: CDC, H Atrash, NCBDDD, 2004
MMR
Health Disparities – United States
Maternal Mortality Rates, US 1920-2000
Log-Maternal Deaths per 100,000 Live Births
10000
White
Other
1000
AA/B
GAP
100
3.4
10
1
1.8
1920
1930
1940
1950
1960
Year
Source: CDC, H Atrash, NCBDDD, 2004
1970
1980
1990
2000
Health Disparities – United States
Infant Mortality Rates, US 1920-2000
Log-Infant Deaths per 1,000 Live Births
1000
White
Other
AA/B
GAP
100
10
2.5
1.7
1
1920 1930 1940 1950 1960 1970 1980 1990 2000
Year
Source: CDC, H Atrash, NCBDDD, 2004
Health Disparities – United States
Log Neonatal Deaths per 1,000 Live Births
Neonatal Mortality Rates, US 1920-2000
100
White
Other
10
AA/B
Gap
2.5
1.4
1
1920
1930
1940
1950
1960
Year
Source: CDC, H Atrash, NCBDDD, 2004
1970
1980
1990
2000
Health Disparities – United States
Postneonatal Mortality Rates, US 1920-2000
Log Postneonatal Deaths per 1,000 Live Births
100
White
Other
AA/B
Gap
10
2.5
1
1.8
1920
1930
1940
1950
1960
Year
Source: CDC, H Atrash, NCBDDD, 2004
1970
1980
1990
2000
Health Disparities – United States
16
14
12
10
8
6
4
2
0
White
AA/B
Hispanic
19
81
19
83
19
85
19
87
19
89
19
91
19
93
19
95
19
97
19
99
20
01
Percent Low Birthweight
Low Birthweight, United States 1981-2002
Year
Source: CDC, H Atrash, NCBDDD, 2004
Health Disparities – United States
20
15
White
AA/B
Hispanic
10
5
0
19
81
19
83
19
85
19
87
19
89
19
91
19
93
19
95
19
97
19
99
20
01
Percent Preterm Births
Preterm Delivery, United States 1981-2002
Year
Source: CDC, H Atrash, NCBDDD, 2004
Increasing Diversity – United States
Projected Population by Race/Ethnicity 2000-2050
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
All Other
Asian
Hispanic
AA/B
White
2000
2010
2020
2030
Year
Source: CDC, H Atrash, NCBDDD, 2004
2040
2050
“Tonight, we’re going to let the statistics speak for
Ideologic tensions around
persistent health inequities
CAUSES
 individual failure, inevitable consequences of modern
society, random adverse events
OR
 a complex web of power, politics, and ideology that
shapes social structures and systems
SOLUTIONS
 Reformation vs transformation
 Remedies vs root causes
“Social Justice” 20 Minute Kickstart
1.
Language: definitions, terms
2. Logistics: structures, barriers,
pathways
THE FUTURE OF
THE PUBLIC’S HEALTH
Healthy people
Committee
on Assuring the
in healthy
Healthcommunities
of the Public in the
21st Century
in the 21st Century
Health = public good
Health = social goal of many sectors
and communities
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
Ecological Model for
Population Health
Living and working conditions
may include:
Over the life
span
• Psychosocial factors
• Employment status and
occupational factors
• Socioeconomic status
(income, education,
occupation)
• The natural and builtc
environments
• Public health services
• Health care services
NOTES: Adapted from Dahlgren and
Whitehead, 1991. The dotted lines denote
interaction effects between and among the
various levels of health determinants
(Worthman, 1999).
Source: Institute of Medicine Report: The Future of the Public’s Health in the 21st Century, November 2002
Racism: Complex interactions between
direct, physiologic effects and indirect
pathways
Racism



Personally mediated
Internalized
Institutionalized
SES
Residential Segregation
Stress
Environmental Exposures
Other
Physiologic
Effects
Health
Behaviors
Health Care Access
Health Care Quality
Health Status
Health Care Disparities:
IOM Report 2002
The Institute of Medicine’s Committee on
Understanding and Eliminating Racial
and Ethnic Disparities in Health Care
concluded that:
A range of patient-level, provider-level,
and system-level factors may be involved
in racial and ethnic healthcare
disparities, beyond access-related
factors
Health Disparities in Healthcare:
Patient-Level factors
 Yes,
minority patients are more likely to:
 Refuse recommended services
 Adhere poorly to treatment
regimens
 Delay seeking care
 But, these factors are unlikely to be
major sources of healthcare disparities
Health Disparities in Healthcare
Provider-Level factors
 Degree
of uncertainty:
 Information from patients
vs. prior experiences
 Bias against minorities
 Beliefs and stereotypes
Health Disparities in Healthcare
System-Level factors
 System
organization affects patient
care:
 Limited access
 Limited resources
 Discriminatory management
 Language barriers
 Time pressure on physicians
 Geographic availability
Health Disparities:
IOM Recommendations
 Multiple
approaches are required
 Most factors are outside the influence
of the health care system:
 Socioeconomic status
 Cultural factors
 Environmental factors
 Discrimination issues
 Political systems
“Social Justice” 20 Minute Kickstart
1.
2.
Language: definitions, terms
Logistics: structures, barriers, pathways
3. Leverage: power, politics
The Public Health System
Communit
y
Governmental
Public Health
Infrastructure
Health
care
delivery
system
Assuring the
Conditions for
Population
Health
Academia
Employers
and
Business
The Media
What will it really take?
POLITICAL
WILL
KNOWLEDGE BASE
SOCIAL
STRATEGY
From: Richmond and Kotelchuck
We want the same things.
“Social Justice” 20 Minute Kickstart
1. Language: definitions, terms
2. Logistics: structures, barriers, pathways
3. Leverage: power, politics
4. Lessons Learned: invisible
heroes
Dr. William Foege
Emory University/Gates Foundation
 Unwarranted optimism: hallmark in
(public) health professionals;
 Placebo effect in population health?
Allows us to go beyond expectations,
beyond the boundaries of existing
science….
“There is no use trying,” said Alice; “one
can’t believe in impossible things.”
 “I dare say you haven’t had much
practice,” said the Queen.
‘When I was your age, I always
did it for a half an hour a day.
Why, sometimes I’ve believed as
many as six impossible things
before breakfast.”
-Lewis Carroll
When will our consciences
grow so tender that we will act
to prevent human misery
rather than avenge it?
Eleanor Roosevelt
Public Health:
a matter of Justice
Social Justice:
a matter of the public’s health
Want to follow up with me?
[email protected]
or go to the CityMatCH website:
http://www.citymatch.org
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