Social Determinants of Health and Equity. The Impacts of Racism on Health
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1 Social Determinants of Health and Equity The Impacts of Racism on Health
2 Levels of health intervention
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15 Addressing the social determinants of health Primary prevention Safety net programs and secondary prevention Medical care and tertiary prevention
16 But how do disparities arise? Differences in the quality of care received within the health care system Differences in access to health care, including preventive and curative services Differences in life opportunities, exposures, and stresses that result in differences in underlying health status
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24 Differences in exposures and opportunities Differences in access to care Differences in quality of care (ambulance slow or goes the wrong way)
25 Addressing the social determinants of equity: Why are there differences in resources along the cliff face? Why are there differences in who is found at different parts of the cliff?
26 Determinants of health Individual behaviors
27 Determinants of health Social determinants of health (contexts) Individual behaviors
28 Determinants of health Determinants of health and illness that are outside of the individual Social determinants of health (contexts) Beyond genetic predispositions Individual behaviors Beyond individual behaviors
29 Determinants of health Determinants of health and illness that are outside of the individual Social determinants of health (contexts) The contexts in which individual behaviors arise Beyond genetic predispositions Individual behaviors Beyond individual behaviors
30 Determinants of health Individual resources Education, occupation, income, wealth Social determinants of health (contexts) Individual behaviors
31 Determinants of health Individual resources Education, occupation, income, wealth Neighborhood resources Housing, food choices, public safety, transportation, parks and recreation, political clout Social determinants of health (contexts) Individual behaviors
32 Determinants of health Individual resources Education, occupation, income, wealth Neighborhood resources Housing, food choices, public safety, transportation, parks and recreation, political clout Social determinants of health (contexts) Individual behaviors Hazards and toxic exposures Pesticides, lead, reservoirs of infection
33 Determinants of health Individual resources Education, occupation, income, wealth Neighborhood resources Housing, food choices, public safety, transportation, parks and recreation, political clout Social determinants of health (contexts) Individual behaviors Hazards and toxic exposures Pesticides, lead, reservoirs of infection Opportunity structures Schools, jobs, justice
34 Determinants of health Societal determinants of context Social determinants of health (contexts) Individual behaviors
35 Determine the range of observed contexts Determinants of health Societal determinants of context Social determinants of health (contexts) Individual behaviors
36 Determine the range of observed contexts Determinants of health Societal determinants of context Social determinants of health (contexts) Individual behaviors Determine the distribution of different populations into those contexts
37 Determine the range of observed contexts Determinants of health Societal determinants of context Include capitalism, racism, and other systems of power Social determinants of health (contexts) Individual behaviors Determine the distribution of different populations into those contexts
38 Determine the range of observed contexts Determinants of health Societal determinants of context Include capitalism, racism, and other systems of power Social determinants of health (contexts) Individual behaviors Determine the distribution of different populations into those contexts The social determinants of equity
39 Addressing the social determinants of health Involves the medical care and public health systems, but clearly extends beyond these Requires collaboration with multiple sectors outside of health, including education, housing, labor, justice, transportation, agriculture, and environment
40 Addressing the social determinants of equity Involves monitoring for inequities in exposures and opportunities, as well as for disparities in outcomes Involves examination of structures, policies, practices, norms, and values Requires intervention on societal structures and attention to systems of power
41 Beyond individual behaviors Address the social determinants of health, including poverty, in order to achieve large and sustained improvements in health outcomes Address the social determinants of equity, including racism, in order to achieve social justice and eliminate health disparities
42 Why racism? To eliminate racial disparities in health, need examine fundamental causes Race is only a rough proxy for SES, culture, or genes Race precisely measures the social classification of people in our race - conscious society Hypothesize racism as a fundamental cause of racial disparities in health
43 What is racism? A system
44 What is racism? A system of structuring opportunity and assigning value
45 What is racism? A system of structuring opportunity and assigning value based on the social interpretation of how we look ( race )
46 What is racism? A system of structuring opportunity and assigning value based on the social interpretation of how we look ( race ) Unfairly disadvantages some individuals and communities
47 What is racism? A system of structuring opportunity and assigning value based on the social interpretation of how we look ( race ) Unfairly disadvantages some individuals and communities Unfairly advantages other individuals and communities
48 What is racism? A system of structuring opportunity and assigning value based on the social interpretation of how we look ( race ) Unfairly disadvantages some individuals and communities Unfairly advantages other individuals and communities Saps the strength of the whole society through the waste of human resources Source: Jones CP, Phylon 2003
49 Reactions to Race module Six-question optional module on the Behavioral Risk Factor Surveillance System since 2002 How do other people usually classify you in this country? How often do you think about your race? Perceptions of differential treatment at work or when seeking health care Reports of physical symptoms or emotional upset as a result of race -based treatment
50 States using the Reactions to Race module 2002 to 2009 BRFSS Arkansas, California, Colorado, Delaware, District of Columbia, Florida, Indiana, Michigan, Mississippi, Nebraska, New Hampshire, New Mexico, North Carolina, Ohio, Rhode Island, South Carolina, Virginia, Washington, Wisconsin
51 States using the Reactions to Race module Arkansas 2004 California 2002 Colorado 2004 Delaware District Columbia 2004 Florida 2002 Indiana 2009 Michigan 2006 Mississippi 2004 Nebraska New Hampshire 2002 New Mexico 2002 North Carolina 2002 Ohio Rhode Island South Carolina Virginia 2008 Washington 2004 Wisconsin
52 Socially-assigned race How do other people usually classify you in this country? Would you say: White Black or African-American Hispanic or Latino Asian Native Hawaiian or Other Pacific Islander American Indian or Alaska Native Some other group
53 General health status Would you say that in general your health is: Excellent Very good Good Fair Poor
54 General health status by socially-assigned "race", 2004 BRFSS percent of respondents White Black Hispanic AIAN Report excellent or very good health
55 General health status by socially-assigned "race", 2004 BRFSS percent of respondents White Black Hispanic AIAN Report excellent or very good health
56 General health status by socially-assigned "race", 2004 BRFSS percent of respondents Report fair or poor health White Black Hispanic AIAN Report excellent or very good health
57 General health status and race Being perceived as White is associated with better health
58 Self-identified ethnicity Are you Hispanic or Latino? Yes No
59 Self-identified race Which one or more of the following would you say is your race? White Black or African-American Asian Native Hawaiian or Other Pacific Islander American Indian or Alaska Native Other Which one of these groups would you say best represents your race?
60 Self-identified race /ethnicity Hispanic Yes to Hispanic/Latino ethnicity question Any response to race question White No to Hispanic/Latino ethnicity question Only one response to race question, White Black No to Hispanic/Latino ethnicity question Only one response to race question, Black American Indian/Alaska Native No to Hispanic/Latino ethnicity question Only one response to race question, AI/AN
61 Two measures of race How usually classified by others White Black Hispanic AIAN... How self-identify White 26,373 Black 5,
62 Two measures of race How usually classified by others White Black Hispanic AIAN... How self-identify White 26,373 Black 5,246 Hispanic 1,
63 Two measures of race How usually classified by others White Black Hispanic AIAN... How self-identify White 26,373 Black 5,246 Hispanic 1,
64 General health status, by self-identified and socially-assigned "race", 2004 percent of respondents Hispanic-Hispanic Hispanic-White White-White Report excellent or very good health
65 General health status, by self-identified and socially-assigned "race", 2004 percent of respondents Test of H 0 : That there is no difference in proportions reporting excellent or very good health Hispanic-Hispanic versus White-White p < Hispanic-Hispanic Report excellent or very good health White-White
66 General health status, by self-identified and socially-assigned "race", 2004 percent of respondents Test of H 0 : That there is no difference in proportions reporting excellent or very good health Hispanic-Hispanic versus Hispanic-White p = Hispanic-Hispanic Hispanic-White Report excellent or very good health
67 General health status, by self-identified and socially-assigned "race", 2004 percent of respondents Test of H 0 : That there is no difference in proportions reporting excellent or very good health Hispanic-White versus White-White p = Hispanic-White Report excellent or very good health White-White
68 Two measures of race How usually classified by others White Black Hispanic AIAN... How self-identify White 26,373 Black 5,246 Hispanic 1,528 AIAN
69 Two measures of race How usually classified by others White Black Hispanic AIAN... How self-identify White 26,373 Black 5,246 Hispanic 1,528 AIAN
70 General health status, by self-identified and socially-assigned "race", 2004 percent of respondents AIAN-AIAN AIAN-White White-White Report excellent or very good health
71 General health status, by self-identified and socially-assigned "race", 2004 percent of respondents Test of H 0 : That there is no difference in proportions reporting excellent or very good health AIAN-AIAN versus White-White p < AIAN-AIAN Report excellent or very good health White-White
72 General health status, by self-identified and socially-assigned "race", 2004 percent of respondents Test of H 0 : That there is no difference in proportions reporting excellent or very good health AIAN-AIAN versus AIAN-White p = AIAN-AIAN AIAN-White Report excellent or very good health
73 General health status, by self-identified and socially-assigned "race", 2004 percent of respondents Test of H 0 : That there is no difference in proportions reporting excellent or very good health AIAN-White versus White-White p = AIAN-White Report excellent or very good health White-White
74 General health status and race Being perceived as White is associated with better health Even within non-white self-identified race /ethnic groups
75 General health status and race Being perceived as White is associated with better health Even within non-white self-identified race /ethnic groups Even within the same educational level
76 General health status by education and "race", 2004 BRFSS Percent "excellent" or "very good" w b w b w b w b w b Education level
77 General health status and race Being perceived as White is associated with better health Even within non-white self-identified race /ethnic groups Even within the same educational level Being perceived as White is associated with higher education
78 General health status by education and "race", 2004 BRFSS w b w b w b w b w b Percent "excellent" or "very good" Education level Percent distribution non-black black Education level
79 General health status by education and "race", 2004 BRFSS w b w b w b w b w b Percent "excellent" or "very good" Education level Percent distribution non-white white Education level
80 Key questions WHY is socially-assigned race associated with self-reported general health status? Even within non-white self-identified race /ethnic groups Even within the same educational level WHY is socially-assigned race associated with educational level?
81 Racism A system of structuring opportunity and assigning value based on the social interpretation of how one looks ( race ) Unfairly disadvantages some individuals and communities Unfairly advantages other individuals and communities Saps the strength of the whole society through the waste of human resources Source: Jones CP, Phylon 2003
82 Levels of racism Institutionalized Personally-mediated Internalized
83 Institutionalized racism Differential access to the goods, services, and opportunities of society, by race Examples Housing, education, employment, income Medical facilities Clean environment Information, resources, voice Explains the association between SES and race
84 Personally-mediated racism Differential assumptions about the abilities, motives, and intents of others, by race Prejudice and discrimination Examples Police brutality Physician disrespect Shopkeeper vigilance Waiter indifference Teacher devaluation
85 Internalized racism Acceptance by the stigmatized races of negative messages about our own abilities and intrinsic worth Examples Self-devaluation White man s ice is colder Resignation, helplessness, hopelessness Accepting limitations to our full humanity
86 Levels of Racism: A Gardener s Tale Source: Jones CP, Am J Public Health 2000
87 Who is the gardener? Power to decide Power to act Control of resources Dangerous when Allied with one group Not concerned with equity
88 What is [inequity]? A system of structuring opportunity and assigning value based on [fill in the blank], which Unfairly disadvantages some individuals and communities Unfairly advantages other individuals and communities Saps the strength of the whole society through the waste of human resources
89 Many axes of inequity Race Social class Geography Nationality, language, and legal status Gender Sexual orientation These are risk markers, not risk factors
90 Health equity Health equity is the realization by ALL people of the highest attainable level of health. Source: National Partnership for Action, ongoing discussions, 2009
91 Achieving health equity Requires valuing all individuals and populations equally Source: National Partnership for Action, ongoing discussions, 2009
92 Achieving health equity Requires valuing all individuals and populations equally, and Entails focused and ongoing societal efforts Source: National Partnership for Action, ongoing discussions, 2009
93 Achieving health equity Requires valuing all individuals and populations equally, and Entails focused and ongoing societal efforts To eliminate health disparities Source: National Partnership for Action, ongoing discussions, 2009
94 Achieving health equity Requires valuing all individuals and populations equally, and Entails focused and ongoing societal efforts To eliminate health disparities By assuring the conditions for optimal health for all groups Source: National Partnership for Action, ongoing discussions, 2009
95 Achieving health equity Requires valuing all individuals and populations equally, and Entails focused and ongoing societal efforts To eliminate health disparities By assuring the conditions for optimal health for all groups, Particularly for those who have experienced historical or contemporary injustices or socioeconomic disadvantage. Source: National Partnership for Action, ongoing discussions, 2009
96 Our goal: To expand the conversation Health services
97 Our goal: To expand the conversation Health services Social determinants of health
98 Our goal: To expand the conversation Health services Social determinants of health Social determinants of equity Jones CP et al. Expanding the Fence or Ambulance Debate: Addressing the Social Determinants of Health and Equity. Under review, 2009.
99 Our tasks Put racism on the agenda Name racism as a force determining the distribution of other social determinants of health Routinely monitor for differential exposures, opportunities, and outcomes by race
100 Our tasks Ask, How is racism operating here? Identify mechanisms in structures, policies, practices, norms, and values Attend to both what exists and what is lacking
101 Our tasks Organize and strategize to act Join in grassroots organizing around the conditions of people s lives Identify the structural factors creating and perpetuating those conditions Link with similar efforts across the country and around the world
102 Camara Phyllis Jones, MD, MPH, PhD 4770 Buford Highway NE Mailstop K-67 Atlanta, Georgia (770) phone (770) fax
103 Resources California Newsreel: Unnatural Causes: Is Inequality Making Us Sick? World Health Organization: Commission on Social Determinants of Health
104 Resources CityMatCH: Undoing Racism Action Group National League of Cities: Reducing Racism and Achieving Racial Justice services/382.aspx
105 Resources UNESCO: International Coalition of Cities Against Racism United Nations: World Conference Against Racism, Racial Discrimination, Xenophobia, and Related Intolerance
106 Resources United Nations: Committee to Eliminate Racial Discrimination USA CERD report: anceversion/cerd_c_usa6.doc NGO shadow reports: ngos-usa.htm
107 Resources CDC Racism and Health Workgroup Communications and Dissemination Education and Development Global Matters Liaison and Partnership Organizational Excellence Policy and Legislation Science and Publications
108 Camara Phyllis Jones, MD, MPH, PhD 4770 Buford Highway NE Mailstop K-67 Atlanta, Georgia (770) phone (770) fax
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