Making Health Equity a Reality: Approaches to Transforming

Public Health PracticeNicolas Freudenberg

ACHIEVE Action InstituteApril 24, 2012

Advancing Health Equity

Nicholas FreudenbergDistinguished Professor of Public Health

City University of New York School of Public Health CDC ACHIEVE Meeting

24 April 2012

2

Today’s Questions 1. What is health equity and why is it important?2. What are the obstacles to health equity?3. What strategies can public health staff, health

advocates and local policy makers use to advance health equity?

4. What are the assets local health departments, community organizations and local elected officials can leverage to promote health equity?

5. How can we get started in making equity a priority in our work?

3

Health equity is achieved when every person has the opportunity to achieve their full potential for health.

Amartya Sen

4

In an equitable society, everyone has opportunity to

Complete education needed to support themselves and families

Find food that sustains healthLive in safe housing Breathe clean air and drink

clean waterParticipate in making decisions

that affect well-being What else?

5

Some Examples of Health Inequalities

• Mortality rate for infants of mothers with less than 12 years of education was 1.5 times higher than for those of mothers with 13 + years of education.

• Native Hawaiians or other Pacific Islanders, American Indians/Alaska Natives, African Americans, Hispanics/Latinos all significantly more likely to have been diagnosed with diabetes compared to White counterparts.

• More than twice as many children (2–5 years) from poor families experienced a greater number of untreated dental caries than children from non-poor families

• 25 year old with less than 9 years of school had average life expectancy 8 years shorter than those who had finished high school, and 12 years shorter than those who had finished at least a year of college. 6

Trends Driving Inequalities in Health

• Increasing poverty and unemployment rates• Cuts in safety net programs for children, poor

people and others • Decline of US manufacturing jobs that

provided road out of poverty • Shift of health care costs from employer to

employee• Reductions in state and local support for

education, health care, and child care7

Changes in Income Equality

8

Racial/Ethnic Differences in School Completion

9

Source: http://filipspagnoli.wordpress.com/stats-on-human-rights/statistics-on-freedom/statistics-on-prisoner-population-rates/

Changes in Incarceration Rates by Race/Ethnicity

10

Strategies for Advancing Health Equity

1. Improve the living conditions that are

fundamental determinants of health2. Protect populations against disease promoting forces3. Support policies that create health promoting

communities4. Bring evidence to those who have the power to

change policy

11

1. Improve the living conditions that are fundamental determinants

of health.

12

13

Deaths Attributable to Social Circumstances, US, 2000

• 245,000 adult deaths attributable to low education, defined as lack of a high school degree;

• 176,000 to racial segregation, • 162,000 death to low social support, not being

connected to people can support health, • 133,000 to individual-level poverty, defined as an

income of less than $10,000, • 119,000 deaths to income inequality, and• 39,000 to area-level poverty. Source: Galea S, Tracy M, Hoggatt KJ, Dimaggio C, Karpati AAm J Public Health. 2011 ;101(8):1456-65.

• 14

Improved school

achievement

Better health

Improved school

achievement

Better lifetime health

15

How education improves health More education

contributes to:• Higher incomes (and the

purchase of better food and housing, more health care, etc.)

• More skills, knowledge and resources to protect health

• More social support and stronger social networks

• Lower rates of unhealthy behavior

Having family members, peers or neighbors with more education also associated with better health 16

What are the health problems that interfere with school achievement?

• Teen pregnancy• Chronic illnesses such as asthma and diabetes• Vision and hearing problems• Learning disorders

• Psychological and emotional problems• Substance use• Family health problems• Violence and bullying• Hunger and obesity• Social isolation

17

Components of a Comprehensive School Health Program

• School based health center with primary care, mental health and reproductive health services

• Comprehensive health and sexuality education• Substance abuse prevention and treatment • Healthy school environment• Safety and violence prevention programs• Family health services• Food services and access to healthy food• Physical activity program

18

What are roles for health professionals in improving school completion rates?

• Educate public and policy makers on education and health virtuous circle

• Develop and advocate for health and other policies and programs that reduce health-related school drop out

• Participate in multi-issue coalitions to improve public schools

• Create an evidence base that can guide policyWhat else?

19

Other areas where evidence shows improved living conditions can reduce

inequalities • Support paid sick leave and

living wage campaigns• End foreclosures and make

affordable housing a policy priority

• Reduce institutional racism and the residential segregation that worsens education, employment and food inequalities

20

2. Protect populations against disease promoting forces

21

US Deaths Related to Products of Key Industries Industry Health outcomes related to

products Estimated Annual Deaths US

Alcohol Accidents, homicides, liver cancer, cirrhosis

100,000

Automobiles Respiratory diseases including lung cancer, heart disease, injuries; obesity and

its associated conditions

43,000

Firearms Homicide, suicide, injuries 35,000

Food and Beverages Obesity, diabetes, heart disease, cancer

365,000(includes deaths attributed to inactivity)

Pharmaceuticals Over and under medication 100,000

Tobacco Heart disease, lung and other cancers, respiratory diseases

435,000

22

Communities fight Big Tobacco

23

3. Support strategies that create health promoting communities

Increase opportunities for safe physical activity

Increase access to healthy foods

Decrease promotion of unhealthy food

Use public space to promote democratic participation

24

4. Bring evidence to those who have power to change policy

2627

Your homework assignment

• Who are the constituencies in your community who can support your efforts to change conditions that allow health inequality to persist?

• What are the messages that will bring these groups together ?

• What are the strategies that will mobilize communities to act to reduce health inequalities?

27

What assets are available to support campaigns to advance

health equity?

• Scientific and health evidence• History of successful efforts • Social Movements and community

organizations • America’s Second Language• Capacity for critical self-reflection

28

Getting started

• Look for deeper causes• Focus on equity• Find your partners• Just do it

29

Stay in touch

Nicholas Freudenberg nfreuden@hunter.cuny.edu

CUNY School of Public Health www.cuny.edu/sph CUNY Doctor of Public Health Program http://web.gc.cuny.edu/publichealthCorporations and Health Watchwww.corporationsandhealth.org

30