advancing health in new york city: channeling the...
TRANSCRIPT
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Presentation Title Goes Here 1
Advancing Health in New York City:
Channeling the Tides to Lift All Boats
Marc N. Gourevitch, MD, MPH
Department of Population Health, NYU School of Medicine
Intersectoral Forum on Advancing Health and Equity in NYC
March 26, 2014
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Overview • Net gains in NYC health over last 10-15 yrs are substantial
and must be preserved and extended
• Unacceptable inequalities persist, some worsening
• Further gains require specific efforts to ↓ inequalities, by: o Sharpening focus on most disadvantaged communities o Engaging other sectors that also produce health o Optimizing impact of healthcare sector on health
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Dowell & Farley, Lancet 2012
Current smoking, ≥18 years old, NYC 1993–2010
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IHME, 2013
Change in life expectancy, Females, 1985-2010
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Alcorn, Lancet 2012
Life expectancy, by Borough, 1985-2009
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NYC DOHMH, Bureau of Vital Statistics, March 2013 7
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NYC DOHMH, Bureau of Vital Statistics, March 2013 8
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NYC DOHMH, 2014 9
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What produces health?
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NY Times, March 16, 2014 12
Median household income & life expectancy, US counties
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Bradley, Elkins, Herrin, Elbel. BMHJ Qual Saf, 2011
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↑ ratio of social : health expenditures in OECD countries → ↓infant mortality ↑ life expectancy ↓ potential life years lost
(after adjusting for level of health expenditures, GDP)
Spending on social programs vs. healthcare: impact on health
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Mortality, USA – Yr 2000: Dx’d vs underlying causes
Diagnosed Causes N = 2.4 million
Heart Cancer Stroke Resp Injury Diabetes Flu/Pneu Other
Underlying Behavioral Causes
N = 1.2 million
Smoking Obes/inact Alcohol MVA Guns Unprot'd sex Drugs
Mokdad JAMA 2004
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Galea, Tracy, Hoggatt, DiMaggio, Karpati, AJPH 2011
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Mortality, USA – Yr 2000: Social factor attribution
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Furman Center Annual Report 2012 16
Education: Bachelor’s Degree & Higher, NYC, 2000 - 2012
0
10
20
30
40
50
60
2000 2012
White Black Hispanic Asian %
NY
C a
dults
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Furman Center Annual Reports, 2006 and 2012 17
Poverty rate, NYC, 2000 - 2012
0
5
10
15
20
25
30
35
2000 2012
White Black Hispanic Asian
% h
ouse
hold
s <
pove
rty
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Furman Center Annual Reports, 2006 and 2012 18
Severe crowding: % of rental households, NYC, 2006 - 2012
(>1.5 household members/room)
0
1
2
3
4
5
6
7
8
9
2006 2012
White Black Hispanic Asian
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NYC DOHMH, 2010 19
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Inequalities in income: Gini coefficients* by borough
*measure of income dispersion in geographic area
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Inequalties in health: which way forward?
Furman Center Annual Reports, 2006 and 2012 21
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Inequalties in health: which way forward?
Furman Center Annual Reports, 2006 and 2012 22
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Inequalties in health: which way forward?
Furman Center Annual Reports, 2006 and 2012 23
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Inequalties in health: which way forward?
Furman Center Annual Reports, 2006 and 2012 24
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House lights and spotlights
• City-wide approaches o Public health and healthcare sectors
Ø Regulatory initiatives, prevention: continued promise
o Other sectors Ø Downstream impact could be even greater
• Community/neighborhood/population – grounded approaches
o Fundamental to eliminating health inequalities
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Complementary approaches: policy and community
2014 2024 2034
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↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑
A B C D E
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Complementary approaches: policy and community
2014 2024 2034
27
↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑
A B C D E
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Complementary approaches: policy and community
2014 2024 2034
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↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑
A B C D E
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Complementary approaches: policy and community
2014 2024 2034
29
A B C D E
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Complementary approaches: policy and community
2014 2024 2034
↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑
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↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑
A B C D E
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Smoking rates – NYC, 2002 - 2012
0
5
10
15
20
25
30
2002 2012
White, M Black, M Hispanic, M Asian, M White, F Black, F Hispanic, F Asian, F
NYC DOHMH, EpiQuery 31
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Strategies forward
1. City-wide health policy approaches • Legislation • Regulation • Procurement
2. Bridge other sectors to tackle upstream determinants
• Health in All Policies 3. Deepen focus on / partnership with highest need communities 4. Extend the population impact of healthcare
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City-wide health policy approaches
• Legislation • Regulation • Procurement
• Examples: o Sugar-sweetened beverage portion size o ↑ age of cigarette purchasing to 21
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Bridging other sectors to tackle upstream determinants
Health in all Policies (HIAP)
• Transportation
• Education
• Housing
• Built environment
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L Brotman, 2014
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• 4248 families in Boston, Baltimore, Chicago, LA, NYC
• Randomly assigned (1994-97) to: 1. housing voucher that could be used to move to a low poverty
(<10%) neighborhood 2. housing voucher with no geographic restrictions 3. control group
• In 2002, one adult (98% female) from each family was
followed up by interview
Moving to Opportunity demonstration
Kling JR, Liebman JB, Katz LF. (http://www.ksg.harvard.edu/jeffreyliebman/MTOcomprehensivejune2005.pdf)
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Obesity Outcomes in MTO
0 5
10 15 20 25 30 35 40 45 50
Low poverty Traditional Control
% O
besi
ty
P = .04
P = .09
Kling JR, Liebman JB, Katz LF. (http://www.ksg.harvard.edu/jeffreyliebman/MTOcomprehensivejune2005.pdf)
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36.7
51.2
22.2
60.2
0
10
20
30
40
50
60
70
HBP Ever Currently taking BP Meds
Black White
Percentage of residents reporting high blood pressure ever and currently taking HTN medications by race (age-adjusted)
NYC Community Health Survey 2012
Deepening partnerships w/ communities at highest risk: Hypertension inequalities in NYC
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Deepening partnerships w/ communities at highest risk: Health Ministry-based BP Dashboard
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Extending the population impact of healthcare delivery • Healthcare system: a minor actor?
But: » Resource-rich » Concentrated focus on health » Strong evidence behind preventive interventions
• New opportunities » Payment mechanisms favoring population-oriented
approach » Primary care » CHWs » Community benefit
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Total area popula+on
Pop’n for which delivery system at risk
Total area popula+on Pop’n for
which delivery system at risk
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42 Jacobson & Teutsch, 2012
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43 Jacobson & Teutsch, 2012
Delivery system?
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2013 2014 2015 2016 2017 2018 2019 2020
Accountable partnership
organizations (APOs)
↑ Affordable housing
Univ pre-K
Minimum wage
Green carts ubiquitous; Safe, well-lit
stairwells
Narcan
Pre
mat
ure
Mor
talit
y 2020 look-back?
Community-grounded, sector-bridging
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Moving forward
• Don’t dim the house lights
• Intensify focus on and deepen partnerships with communities at greatest disadvantage
• Broaden interface of healthcare and community health
• Actively adopt health strategies in key health-producing sectors
• Address income inequality – Tax policy; affordable housing policy; new entry level jobs