J. Michael Oakes, PhD

Associate Professor

Co-Director, US Census Research Data Center

Division of Epidemiology University of Minnesota

oakes007@umn.edu

MPHA June 2014

Health Disparities & HiAP

Conclusion

1.  Stark health disparities must be mitigated

2.  Health in all policies is needed and important

On being asked to talk on the principles of research, my first thought was to arise… and say,

“Be careful”

and to sit down.

J Cornfield 1959

Why do we get sick and ultimately die?

Some items from: Baicker & 2008. "Myths and misconceptions about U.S. health insurance." Health Aff 27:w533-43.

Myths about Health Insurance

•  Narrowly, not having health insurance does not make you sick… the reason you got a headache is not because you didn’t have an aspirin.

•  It’s not clear how much health insurance or even medicine prevents disease

•  Health insurance does not imply quality care

Mensah and Brown. 2005. An Overview Of Cardiovascular Disease Burden In The United States, Health Affairs, Vol 26, Issue 1, 38-48

Mokdad, et al "Actual causes of death in the United States, 2000." JAMA 291:1238-45.

What Causes Disease?

Physiology Molec. Bio. Genetics Germs

Behavior Life-Style

Choice

Social Forces Markets Norms

Racism; Sexism

Fundamental/Upstream

Cause of Disease

Immediate/Proximal

D

Health disparities are systematic, plausibly avoidable health differences adversely affecting socially disadvantaged groups…

Braveman et al Health Disparities and Health Equity: The Issue Is Justice. American Journal of Public Health: December 2011, Vol. 101, No. S1, pp. S149-S155. doi: 10.2105/AJPH.2010.300062

A Couple of Basic Facts on

Health Disparities

Harper et al. 2007. "Trends in the black-white life expectancy gap in the United States, 1983-2003." JAMA 297:1224-32.

Infant Mortality Rates by Race, US 1900 - 1998

0

50

100

150

200

250

300

350

1900

1904

1908

1912

1916

1920

1924

1928

1932

1936

1940

1944

1948

1952

1956

1960

1964

1968

1972

1976

1980

1984

1988

1992

1996

Dea

ths

per 1

000

liveb

irths Non-White

White

Homicide, HIV, and perinatal death, although demonstrating favorable trends, continue to keep the black-white gap unnecessarily large… However, cardiovascular-related diseases remain the leading cause of black/white differences in life expectancy. If all cardiovascular causes and diabetes are considered together, they account for 35% and 52% of the gap for males and females, respectively.

Harper et al. 2007. "Trends in the black-white life expectancy gap in the United States, 1983-2003." JAMA 297:1224-32.

International Comparisons

• Kunitz & Pesis-Katz. 2005. "Mortality of white Americans, African Americans, and Canadians: the causes and consequences for health of welfare state institutions and policies." Milbank Q 83:5-39.

Lower Life Expectancy?

Low Class High Class

USA (1980-82) 73.0 75.8

England/Wales (men 1971-76) 66.5 72.0

Brazil (1970) 53.2 62.0

Life Expectancy at Birth

-3

+20 +11

Under 5 Mortality Rate (2010)

(deaths per 1,000 children)

United States = 7.5 Tanzania = 91.3

Tabulation from Ghiselli 2011: 2010 DHS

Avg U5MR = 91

0 50 100 150

Under 5 Mortality per 1,000 Live Births

MaraLindi

IringaMtwaraTanga

MorogoroKigomaKagera

DodomaDar es Salaam

RukwaPemba North

Zanzibar NorthMbeya

Pemba SouthRuvuma

TaboraPwani

MwanzaShinyanga

Zanzibar SouthTown West

SingidaArusha

ManyaraKilimanjaro

Child Mortality in Tanzania, by Region

What surprises me?

What aren’t disparities bigger?

Some Issues

Justice?

Utilitarian: Greatest good for greatest number

Platonic: To the victor, the spoils

Rawlsian: Max welfare of least well off: fairness

Nozickian: Just rules = Just outcome

Marxist: From each according to their ability, to each according to their need

Meritocratic: From each according to their effort, to each according to their effort

Theist: God’s will

Oakesian: Tall people decide

Hippie: Let’s all share; give me some of yours

Golden Rule: Do unto others…

Aristotelian: Treat equals equally, unequals unequally

Egalitarian: Equal outcomes

0

2000

4000

6000

8000

Milli

ons

of P

eopl

e

1000 1200 1400 1600 1800 2000

Year

World Population Growth (1000-2000 CE)

Difference/Disparity in

Outcome or

Opportunity?

Difference or Ratio?

There is nothing new here

Source: Coleman, W. (1982). Death is a Social Disease: Public Health and Political Economy in Early Industrial France. Madison, WI, University of Wisconsin Press.

Source: Coleman, W. (1982). Death is a Social Disease: Public Health and Political Economy in Early Industrial France. Madison, WI, University of Wisconsin Press.

US Child (0-19 years) Mortality Rates, by time and SES

DiLiberti "The relationship between social stratification and all-cause…." Pediatrics 105.1 (2000)

Steckel, Richard H. "A dreadful childhood: The excess mortality of American slaves." Social Science History 10.4 (1986): 427-465.

Causes of Health Differences

Source: Aber, J. L., N. G. Bennett, et al. (1997). "The effects of poverty on child health and development." Annual Review of Public Health 18: 463-83.

Today: Poverty and Child Health •  Intrauterine effects •  Infant mortality •  Low birth weight •  Accidental death •  Blood lead •  Cognitive deficiencies •  Sick days at School •  Lower educational attainment •  Obesity •  Asthma •  Hearing loss •  Chronic stress •  etc…

14

3836

54

25

37

25 25

36

21

25

16

21

4

12

5 4

02

00

20

40

60Pe

rcen

t in

Leve

l

1 2 3 4 5

(Prose Reading)

Reading Level by Race/Ethnicity

White Black API Mexican

Five categories of reading proficiency: 5 = High

Tabulated from NCES 2002 “Adult Literacy in America” National Center for Education Statistics. 1993-5

Hart & Risley 1995. Meaningful Differences in the Everyday Experience of Young American Children.

Estimates for the first 4 years of life reveal… a child of a professional family would accumulate 560,000 more encouragements than discouragements. But a child from a welfare family would accumulate 125,000 more discouragements than encouragements.

Hart & Risley 1995. Meaningful Differences in the Everyday Experience of Young American Children.

PERIOD LOW HIGH

1ST Grade 49 45 2ND Grade 43 42

Total 1st-5th Grade 186 186

Summer 1st – 2nd -5 9 Summer 2nd – 3rd -5 3 Total Summer 1-5 -8 25

Math Gains in Math Achievement Test, by SES

Heckman & Krueger 2005 “Inequality in America” Summary of Table 1.2 (page 31)

Percent who reject Evolution (2005) Source: National Geographic

Different Environments

Sure, but where does environment come from?

HiAP

Whose health? What do you mean by “health”? What policies? Who gets to decide?

Change health to social welfare and you’ll find 250 years of scholarship on how all policies impact social welfare, and which are deemed just/fair by what criteria.

Source: Slide by Linda Rudolf, MD, Public Health Inst

$1,000,000 each, just to get started

$13,000,000,000 to just build

Remedial Models

Poor

Rich

Health Disparity = 3

Soc

ioec

onom

ic s

tatu

s

White

Black

Poor

Excellent

Poor

Rich

Health Disparity = 7

Soc

ioec

onom

ic s

tatu

s

Poor

Excellent

Poor2

Rich

Health Disparity = 2

Poor1

Poor

Excellent

Poor

Rich

Health Disparity = 2

Poor

Poor

Rich

Health Disparity = 3

Soc

ioec

onom

ic s

tatu

s

Health Loss = 5

Poor

Excellent Rich

Health Disparity = 2

Health Loss = 7

Health Loss = 1

Poor

Excel1

Poor1

Rich

Health Disparity = 6

Excel2

Poor2

Health Loss = 2

Health Gain = 2

Poor

Excel2

Poor1

Rich

Health Disparity = 11

Poor2

Health Gain = 4

Health Gain = 5

Excel1

HiAP

Food for Thought

In 2013, the WHO reported that globally, nearly 1/3 of all women are victims of physical or sexual violence. The vast majority of these are attacked by their husbands or boyfriends.

The Atlantic

Simple Results: •  Approx 40% of families eligible to move chose not to

•  Many target communities rejected study families

•  Approx 20% of families that moved to better neighborhoods, moved back

•  No discernable effects on employment rates

•  Self-reported mental health of adults appears to have improved

•  Girls seemed to improve, boys suffered

The $10,000,000 question.

“Mike, you’re the expert,

What should we do?”

•  Create jobs •  Improve schools •  Add PH nurses services •  Increase prenatal services •  Give each HH $10k •  Help increase program take-up •  Add cops to street •  Buy, renovate, and rent houses •  Fund free clinic •  Increase family (abuse) services •  …

•  Early childhood education

•  Provision of health insurance

•  Medical screening

•  Assistance coordination

•  ???

Eden Prairie School District’s 2009 Boundary Re-Drawing

New boundaries would rebalance the schools' enrollments socioeconomically and by school capacity

At Forest Hills Elementary the percent of students receiving free and reduced lunch has climbed to more than 42 percent; but at Cedar Ridge Elementary, it's less than 10 percent. Under the new boundary plan, that discrepancy would fall from a 33-point difference to 2 points.

Conclusion

1.  Stark health disparities must be mitigated

2.  Health in all policies is needed and important

This stuff is too important to be sloppy

in our thinking…

This stuff is too important to be sloppy

in our thinking…

Let’s get to work!

Thank you