Structural Ways to Advance Health Equity MPHA

June 4, 2014

Vayong Moua, MPA

Senior Advocacy and Health Equity Principal

Center for Prevention, Blue Cross and Blue Shield of MN

“Of all the forms of

inequality, injustice in

health care is the most

shocking and inhumane.”

― Martin Luther King Jr.

Spirit Catches You and You Get Up!

Blood Money Bleeding Blue

“The Minnesota Settlement has

been recognized as one of the

most important public health

events of the second half of the

20th Century” - C. Everett Koop, U.S. Surgeon General

1982-1989

Center for Prevention: OUR HISTORYAugust 1994

Blue Cross and the State

of MN file a historic

lawsuit against tobacco

manufacturers

January 1998

Tobacco trial

begins

May 1998

Blue Cross

announces

landmark

settlement

with the

tobacco

industry

November 2001

Blue Cross files

plan to use tobacco

settlement

proceeds to reduce

tobacco use and

improve health

July 2002

Class action

lawsuit filed

against Blue

Cross; plan

put on hold

September 2005

Court approves

end of related

lawsuit

January 2006

Blue Cross

launches

Prevention

Minnesota, a

statewide

initiative to

improve the

health of all

Minnesotans

‘94 ‘98 ‘01 ‘02 ‘05 ‘06 ‘07

October

2007

Freedom to

Breathe law

goes into

effect

‘12

Spring 2013

Working to pass a significant

increase in the tobacco tax

Funding 13 new Health Equity

in Prevention contracts

‘10

May 2010

MN Complete

Streets

legislation signed

June 2010

Nice Ride MN

launches in

Minneapolis

WE ARE IN THE BUSINESS OF…

> Creating healthy communities

> Changing norms, attitudes and behaviors through public awareness initiatives

> Reducing health inequities

> Advocating for policy changes

> Evaluating and continually improving our work

This requires an INNOVATIVE APPROACH

7

This is what we’re up against!

9

WHO IS THE TARGET AUDIENCE?

Social Determinates Or Political Determinants of Health?

Reframing Health: Pulling Togetherhttp://www.youtube.com/watch?v=E2AKhdOge3E

Courageous Conversations: EQ and Cultural Competence

Layers of Racism

Internalized—The set of private beliefs, prejudices, and ideas that individuals have about the

superiority of whites and the inferiority of people of color. Among people of color, it manifests as

internalized oppression. Among whites, it manifests as internalized racial superiority.

Interpersonal—The expression of racism between individuals. It occurs when individuals

interact and their private beliefs affect their interactions.

Institutional—Discriminatory treatment, unfair policies and practices, inequitable opportunities

and impacts within organizations and institutions, based on race, that routinely produce racially

inequitable outcomes for people of color and advantages for white people. Individuals within

institutions take on the power of the institution when they reinforce racial inequities.

Structural—A system in which public policies, institutional practices, cultural representations,

and other norms work in various, often reinforcing ways to perpetuate racial group inequality. It

is racial bias among institutions and across society. It involves the cumulative and compounding

effects of an array of societal factors including the history, culture, ideology and interactions of

institutions and policies that systematically privilege white people and disadvantage people of

color.

> *Adapted from Applied Research Center

Structural Inequities: Race Conscious and Beyond

Structural Racism

“ Structural racism — the normalization of historical,

cultural, institutional and interpersonal dynamics that

routinely advantage white people while producing

cumulative and chronic adverse outcomes for people of

color and American Indians — is rarely talked about.

Revealing where structural racism is operating and

where its effects are being felt is essential for figuring

out where policies and programs can make the greatest

improvements.”

---MDH’S Advancing Health Equity Report

Color Blind = Just Blind

Tragedy and Triumph

> Central Corridor Light Rail

> SHIP’s Evolution

> Tobacco Control and Sacred Use of Tobacco

> Complete Streets …but for who and where?

> Big Tobacco and Big Food/Beverage

(Triangulation of Priorities)

> Tobacco Tax and Health Equity

Unatural and Unacceptable Causes

Our Predisposition for Structural Change

Hello…we already get it!

>Socio-ecological Model

>Social Determinants of Health

>PSE Changes

HiAP = Upstream Alignment and Connectivity

HEALTH EQUITY IN ALL POLICIES (HIAP)

• 21

The Master Framework

HEALTH

BEHAVIORS

INDIVIDUALPerceived

social norms∙ Peers

∙ Family

∙ Culture

Attitudes∙ Benefits

∙ Susceptibility

Self-efficacy∙ Barriers

∙ Skills

Knowledge

SOCIAL

Communities∙ Neighborhoods

Organizations∙ Schools

∙ Worksites

∙ Faith-based

∙ Clinics Family/Friends∙ Traditions

Communications∙ TV

∙ Radio

∙ Internet

∙ Newspaper

STRUCTURAL

Physical environment• Transportation and

Infrastructure

• Roads/bike paths

∙ Convenience stores

Policy environment∙ Health policies

∙ Laws and enforcement

∙ Economic policies

∙ Social policies

Industry∙ Marketing

∙ Lobbying

∙ Practices

∙ Products

Demographics

Biology

Culture∙ Social norms

∙ Behavior

∙ Tobacco Use

∙ Exposure to SHS

∙ Physical Activity

∙ Healthy Eating

HEALTH

OUTCOMES

Decrease

cardiovascular

risk

Decrease

cancer risk

Health Equity By Design: (Un) Common Good

> Embed Health Equity Criteria in projects,

plans, programs, and policies

> Local and Regional PSE

> Community Organizing and Coalition Building

Among Unusual Suspects

> Interrogate Common Good/Population Health

Health in All Policies (HiAP)

Recommendations from National Prevention Council, US Surgeon General

• Facilitate collaboration among diverse sectors (e.g., planning, housing, transportation, energy, education, environmental regulation, agriculture, business associations, labor organizations, health and public health) when making decisions likely to have a significant effect on health.

• Include health criteria as a component of decision making (e.g., policy making, land use and transportation planning).

• Conduct comprehensive community health needs assessments

and develop state and community health improvement plans.

Structural Inequities Requires Structural Equity

> Health Impact Assessments: Healthy Corridor

for All

> Seattle King County Equity Ordinance

> EXECUTIVE ORDER S-04-10

> HiAP and/or Equity Cabinet in MN?!

> HiAP Toolkit (for and from MN)

Full Integration: Universal Design and Cultural Tailoring

Health Equity: 5p’s

–Principles

–Plans

–Projects

–Practices

–Policies

Structural Opportunities: Fight for Equity in Process and Outcome

> Move MN (Active and

Equitable

Transportation)

> Thrive 2040 (and beyond)

> SHIP 3.0

> Food Charter

> Comprehensive Plans

> Municipal/County policies

> DHS’s Cultural and Ethnic

Communities Council

> Equity Cabinet plus

> HiAP Toolkit Underway

>Leverage MDH’s

Health Equity

Report

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Solutions for Most Vulnerable= Solutions for All

Transportation Equity: About 1/3 of Americans Do Not Drive

This includes:

>21% of Americans over 65.

>All children under 16.

>Many low income Americans

who cannot afford automobiles.

>Community members who

choose not to or cannot drive Dan Burden, pedbikeimages.org

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HEALTH EQUITY AND TRANSPORTATIONThe Transportation Prescription

“ For too long now, our

transportation decision

making has failed to address

the impacts that our

infrastructure network has on

public health and equity.”

-Congressman James Oberstar

Community Competence: Early, Often, and Authentic Engagement of Diverse Communities

MDH’s Recommendations for Advancing Health Equity throughout Minnesota

1: Advance health equity through a health in all policies approach across all sectors

2: Continue investments in efforts that currently are working to advance

health equity

3: Provide statewide leadership for advancing health equity

4: Strengthen community relationships and partnerships to advance health

equity

5: Redesign MDH grant-making to advance health equity.

6: Make health equity an emphasis throughout MDH

7: Strengthen the collection and analysis of data to advance health equity

Next steps: Air and Ground Support for MDH

Establish the Minnesota Center for Health Equity

Implement the Advancing Health Equity

recommendations

Convene and coordinate a cabinet-level health

equity effort

Change Equation

Sick and Tired of being Sick and Tired…time for action

1. Prioritize, centralize, and integrate health equity

throughout

2. Focus on mutual capacity building

3. ID key PSE changes to advance Heq in process

/outcome through cross cultural alliances

4. Counter and reframe popular notions that

perpetuate status quo: Create the (un)common

good

Quantum Civics: Be the Policy Maker

Question Bank

> How is it that a nation legally committed to equal opportunity

for all—regardless of race, creed, national origin, or gender—

continually reproduces patterns of racial inequality?

> Why, in the world’s wealthiest country, is there such enduring

poverty among people of color?

> How is it that in our open, participatory democracy, racial

minorities are still underrepresented in positions of power and

decision making?

> Why does Minnesota have some of the worst inequities in

health, education, housing, employment, etc. ? What conditions

allow this to happen and be maintained?

Resources

STRUCTURAL RACISM AND COMMUNITY BUILDING:https://www.aspeninstitute.org/sites/default/files/content/docs/rcc/aspen_structural_racism2.pdf

MDH’s Advancing Health Equity Report:http://www.health.state.mn.us/divs/chs/healthequity/

Forthcoming: Health in All Policies Toolkit (BCBS of MN and PHLC)

THANK YOU

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Vayong Moua, MPA

Senior Advocacy and Health Equity

Principal

1750 Yankee Doodle Road, s113

Eagan, MN 55121

651-662-9530

Vayong_moua@bluecrossmn.com