Bloyd_HMPRGBoardMtg_Sept62016FINAL

Escapingthepublichealthfantasyworldtoconfrontthepoli6csofhealthinequity

JimBloyd,MPHCookCountyDepartmentofPublicHealthCollabora6veforHealthEquityCookCounty

September6,2016BoardMee6ng

HealthandMedicinePolicyResearchGroupChicago,Illinois

Mypoints…

•  NeoliberalcontextdominantinChicago,Illinois&USA

•  Publichealthhascreatedafantasy(“fantasyparadigms”)inwhichitbelieves—againsttheevidence--thatfocusonbehaviorchange,medicalcare,and‘downstream’factorswilleliminatehealthinequi6es

•  Opportuni6es&examplesexisttoescapethefantasy&liveuptoourcharge&ethics

ScoZ-Samuel&Smith:“…whileitcanbepoli6callyexpedientforgovernmentstoengagewithhealthinequali6es,theycannot,withintheconfinesofneo-liberalism,realis6callyproposeac6onsthatevidencesuggestswilleffec6velyreducethem-suchastacklingpowerinequali6es,socialstatusandconnec6onsorclassinequality.”“…somepolicyactorsandresearchershavedevisedaparallelfantasyworldinwhichproximal,downstream,easilytackledexposuresarepositedaspoten6alsolu6onstohealthinequali6es.”ScoZ-Samuel&Smith2015p.1

RWJFOvercomingObstaclestoHealth WHOCSDHReport

“Goodhealthdependsonpersonalchoiceandresponsibility....Eachofusmustmakeacommitmentto:

“Socialinjus6ceiskillingpeopleonagrandscale”

Eatahealthydiet “healthinequi6es…arecausedbytheunequaldistribu6onofpower,income,goods,andservices,globallyandna6onally,theconsequentunfairnessintheimmediate,visiblecircumstancesofpeople’slives”

Physicalac6vity “Thisunequaldistribu6onofhealthdamagingexperience...istheresultofatoxiccombina6onofpoorsocialpoliciesandprogrammes,unfaireconomicarrangementsandbadpoli6cs.”

Avoidriskybehaviors

Avoidhealthandsafetyhazardsathomeandatwork

Nurturechildren”

Source:Marmot&Bell(2011)

•  theanswertoourhealthdisadvantagecannotbesolvedbyreforminghealthcarealoneorbyadmonishingAmericanstoadopthealthierhabits.Rather,thesocialandfiscalissuesthatdominatetoday’snewsmaymaZerasmuchorevenmoretoourhealththananycuremedicinecanrender.(Woolf&Aron2016)

Publichealthispoli6cal

Thehealthofpopula,onsandplacesisnotonlyunderthecontrolofindividualci,zensorlocalcommuni,es,butitisalsosubjecttothewiderpoli,calrela,onsofthestate,theeconomyand

society.Further,changingsocietyisonlyachievablethroughpoli,csandpoli,cal

struggle.Bambra2016

Thepolicyviewsofthe1%:moreconserva6veandmoreinfluen6al

•  Pageetal(2013)DemocracyandthepolicypreferencesofwealthyAmericans

•  McElwee(2016)HowChicago'sWhiteDonorClassDistortsCityPolicy.

•  Gilens(2012)Affluenceandinfluence:Economicinequalityandpoli,calpowerinamerica

DisagreementsaboutUSAFedGovtSpendingLevels‘expand,’‘cutback,’or‘keepthesame’

-100 -80 -60 -40 -20 0 20 40 60

Improveinfrastructure-scien6ficresearchaidtoeduca6onJobsprograms

Environmentalprotec6onHomelandsecurity

HealthcareFoodstamps

SocialSecurityDefensespending

Economicaidtootherna6onsFarmsubsidies General

Public

Wealthy(1%)

Cutback Expand

(Page,Bartels&Seawright2013)

2/15/16Collabora6veForHealthEquityCook

CountyWHEREPEOPLEPLACEANDPOWERMATTER

8

Pageetal2013

8

32

35

53

61

87

0 10 20 30 40 50 60 70 80 90 100

Thefederalgovernmentshouldprovidejobsforeveryoneableandwillingtoworkwhocannot

findajobinprivateemployment

Favorna6onalhealthinsurance,whichwouldbe

financedbytaxmoney,payingformostformsofhealthcare

Thefederalgovernmentshouldspendwhateverisnecessarytoensurethatallchildrenhavereallygoodpublicschoolsthey

cangoto

%GeneralPublic

%Wealthy



9

AffluenceandInfluence:The“preference/policylink”(Gilens2012)•  “…undermostcircumstances,thepreferencesofthevastmajorityofAmericansappeartohaveessen6allynoimpactonwhichpoliciesthegovernmentdoesordoesn’tadopt.”[loca6on203]

•  “Whenless-well-offAmericansholdpreferencesthatdivergefromthoseoftheaffluent,policyresponsivenesstothewell-offremainsstrongbutresponsivenesstolower-incomegroupsallbutdisappears.”[Loca6on285]



10

Whenwefight,Wewin!Jobin-Leeds&AgitArte2016TheNewPress.NewYork

•  Movementsaresourcesoflessons•  Tryingisthepathtovictory•  Winningrequiresa“we”•  Transforma6vechange,inthefaceofpowerfulforces,requiresafight

•  Wewinourownpersonaltransforma6on•  ClaimingourhumanityandrighttofightisawinWhenwefightwewin:voicesofcusngedgeleadersaddressingrootcausesofinequi6es



12

IllinoisTippedMinWage$4.95(AllegreZo&Cooper2014)

“Therighttosearchfortruthimpliesalsoaduty;onemustnotconcealanypartofwhatonehasrecognizedtobetrue.”AlbertEinstein

Source:Na6onalAcademiesofSciences;Tsaoetal2016;Komroetal2016)

CustomerssubsidizebusinessesinUStwo-6eredwagesystemAllegreZo&Cooper(2014);Jayaraman(2016)

Workersadvocates

NRAPresHermanCain1996

USCongress

1996DealFreezesTippedworkerswages

ChicagoCensusTractIncomeDistribu6on

Nolan(2015)VoorheesCenter

Nolan(2015)VoorheesCenter

StructuralRacism-20-24year-oldsnotworking/inschool(GreatCi6esIns6tute2016)

•  www.checookcounty.org@CHECookCounty•  SpearheadingCCDPHstructuralracism-healthinequi6espriorityinWePLAN2020

•  17-MembergoverningSteeringCommiZee•  1of19teamsintheUSNa6onalCollabora6vesforHealthEquity;communityofprac6ce;BrianSmedley

CHELeadershipDevelopment:Videoapplica6ontoRobertWoodJohnsonFounda6onCultureofHealthavailableathZps://youtu.be/

ZzfvuktE0jo

ICEMeasure

Data & Map Prepared by: Jasmine Smith & Erika MarshallProjection: NAD 1983 State Plane Illinois EastData Source: U.S. Census Bureau, ACS 2014 5-Year Estimate; Chicago Data Portal, Community Area boundaries 2015l;CMAP, Municipality boundaries 2014July 15, 2016For CHE Cook County: http://www.checookcounty.org/

Index of Concentration at the Extremes (ICE)Income by Census Tract in Cook County 2012

Draft

¯0 3.5 7 10.5 141.75Miles

Where:Ai = # Affluent Households in Census Tract(>=$100,000 Household Income)Pi = # Poor Households in Census Tract(<$25,000 Household Income)Ti = Total # Households in Census Tract

-1 = 100% of Pop. Concentrated Deprivation 0 = Equal Concentration Deprivation/Privilege 1 = 100% of Pop. Concentrated Privilege

ICEi = (Ai - Pi)/Ti

ICE: Income(in Quintiles)

-1.00 - -0.30

-0.31 - -0.11

-0.12 - 0.03

0.04 - 0.22

0.23 - 0.81

1.  SteepergradientswithhealthinequityinNYCthantypical%povertymeasure(Krieger2016)

2.  Focusonconcentratedprivilegeaswellasdepriva6on

3.  Canjointlymeasureincome&race-ethnicitysegrea6on

4.  UnlikeGini&dissimilarityindex,hasmeaningatsmallgeographies(Massey)

5.  CHECookCounty(JasmineSmith;ErikaMarshall),DePaul,UIC,CCDPH,CDPH

ThankYou!

www.checookcounty.orgwww.cookcountypublichealth.org@CHECookCounty @CookCoHealthYoutube.com/ccplacemaZersJimBloyd,MPH,RegionalHealthOfficerCookCountyDepartmentofPubicHealth15900S.CiceroAvenueOakForest,[email protected]

Addi6onalmaterialtodiscuss--6mepermisng!

Challenges

•  Censorship/Useoflanguage•  Lackofexplicitnessofframework•  Lackofexplicitnessofvalues

Tes6ngFundamentalCausetheory:implica6onsforac6ontoreducehealthinequali6es

ScoZetal(2013)

Behaviorisdeterminedbysocialfactors(Marmot2007)

Behaviorisdeterminedbysocialfactors(Marmot2007)

RWJF,framing,socialgradient(MarmotBell2011)

LifeExpectancyGradientCookCounty

USPolicyChoice:ChildPovertyOutlierMarmot(2007)

“WeinhealthcareneedtodoabeZerjobofsuppor6ngeffortsforpreven6oninothersectors–likechildcare,educa6on,housing,andurbanplanning—thatarethelargestdeterminantsofwhogetssickinthefirstplace.Doctorsandothercliniciansneedtobepartofthatworkandbeinvolvedingesngtheirclinicstodomoretoaddresssocialdeterminantsofhealth.Theyneedtools,examplesandrolemodels.”PaulaBravemanManchanda(2013)

“Formanydecades,thefieldhasbeenconstrainedbyself-imposedlimita6onsand,alltooo}en,hasavoidedengagementwiththosewhochallengecomplacencyandexis6ngpower

rela6onships.”AmyFairchild(Fairchildetal2010)

HealthDivides:Whereyoulivecankillyou(Bambra2016)

Placebothcreatesandcontainssocial,economicandpoli,calrela,onsaswellasphysicalresources.Spa,alinequali,esinhealthare

thereforearesultofacomplexmixofeconomic,social,environmentalandpoli,calprocesses-

comingtogetherinpar,cularplaces.

Itisnotinequali,esthatkillpeople,[…]itisthosewhoareresponsiblefortheseinequali,es

thatkillpeople.VicenteNavarro2009(emphasisintheoriginal)

“Theresult[ofthesocialsitua6on]isthesameasiftwentyorthirtythousandofthesepeoplewereannuallytakenoutoftheirwretched

dwellingandputtodeath.”EdwinChadwick,CommissioneroftheBoardofHealthofGreatBritain(1848-1854)(Chernomas&Hudson2009)

Stra6fica6on

•  Allsocie6esarestra6fiedalonglinesofethnicity,race,gender,educa6on,occupa6on,income,andclass.Healthinequi6esresultfromunequaldistribu6onofpower,pres6ge,andresourcesamonggroupsinsociety.Marmot2007

CommissionontheSocialDeterminantsofHealthConceptualFramework(WHOSolar&Irwin2010)

ReferencesAllegreZo,S.A.,&Cooper,D.(2014).Twenty-threeyearsands,llwai,ngforchange:Whyit's,metogive,ppedworkerstheregularminimumwage(p.27).Washington,DC:EconomicPolicyIns6tute.(OriginalworkpublishedJuly10,2014)RetrievedfromhZp://www.irle.berkeley.edu/cwed/briefs/EPI-CWED-BP379-1.pdfBambra,C.(2016).Healthdivides:Whereyoulivecankillyou.Bristol,UK:PolicyPressChernomas,R.,&Hudson,I.(2009).Socialmurderandconserva6veeconomics.CriminalJus,ceMaVers,77(1),2-3.doi:10.1080/09627250903138852Fairchild,A.L.,Rosner,D.,Colgrove,J.,Bayer,R.,&Fried,L.P.(2010).TheEXODUSofpublichealth.Whathistorycantellusaboutthefuture.AmericanJournalofPublicHealth,100(1),54-63.doi:10.2105/AJPH.2009.16395Fafard,P.(2008).Evidenceandhealthypublicpolicyinsightsfromhealthandpoli,calsciences.OZawa,Ont.:CanadianPolicyResearchNetworks.RetrievedfromNa6onalCollabora6ngCentreforHealthyPublicPolicy:hZp://www.ncchpp.ca/docs/FafardEvidence08June.pdGilens,M.(2012).Affluenceandinfluence:Economicinequalityandpoli,calpowerinamerica.Princeton,N.J:PrincetonUniversityPress;NewYork:RussellSageFounda6on.InternalRevenueServices.ScheduleHForm990.(n.d.).ScheduleHform990.[Pamphlet)Jayaraman,S.(2016).Forked:Anewstandardforamericandining.NewYork,NY:OxfordKomro,K.A.,Livingston,M.D.,Markowitz,S.,&Wagenaar,A.C.(2016).Theeffectofanincreasedminimumwageoninfantmortalityandbirthweight.AmericanJournalofPublicHealth,106(8),1514-6.doi:10.2105/AJPH.2016.30326Krieger,etal.(2016).Publichealthmonitoringofprivilegeanddepriva6onwiththeindexofconcentra6onattheextremes.AmericanJournalofPublicHealth,106(2),256-263.doi:10.2105/AJPH.2015.30295Manchanda,R.(2013).TheUShealthdisadvantageandclinicians:Aninterviewwithpaulabraveman.Healthaffairsblog[Webpage].RetrievedfromhZp://healthaffairs.org/blog/2013/02/22/the-us-health-disadvantage-and-clinicians-an-interview-with-paula-bravemanMarmot,M.(2007).Achievinghealthequity:Fromrootcausestofairoutcomes.Lancet,370(9593),1153-1163.doi:10.1016/s0140-6736(07)61385-Marmot,M.,&Bell,R.(2011).Improvinghealth:Socialdeterminantsandpersonalchoice.AmericanJournalofPreven,veMedicine,40(1S1),S73-S77.doi:10.1016/j.amepre.2010.10.01Massey,D.(2001).Theprodigalparadigmreturns:Ecologycomesbacktosociology..InDoesittakeavillage?Communityeffectsonchildren,adolescents,andfamilies.BoothA,crouterA,editors(pp.41-48).NewJersey:LawrenceErlbaumAssociates.McElwee,S.(2016).Howchicago'swhitedonorclassdistortscitypolicy.RetrievedfromhZp://www.demos.org/publica6on/how-chicagos-white-donor-class-distorts-city-policNa6onalAcademiesofSciences(2016)hZp://www.nasonline.org/about-nas/visi6ng-nas/nas-building/the-einstein-memorial.htmlAccessed9/3/16.Navarro,V.(2009).Whatwemeanbysocialdeterminantsofhealth.Interna,onalJournalofHealthServices:Planning,Administra,on,Evalua,on,39(3),423-41Nolan,L.(2015).Adeepeningdivide:Incomeinequalitygrowsspa6allyinchicago.RetrievedfromhZps://voorheescenter.wordpress.com/2015/03/11/a-deepening-divide-income-inequality-grows-spa6ally-in-chicago/?blogsub=confirming#subscribe-blogPage,B.,Bartels,L.,&Seawright,J.(2013).Democracyandthepolicypreferencesofwealthyamericans.Perspec,vesonPoli,cs,11(01),51-73.doi:10.1017/S153759271200360RobertWoodJohnsonFounda6on.OvercomingObstaclestoHealth:reportfromtheRobertWoodJohnsonFounda6ontotheCommissiontoBuildaHealthierAmerica.PrincetonNJ:RobertWoodJohnsonFounda6on,2008.Singh,S.R.,Young,G.J.,DanielLee,S.-Y.,Song,P.H.,&Alexander,J.A.(2015).Analysisofhospitalcommunitybenefitexpenditures�alignmentwithcommunityhealthneeds:Evidencefromana6onalinves6ga6onoftax-exempthospitals.AmericanJournalofPublicHealth,105(5),914-921ScoZ,S.,Curnock,E.,Mitchell,R.,Robinson,M.,Taulbut,M.,Tod,E.,&McCartney,G.(2013).Whatwouldittaketoeradicatehealthinequali,es?Tes,ngthefundamentalcausestheoryofhealthinequali,esinscotland.NHSHealthScotlandSolar,O.,&Irwin,A.(2010).Aconceptualframeworkforac,ononthesocialdeterminantsofhealth.Socialdeterminantsofhealthdiscussionpaper2(policyandprac,ce)Geneva:WorldHealthOrganiza6on.Tsao,T.Y.,Konty,K.J.,VanWye,G.,Barbot,O.,Hadler,J.L.,Linos,N.,&BasseZ,M.T.(2016).Es6ma6ngpoten6alreduc6onsinprematuremortalityinnewyorkcityfromraisingtheminimumwageto$15.AmericanJournalofPublicHealth,106(6),1036-41.doi:10.2105/AJPH.2016.303188Woolf,S.,&Aron,L.(2016).TheU.S.Healthdisadvantageandtheroleofspending.HealthAffairsBlog[Webpage]RetrievedfromhZp://healthaffairs.org/blog/2016/06/01/the-u-s-health-disadvantage-and-the-role-of-spending

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Bloyd_HMPRGBoardMtg_Sept62016FINAL