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David Ansell, MD, MPH Michael E. Kelley Professor of Internal Medicine
SVP and Associate Provost for Community Health Equity
Rush University Medical Center
How Inequality Kills: Social Medicine as a Core Med Ed Competency
I have no disclosures
A Talk in 3 Parts • Part 1: Why Social Medicine?
• Part 2: How Inequality Kills: Structural Violence
• Part 3: Social Medicine as a Core Competency for Med Education
Part 1: Why Social Medicine?
If Health is a Human Right
Then what are the implications for Medical Education?
One street, two worlds
“Doctors within Borders”
Part 2: How Inequality Kills: Equity and Structural Violence
Healthy Chicago 2.0 Map of Communities with Hardship
Z
Source: Healthy Chicago 2.0 Plan, http://www.cityofchicago.org/content/dam/city/depts/cdph/CDPH/HC2.0Plan_3252016.pdf
Chance of a 16 year Black teen on the South Side of Chicago living to 65?
50%
Chicago Black Women 62% More Likely To Die Of Breast Cancer
Age-Adjusted Female Breast Cancer Mortality for
Chicago, Per 100,000 Population.
Prepared by The Sinai Urban Health Institute
De
ath
s p
er
10
0,0
00
wo
me
n
1981-
1983
1984-
1986
1987-
1989
1990-
1992
1993-
1995
1996-
1998
1999-
2001
2002-
2004
50
40
30
20
10
0
38
24
35
39
Black
White
38 per 100,000 is
62% more deaths than 24 per 100,000
2005-
2007
Geography Of the Death Gap Chicago Community Areas with the
Highest Annual Breast Cancer Mortality Rates
2000 - 2005
Predominately African American Communities
Non- African American Communities
Hospitals with American College of Surgeons
Approved Cancer Programs
6 Ways Structural Racism Kills • Concentration of Black Disadvantage (White
Advantage)- location effect
• Structural racism: police, incarceration, schools, housing, jobs, food
• Embodiment of Racism (Embodiment of Privilege)
• Bias (Implicit and Explicit)
• Inequality in quality of health care delivery
• Inequity in health outcomes
Equity and Equality: The social, structural and political determinants of health
Worldwide life expectancy growing
20 year life expectancy gap between rich and poor
Average life expectancies hide large societal death gaps
©2003 RUSH University Medical Center
Global Income Inequality
©2003 RUSH University Medical Center
National Income Inequality Gaps
Income Inequality
Income inequality in OECD countries is at its highest level for the past half century. The average income of the richest 10% of the population is about nine times that of the poorest 10% across the OECD, up from seven times 25 years ago.
60
65
70
75
80
1950 1960 1970 1980 1990 2000 2005
Canada USA
How Does Health Care Influence Life Expectancy?
Lifespan Growing Faster for Canadians than Americans
48
55
51
57
53
59
54
59
55
60
20
30
40
50
60
1991 2006
Poorest Q2 Q3 Q4 Richest
Remaining life
expectancy at age 25
Mortality Gap by Income is Shrinking in Canada
Growing Gap in Life Expectancy by Income
National Academy of Sciences, 2015
The gap is growing in the US Dramatic gains for the wealthy; losses for lower income
Remaining life
expectancy at
age 50
32.3
28.3
31.4 29.7
32.4 32.4 33.4 33.1
36.2
41.9
20
25
30
35
40
45
Turned 50 in 1980 Turned 50 in 2010
Poorest Q2 Q3 Q4 Richest
It is not just about spending
Public includes benefit costs for govt. employees & tax subsidies
for private insurance
Data are for 2014 or most recent year
Sources: OECD 2015; NCHS; Health Affairs 2002 21(4)88
$3,240 $3,710
$4,120 $4,430
$4,720 $5,000 $5,220
$6,470 $6,292
$3,398
$-
$2,000
$4,000
$6,000
$8,000
$10,000
UK JAP FRA CAN GER SWE HOL SWI USA
Total US Public US Private
20
13
he
alt
hca
re s
pe
nd
ing p
er
ca
pit
a
$9,160
29
23 33
41
18
60
42
56
37
47
17
45 40 37
22
54 53 61
39 46 46
15
0
20
40
60
80
100
AUS CAN FR GERNETH NZ NOR SWE SWIZ UK US
2009 2012
Percent
Physician Views of their Health Systems “System Works Well, Only Minor Changes Needed”
Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
Part 3. Social Medicine as a Core Competency
“I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as
well as the infirm.” Hippocratic Oath
“The physicians are the natural
attorneys of the poor, and social
problems fall to a large extent within their jurisdiction.”
Narrative + Data+ Public Action= Change
White Coats for Black Lives
7 Social Medicine Competencies
• Respect for History/ Cultural Humility/Privilege
• Narrative as a tool for “seeing the invisible”
• Improvement skills for mitigating health inequities
• Skills to conduct a structural inequity analysis- social, structural and political determinants of health-”how does structural racism work here?”
• Structured mentored clinical experiences with marginalized populations with reflection
• Advocacy and activism training- “teach speech”
• Tools to manage “empathetic distress”
Differential Incentives leads to Inequality
Health care is a human right
