Social Determinants of Health

1. Social Determinants of Health Social Determinants of Equity

2. Camara Phyllis Jones, MD, MPH, PhD Research Director on Social Determinants of Health and Equity Emerging Investigations and Analytic Methods Branch Division of Adult and Community Health National Center for Chronic Disease Prevention and Health Promotion Coordinating Center for Health Promotion Centers for Disease Control and Prevention

17. But how do disparities arise? Differences in the quality of care received within the health care system Differences in access to health care, including preventive and curative services Differences in life opportunities, exposures, and stresses that result in differences in underlying health status

18. Through inequities

19. Through inequities

20. Through inequities

21. Through inequities

43. Addressing the social determinants of health Involves the medical care and public health systems, but clearly extends beyond these Requires collaboration with multiple sectors outside of health, including education, housing, labor, justice, transportation, agriculture, and environment

44. Addressing the social determinants of equity Involves monitoring for inequities in exposures and opportunities, as well as for disparities in outcomes Involves examination of structures, policies, practices, norms, and values to answer, �How are these inequities being maintained?� Requires intervention on societal structures and attention to systems of power

45. We need to do both Address the social determinants of health, including poverty, in order to achieve large and sustained improvements in health outcomes Address the social determinants of equity, including racism, in order to achieve social justice and eliminate health disparities

46. Levels of racism Institutionalized Personally-mediated Internalized

47. Institutionalized racism Differential access to the goods, services, and opportunities of society, by �race� Examples Housing, education, employment, income Medical facilities Clean environment Information, resources, voice Explains the association between SES and �race�

48. Personally-mediated racism Differential assumptions about the abilities, motives, and intents of others, by �race� Prejudice and discrimination Examples Police brutality Physician disrespect Shopkeeper vigilance Waiter indifference Teacher devaluation

49. Internalized racism Acceptance by the stigmatized �races� of negative messages about our own abilities and intrinsic worth Examples Self-devaluation White man�s ice is colder Resignation, helplessness, hopelessness Accepting limitations to our full humanity

50. Levels of Racism: A Gardener�s Tale

51. Who is the gardener? Power to decide Power to act Control of resources Dangerous when Allied with one group Not concerned with equity But there is a very important question that I have not raised so far. Who is the gardener? It is the one with agency and the control of resources, and in this country that is the government. It is particularly dangerous when the gardener is allied with one group over others (you see I have colored the gardener red, explaining the preference for red flowers). It is also dangerous when the gardener is not concerned with equity. If she had been, she would have asked the question why the pink flowers were not faring so well. Just asking the question would have led her to seek solutions. So that is the end of my story on levels of racism. The story was meant to illustrate the different levels of racism and how they are related, and to highlight that institutionalized racism is the most fundamental level. If you want to make real change in the garden, you have to at least deal with the institutionalized racism, even as you might also want to address the other two levels. Also, when you do address the institutionalized racism, the other levels will fix themselves over time. But there is a very important question that I have not raised so far. Who is the gardener? It is the one with agency and the control of resources, and in this country that is the government. It is particularly dangerous when the gardener is allied with one group over others (you see I have colored the gardener red, explaining the preference for red flowers). It is also dangerous when the gardener is not concerned with equity. If she had been, she would have asked the question why the pink flowers were not faring so well. Just asking the question would have led her to seek solutions. So that is the end of my story on levels of racism. The story was meant to illustrate the different levels of racism and how they are related, and to highlight that institutionalized racism is the most fundamental level. If you want to make real change in the garden, you have to at least deal with the institutionalized racism, even as you might also want to address the other two levels. Also, when you do address the institutionalized racism, the other levels will fix themselves over time.

52. Our tasks Put racism on the agenda Name racism as a force determining the distribution of other social determinants of health Routinely monitor for differential exposures, opportunities, and outcomes by �race�

53. Our tasks Ask, �How is racism operating here?� Identify mechanisms in structures, policies, practices, and norms Attend to both what exists and what is lacking

54. Our tasks Organize and strategize to act Join in grassroots organizing around the conditions of people�s lives Identify the structural factors creating and perpetuating those conditions Link with similar efforts across the country and around the world