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The William T. Small Keynote Lecture School of Public Health University of North Carolina-Chapel Hill March 1, 2002

The William T. Small Keynote Lecture School of Public Health University of North Carolina-Chapel Hill March 1, 2002. UNC School of Public Health 1973-74. Social Determinants of Health Implications for Intervening on Racial and Ethnic Disparities Sherman A. James, Ph.D.

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The William T. Small Keynote Lecture School of Public Health University of North Carolina-Chapel Hill March 1, 2002

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  1. The William T. Small Keynote LectureSchool of Public HealthUniversity of North Carolina-Chapel HillMarch 1, 2002

  2. UNC School of Public Health 1973-74

  3. Social Determinants of Health Implications for Intervening on Racial and Ethnic Disparities Sherman A. James, Ph.D. University of Michigan

  4. SOCIALDETERMINANTS Life enhancing resources - the food supply, economic and social relationships, educational opportunities, housing, medical care, transportation, the built environment, etc. - whose distribution across populations effectively determines inter-population differences in length and quality of life.

  5. Why is the elimination of racial and ethnic health disparities of such vital importance to the country? What are some important factors that underlie persistent racial and ethnic disparities in health? What standards are appropriate for measuring progress in eliminating racial and ethnic health disparities? How might we organize our work so that real progress toward this goal is made during this decade?

  6. Source: Smith and Edmonston 1997 (National Research Council Report)

  7. All Cause Age-adjusted1 Death Rates and Rate Ratios by Race/Ethnicity: United States, 1990 and 1998 Race/Ethnicity 1990 1998 Rate2 RR Rate2 RR White 910 855 Black 1250 1.37 1136 1.33 Hispanic 692 0.76 596 0.70 American 716 0.79 705 0.83 Indian/Native Alaskan Asian/Pacific 582 0.64 517 0.60 Islander 1Direct Method, 2000 US population as standard; 2deaths per 100,000 Source: Health, United States 2001

  8. DIABETES MELLITUS A complex metabolic disorder - poorly understood and poorly managed Source: J. McKinley, L. Marceau, Lancet 2000; 356: 757-61 Complications - eye disease, kidney disease, heart disease, and nervous system damage Costs US economy ~ $100 billion/year Preventable through healthy eating, regular exercise and weight control

  9. Men’s Fitness February 2002, p. 69

  10. and 1998 1998 Rate2 RR 21.9 48.4 2.21 32.1 1.47 45.9 2.10 16.9 0.77 Diabetes Age-adjusted1 Death Ratesand Rate Ratios by Race/Ethnicity: United States, 1990 Race/Ethnicity 1990 Rate2 RR White 18.8 Black 40.5 2.15 Hispanic 28.2 1.50 American 34.1 1.81 Indian/Native Alaskan Asian/Pacific 14.6 0.78 Islander 1Direct Method, 2000 US population as standard; 2deaths per 100,000 Source: Health, United States 2001

  11. HEALTHY PEOPLE 2010 “Our goal is to eliminate disparities in health among all population groups by 2010…” Hon. Tommy G. Thompson US Secretary Health and Human Services Press Release: January 24, 2002

  12. HEALTHY COMMUNITIES INITIATIVE ...demonstration projects in 5 communities to enhance access to services and encourage positive behavioral changes... Source: HHS Press Release, February 6, 2002 Participating communities will match federal resources to develop coalitions between private and public organizations... in prevention, medical, social, educational, business, religious and civic services

  13. LEVEL Authors Neighborhood Individual Outcome Findings Yen & Census tract Income Mortality 50-60% higher mortality in Kaplan Socioenvironment Education Score AJE, 1999 poorer areas Setting Alameda County, CA 1983-94 follow up Multi-level Socioeconomic Effects on Health, Health Behaviors and Health Resources

  14. LEVEL Diez Roux Census Block Income 2-3 fold Authors Neighborhood Individual Outcome Findings et al Socioenvironment Score, 1990 Education Occupation Higher incidence in poor neighborhoods NEJM, 2001 CHD incidence ARIC Communities Setting 1987-97 follow up Multi-level Socioeconomic Effects on Health, Health Behaviors and Health Resources

  15. LEVEL Authors Neighborhood Individual Outcome Findings Diez Roux Census block Family Income Higher income associated with healthier diets et al median household income, 1990 Daily F/V/M* consumption JECH, 1999 ARIC Communities Setting 1987-97 follow up *Fruits/Vegetables/Meat Multi-level Socioeconomic Effects on Health, Health Behaviors and Health Resources

  16. LEVEL Authors Neighborhood Individual Outcome Findings Morland et al Census tract Prevalence of food stores More food stores in wealthier areas median home value, 1990 NA AJPM, 2002 Setting 216 census tracts in ARIC communities Multi-level Socioeconomic Effects on Health, Health Behaviors and Health Resources

  17. LEVEL Authors Neighborhood Individual Outcome Findings NA Census tract % Black residents, 1990 Morland et al Prevalence of food stores Fewer food stores in predominately Black areas AJPM, 2002 Setting 216 census tracts in ARIC communities Multi-level Socioeconomic Effects on Health, Health Behaviors and Health Resources

  18. 1985 2000 CANCER Breast Yes Yes Prostate Yes Yes DIABETES ? ? HEART DISEASE Yes Yes Sources: Mayberry et al, 2000; Kaiser Family Foundation Report, October 1999 Racial/Ethnic Differences in Access to Medical Care?

  19. Differences in Heart Surgery Rates by Race, Disease Severity, and Survival Benefit Percent Receiving Coronary Artery Bypass Graft Surgery 80% 61% 60% White Black 45% 42% 40% 35% 31% 25% 20% 0% Severe Disease >1 Year Life Extension Expected with Surgery Mild Disease SOURCE: Peterson, et al., 1997

  20. CDC’S REACH12010 INITIATIVE EliminateRacial/Ethnic Disparities in Six Areas: Infant Mortality Cancer Screening and Management Cardiovascular Disease Diabetes HIV Infection/AIDS Child and Adult Immunizations 1Racial and Ethnic Approaches to Community Health

  21. OAKLAND COUNTY “Oakland county ranks in the top five in the country in many areas crucial to reading a County’s success. Our mix of economic activity and quality of life programs and resources make Oakland County an ideal destination for families and businesses…Oakland County ranks second in per capita income for counties with over one million people, and we have a coveted triple AAA bond rating by both Standard and Poors and Moody’s, putting the County in the top one percent of all counties…” Source: http://www.co.oakland.mi.us/aboutcommunity/

  22. Total Number of Jobs by Location in Metro Detroit, 1960 - 1990 Suburban Ring Number of Jobs (Thousands) City of Detroit 1960 1970 1980 1990 Source: Farley et al DetroitDivided, 2000

  23. Majority Race by Census TractMetro Detroit, 2000

  24. Health Status and Health Behaviors, Tri-County Metro Detroit

  25. Health Promotion Resources Per 100,000 Residents in Metro Detroit Oakland Macomb Wayne Detroit Primary Care 168.0 52.2 75.1 Physicians1 Fitness Centers2 10.5 7.0 4.6 4.8 5.2 4.96 0.76 Major Supermarkets3 (Out-Wayne) Sources: 1 Michigan Behavioral Risk Factor Surveys, 1995-99 2 Michigan Economic Development Corporation, 1999 3 Metro Detroit yellow pages, 2002

  26. All Cause Death Rates for 25-64 Yr. Old Persons by Race and Place, Metro Detroit 1999/2000 Men 1 2 Suburbs Rate RR White 392 Black 793 2.0 Detroit White 968 2.47 Black 1124 2.87 1Oakland, Macomb, and Out-Wayne Counties 2Per100,000 Age-adjusted by Direct Method, sex-specific standard population of 25-64 year olds in Tri-County Suburbs

  27. All Cause Death Rates for 25-64 Yr. Old Persons by Race and Place, Metro Detroit 1999/2000 Women 1 2 Suburbs Rate RR White 237 Black 472 1.99 Detroit White 522 2.20 Black 564 2.38 1Oakland, Macomb, and Out-Wayne Counties 2Per100,000 Age-adjusted by Direct Method, sex-specific standard population of 25-64 year olds in Tri-County Suburbs

  28. Source: The New Yorker Magazine

  29. PARTNERS WHO CAN treat health problems effectively promote healthy behaviors among individuals and families Source: J. McKinlay and L. Marceau, Lancet, 2000; 356: 757-61 COALITIONS WITH MULTI-LEVEL PROBLEM SOLVING SKILLS increase goods and services in poor communities advocate for healthy public policies design/evaluate interventions

  30. REACH DETROIT* Towards a Social Ecology of Health *Funded by CDC grant number CCU517264

  31. Communities Health Care Systems 20 MD’s Families 150 Black 150 Hispanics FHA’s 5 Black 5 Hispanics CHA’s 4 Black 4 Hispanics Detroit Hlth Dept. EducationPrograms UMSPH Evaluation

  32. CONCLUSIONS US racial/ethnic disparities in health remain unacceptably large These disparities are largely socially determined, reflecting structural inequalities in neighborhood resources and access to quality medical care Elimination of racial/ethnic health disparities requires broad-based coalitions - including strong governmental leadership - capable of solving problems at multiple levels

  33. ACKNOWLEDGEMENTS Debbie Barrington Miwon Choe Lynda Fuerstnau Arline Geronimus Trevillore Raghunathan Anita Vashi Amanda Wobbema Institute for Social Research John VanHoewyk Hatcher Graduate Library JoAnn Dionne UNIVERSITY OF MICHIGAN School of Public Health

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