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Eliminating Health Inequalities Intersections and Ethics . John R. Stone, MD, PhD Creighton University School of Medicine Center for Health Policy and Ethics. Aims. Summarize that: Health inequalities are significant

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eliminating health inequalities intersections and ethics

Eliminating Health Inequalities Intersections and Ethics

John R. Stone, MD, PhD

Creighton University School of Medicine

Center for Health Policy and Ethics

slide2
Aims
  • Summarize that:
    • Health inequalities are significant
    • Eliminating health inequalities should involve what justice demands in light of intersecting bases of well-being.
    • Intersectional, multidimensional approaches are essential, including affected communities
  • Have a discussion
inequalities disparities in health status and healthcare
Inequalities (Disparities) in Health Status and Healthcare
  • Tragic
  • Horrendous
  • Ethically unacceptable
  • Moral problems of the first order
universal and substantial healthcare
Universal and Substantial Healthcare
  • Respect and justice demand such healthcare.

BUT

  • To eliminate disparities in health status, much more must be done.
influence on excess mortality poor minorities
Influence on Excess Mortality: Poor & Minorities

H. Jack Geiger. Health Disparities: What do we know? What do we need to know? What should we do?. In Gender, Race, & Health: Intersectional Approaches. Edit by Amy J. Schulz & Leith Mullings. San Francisco. Jossey-Bass, 2006, p. 265.

interactive determinants
Interactive Determinants
  • “The determinants that interact to create good or ill health derive from various sources and sectors. Among other factors, health is shaped by laws and policies, employment and income, and social norms and influences.”

The Future of the Public's Health in the 21st Century (2002). Board on Health Promotion and Disease Prevention (HPDP) Institute of Medicine (IOM). The National Academies Press. P. 2 http://books.nap.edu/openbook.php?record_id=10548&page=R1 (Accessed 4/13/2007)

missoula county gender race ethnicity
Missoula County*Gender, “Race,” Ethnicity

Health Status?

* 2000 Census, http://www.dphhs.mt.gov/PHSD/health-profiles/pdf/missoula.pdf, accessed 4/13/2007

missoula county income
Missoula County: Income

* 1 2000 Census, 2 MT. Dept. Labor & Industry 2001 http://www.dphhs.mt.gov/PHSD/health-profiles/pdf/missoula.pdf, accessed 4/13/2007

slide10

 Less than 10%

 10% to 12%

 13% to 17%

 More than 17%

Health Insurance Coverage of Children 0-18

Living Near Poverty

(100% - 199% FPL) States (2004-2005), U.S. (2005)

http://www.statehealthfacts.org/cgi-bin/healthfacts.cgi?action=compare&category=Health+Coverage+%26+Uninsured&subcategory=Health+Insurance+Status&topic=Near+Poor+Children&link_category=&link_subcategory=&link_topic=&datatype=&printerfriendly=0&viewas=map&showregions=0&from=none&sortby=Uninsured (Accessed 4/13/2007)

slide11

Health Insurance Coverage of Children 0-18

States (2004-2005), U.S. (2005)

States with 15% uninsured: 2

States with > 15% uninsured: 4

Range of uninsured: 6%-20%

http://www.statehealthfacts.org/cgi-bin/healthfacts.cgi?action=compare&category=Health+Coverage+%26+Uninsured&subcategory=Health+Insurance+Status&topic=Children+%280%2d18%29&link_category=&link_subcategory=&link_topic=&printerfriendly=0&from=none&viewas=table (Accessed 4/13/2007)

health insurance coverage of adults 19 64 states 2004 2005 u s 2005
Health Insurance Coverage of Adults 19-64States (2004-2005), U.S. (2005)

http://www.statehealthfacts.org/cgi-bin/healthfacts.cgi?action=compare&category=Health+Coverage+%26+Uninsured&subcategory=Health+Insurance+Status&topic=Adults+%2819%2d64%29&link_category=&link_subcategory=&link_topic=&printerfriendly=0&from=none&viewas=table (Accessed 4/15/2007)

healthcare s major influences
Healthcare’s Major Influences
  • Disability
  • Pain
  • Suffering
  • Quality of life

H. Jack Geiger. Health Disparities: What do we know? What do we need to know? What should we do?. In Gender, Race, & Health: Intersectional Approaches. Edit by Amy J. Schulz & Leith Mullings. San Francisco. Jossey-Bass, 2006, p. 272.

health status major determinants
Health Status: Major Determinants
  • Providers
  • Institutions
  • Systems
  • Policies

H. Jack Geiger. Health Disparities: What do we know? What do we need to know? What should we do?. In Gender, Race, & Health: Intersectional Approaches. Edit by Amy J. Schulz & Leith Mullings. San Francisco. Jossey-Bass, 2006.

collaborative effort
Collaborative Effort
  • “There is a growing recognition that individuals, communities, and various social institutions can form powerful collaborative relationships to improve health that government alone cannot replicate.”

The Future of the Public's Health in the 21st Century (2002). Board on Health Promotion and Disease Prevention (HPDP) Institute of Medicine (IOM). The National Academies Press. P. 2 http://books.nap.edu/openbook.php?record_id=10548&page=R1 (Accessed 4/13/2007)

proposed areas of action and change
Proposed “areas of action and change”
  • “Adopting a population health approach that considers the multiple determinants of health;”
  • “Building a new generation of intersectoral partnerships that also draw on the perspectives and resources of diverse communities and actively engage them in health action;” [bold added]

The Future of the Public's Health in the 21st Century (2002). Board on Health Promotion and Disease Prevention (HPDP) Institute of Medicine (IOM). The National Academies Press. P. 4 http://books.nap.edu/openbook.php?record_id=10548&page=R1 (Accessed 4/13/2007)

public health potential agents
Public HealthPotential Agents
  • Governmental Public Health
  • Healthcare
  • Academia
  • Communities
  • Community organizations
  • Businesses

The Future of the Public's Health in the 21st Century (2002). Board on Health Promotion and Disease Prevention (HPDP) Institute of Medicine (IOM). The National Academies Press. P. 2 http://books.nap.edu/openbook.php?record_id=10548&page=R1 (Accessed 4/13/2007)

intersections eliminating health inequalities

Centers

University

Disciplines

Professionals

Healthcare

Institutions

IntersectionsEliminating Health Inequalities

Public

Health

Government

Community

Community

Agencies

& Orgs

Businesses

ethics health of the public ethical foundations
Ethics & Health of the PublicEthical Foundations

Amartya Sen

John Rawls

Martha Nussbaum

Norman Daniels

Madison Powers

Ruth Faden

Public Health

Consequentialism

Social Justice: The Moral Foundations of

Public Health and Health Policy.

NY. Oxford, 2006.

madison powers ruth faden social justice the moral foundations of public health and health policy
Madison Powers & Ruth FadenSocial Justice: The Moral Foundations of Public Health and Health Policy
  • Health: one of six major, interactive, components of well-being
  • “Sufficiency” account
  • Denial of separate spheres of justice
  • Community involvement
  • Reduced significance of healthcare
well being justice powers faden
Well-being & JusticePowers & Faden
  • “Sufficiency” of the “essential dimensions”
  • Understanding of dimensions’ interactions
  • Assume “inequalities beget inequalities”: e.g. oppression and subordination involved in racism and sexism (p. 8)
  • Target systematic patterns that influence self-determination.
  • Stress “children and their futures” (p. 8)
justice powers and faden
Justice: Powers and Faden
  • “Justice in our view requires ensuring for everyone a sufficient amount of each of the essential dimensions of well-being, of which health is one.” (p. 9) “Insofar as possible.” (16)
  • Essential dimensions are those “characteristically present within a decent life” (p. 15)
the job of justice powers faden
“The Job of Justice”Powers & Faden
  • “The achievement of a sufficiency of six essential dimensions of human well-being” (p. 5)
  • A “nonideal theory” that addresses “which inequalities matter most” in “a concrete empirical context” (p. 5)
  • Concerned not just with distrubutive principles, but also inter-personal relations (p. 6)
madison powers ruth faden social justice the moral foundations of public health and health policy26
Madison Powers & Ruth FadenSocial Justice: The Moral Foundations of Public Health and Health Policy
  • Cost-effectiveness analysis is not paramount
  • Denial of public health’s primary focus on aggregative health, constrained by justice and liberty
  • Job of justice: “to specify those background social and economic conditions that determine whether…inequalities…are unfair.”(xi)
powers faden

Group Situations

Powers & Faden

Biomed Culture

Structures

Policy

Healthcare

Health

History

Well-being

Social

Determinants

Social

Context

Dominance

Power

Multiculturalism

Lens of Social Justice & Public Health

related concerns
Related Concerns
  • Cross-cultural health and healthcare
  • Principles
    • Respect
    • Justice
    • Care
    • Community
  • Insurgent multiculturalism
conclusions
Health inequalities are important and tragic

Powers & Faden’s ethical framework is promising

Research and interventions should be in light of interactive dimensions of well-being

Intra-academic partnering is essential

Multi-dimensional collaboration is crucial

Healthcare institutions and professionals must be part of the solution

Dominant hierarchies & power structures need changing, including whiteness & male dominance

Conclusions