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Health Equity and Social Justice: Community Models, National Priorities. Adewale Troutman, M.D., M.P.H. Director, Fulton County Department of Health and Wellness Atlanta Georgia . A Review of the Data. Some Selected Data.

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health equity and social justice community models national priorities

Health Equity and Social Justice: Community Models, National Priorities

Adewale Troutman, M.D., M.P.H.

Director, Fulton County Department of Health and Wellness

Atlanta Georgia

some selected data
Some Selected Data
  • 278,440 deaths annually in AA community estimated 80-90,000 excess deaths in 2000
    • Almost 1 in 3 deaths were excess deaths
  • 16% of the nation is without health insurance, 38% of Latino adults, 26% of African American adults, compared with 14% of white adults (Commonwealth Fund)
some selected data4
Some Selected Data
  • Homicide rate for AA is 6x’s that for whites
  • Hypertension rate is 4x’s greater for AA than for whites
  • AA life expectancy is 71.3, 61.5 for AA men in Fulton County
    • >78 for the nation
  • Infant mortality rate for AA> 2x white rate
    • In some areas >6x white rate
data cont
Data (Cont.)
  • Breast cancer incidence & mortality
    • Whites 113.2/100,000 & 25.7/100,000
    • African Americans 99.3/100,000 & 31.4/100,000
    • Latinos 69.4/100,000 & 15.3/100,000
  • Latinos almost twice as likely to die from diabetes as whites
  • Pima Indians have one of the highest diabetes rates in the world
data cont6
Data (Cont.)
  • African American men have the highest incidence & mortality rates of prostate cancer in the world
  • Prostate cancer rate AA man > 2x that of white men
  • African American men 3x more likely to die from prostate cancer than white men in Georgia
data cont7
Data (Cont.)
  • HIV/AIDS: 56% of the >700,000 AIDS cases are either African American or Latino
    • AA 37% but 12 % of population
    • Latino 18% but 13% of population
    • 81% of female cases with & 58% of pediatric cases in AA community
  • In 1999, AIDS accounted for 50% of all African American deaths & 18% of Latino deaths
more data
More Data
  • African American age adjusted death rates exceeded those for whites
    • By 77% in stroke
    • By 47% for heart disease
    • By 34% for cancer
    • By 655% for HIV infection
life expectancy
Life Expectancy
  • Nationally (African American men = 67)
  • Fulton County 61.5
  • White men 70.7
  • White women 79+
socioeconomic status and health
Socioeconomic Status and Health
  • Occupation
  • Education
  • Income
    • Believed to be the biggest contributor to health status
  • SES as correlate to health outcomes
  • PQLI and literacy
socioeconomic factors
Socioeconomic Factors
  • Correlate of race
  • Must correct for SES when looking at race
  • Prevailing measures imperfect proxies
    • Multiple variations within SES
  • Standard measures have different meanings for different races
    • Purchasing power will differ between races
    • Low SES AA pay more than whites for rent
ses cont
SES (Cont.)
  • At every level, whites have more assets that blacks
  • Blacks have less valuable homes
  • Whites earn 1.5x’s than Blacks, possess 4 times as much wealth
  • Blacks more likely to be first generation middle class
  • More likely to be supporting poorer relatives
ses cont14
SES (Cont.)
  • Do not capture effect of lifetime exposure to deprivation
  • Lack of childhood prevention may have long term effects
the world as we know it
The World As We Know It
  • The reality of the haves and the have nots
  • The growth of the gap
    • Concentration of wealth in the hands of a shrinking few
    • The immorality and unacceptable nature of a permanent underclass
medical care17
Medical Care
  • Persistence in huge variations in quality and quantity of care
  • AA more than twice as likely to receive care in hospital ER’s and clinics where less likely to receive continuity of care (different provider each visit)
  • AA more likely to be dissatisfied with care
medical care18
Medical Care
  • More likely to receive inadequate information about care, instructions, medication information and information about presenting problem
  • Increased proportion of AA without health insurance (increased from18-25% in 10 years)
more data19
More Data
  • Survey of physician attitudes (Van Ryn& Burke 2000) after correction for SES
    • AA less intelligent, less educated, more likely to be alcoholics and drug abusers, more likely to fail to comply
    • Less likely to have social support
    • Less likely to participate in cardiac rehabilitation
  • “Not merely the absence of disease but the presence of physical, psychological, social economic and spiritual well being”
  • “The harmonious balance of mind, body and spirit”
  • Justice according to natural law or right
  • Freedom from bias or favoritism
  • The quality of fairness
  • The principle of moral rightness; equity
  • Conformity to moral rightness in action or attitude
social justice
Social Justice
  • The application of principles of justice to the broadest definition of society
  • Implies
    • Equity
    • Equal access to societal power, goods and services
  • Universal respect for human and civil rights
  • “An ideology of inferiority that is used to justify the unequal treatment of members of groups defined as inferior, by both individuals and social institutions”
levels of racism
Levels of Racism
  • Personally Mediated: Differential assumptions and about the abilities, motives and intentions of others according to their race that may lead to differential actions towards members of that race
  • Internalized: Acceptance by members of the stigmatized race of negative messages about their own intrinsic self worth (self devaluation, helplessness and hopelessness)
levels of racism27
Levels of Racism
  • Institutionalized: The differential access to goods, services and opportunities of society by race. May be manifested through law, institutional structure, covert or overt privilege & inherited disadvantage

Human Rights: A higher order right MORALLY based and UNIVERSAL. It belongs to all persons equally because they are human beings(Declaration of Independence)

the right to health
The Right to Health
  • Preamble to the constitution of the WHO states “The enjoyment of the highest standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition”
the right to health32
The Right to Health
  • The Declaration of Alma Ata, International Conference on Primary Health Care “The right to health is the most important social goal”
the right to health33
The Right to Health
  • The International Declaration of Human Rights “Everyone has a right to a standard of living adequate for the health and well being of his family including food, clothing, housing and medical care”
the right to health34
The Right to Health
  • Affirmed by:
    • The Covenant of the Rights of the Child
    • The Convention on the Elimination of All Forms of Racial Discrimination Against Women
    • The ICESCR
      • “The right to the enjoyment of the highest standard of physical and mental health”
the international bill of human rights
The International Bill of Human Rights
  • The Universal Declaration of Human Rights 1948
  • The International Covenant on Civil and Political Rights 1966
  • The International Covenant on Economic, Social and Cultural Rights ( ICESCR )
“The time has come to herald human rights as both the foundation of public health and the compass of public policy”JAPHA 2000

The existence of health disparities concentrated among specific racial groupings is a violation of United Nations covenants, international principles of human rights and all principles of universal justice

a call to action advancing health for all through social and economic change
A Call to Action: Advancing Health For All Through Social and Economic Change
  • People with higher income enjoy healthier longer life
  • Disease and death rates are higher in populations that have a greater gap in income
  • People are healthiest when they feel safe
  • People are healthiest when they feel their job is secure
a call to action cont
A Call to Action (Cont.)
  • People are healthiest when they feel the work they do is important and valued
  • Discrimination and racism play a crucial role in explaining health status and health disparities
race and racism
Race and Racism
  • Health and health care industry suffer same history as other sectors of American society
  • Examples of access limitation secondary to race
    • CABG, angioplasty
    • AIDS medications
    • Referrals for coronary catheterization
    • Anecdotes
policies for social justice policies for health equity
Policies For Social Justice, Policies For Health Equity
  • Short term and long term solutions
  • Short term
    • Attention to symptoms (nutrition, physical activity, cholesterol, access)
    • Creating environment to promote health
  • Long term
    • Empowerment
    • Redistributive policies
  • Expand focus on the effects of public policy on the health of those suffering inequities
    • Welfare reform
    • Housing and development
    • Job development and health insurance
    • Literacy and health outcomes
    • Tax laws
    • Environmental policies
  • Measuring progress through “Social Health Indexing”
  • Living wage
  • Educational reform
  • Attention to short term only will just create a healthier underclass and will not create health equity because there is no social justice
what do we know
What Do We Know
  • There is a direct relationship between poverty and health outcomes
  • Disparities in health are linked to disparities in wealth
  • Health equity and social justice are inseparable
  • Racism manifests itself in health disparities
what do we know48
What Do We Know
  • This is a human rights issue
  • The right to health and health care
  • The civil rights movement didn’t go far enough
  • Disproportionate share of uninsured, unemployed, undereducated
  • Radical gaps in income
what to do
What To Do
  • The acquisition of the tools of a systematic human rights analysis
  • Learning the language of human rights
  • Determine best practices for evidence based health policy
  • Balance between promoting and protecting human rights and promoting public health as a national policy
what to do50
What To Do
  • The integration of human rights education into all levels of academic and professional training of health professionals
  • Partnering with traditional human rights activists
  • Public policy aimed at economic equity
  • Universal coverage and access to high quality single standard of care
  • A new paradigm
  • Transformation of self
  • Movement from victim to empowered position
  • Conquer the them vs. us mentality
  • The force of self determination
social justice54
Social Justice
  • Health Status inequities are directly related to the continued existence of social injustice
  • The existence of social injustice typified by the continued growth of the gap between the haves and the have-nots, lack of access to services and care, preventive and curative is unethical and immoral
leadership development
Leadership Development
  • The opportunity to change the world view of public health
  • The institution in the mirror
  • Workforce development for social change
  • Healthy People 2010 & health equity
  • Core functions, essential services & social justice
  • MAAP & Social Health Indexing
leadership development cont
Leadership Development (Cont.)
  • Personal growth and development
  • Taking on the challenge of racism
  • Cultural competence (consciousness)
  • The use of the tools of public health in creating health equity through social justice
social justice58
Social Justice
  • The mere concept of a permanent “underclass” is inherently unethical
  • Public health practice must be manifested by a new and unrelenting movement for social justice and health equity
  • NACCHO initiative
some final thoughts
Some Final Thoughts
  • The fallacy of improved health for all
  • The recognition of social determinants as the foundation of health
  • SES & racism are key elements of causation
  • There are universal principles
  • Empowerment vs. victimization
  • The students role in understanding & change
moving from rhetoric to action
Moving From Rhetoric to Action
  • Definition of Healthy Communities
  • Focus on “Social Health & Social Determinants”
  • Address race, class & health
  • Tool of BRFSS
  • Curriculum changes (all levels)
  • Policy initiative
    • Incrementalism vs. Radical Change
  • A question of quality
  • The tool of regulation (Hill-Burton)

What we are willing to turn our backs on, ignore or deny, is the measure of our willingness to live as hypocrites and deny the core value of ethics in our daily practice of public health and more importantly in our very lives.


We need a social revolution based on social justice and health equity & supported by sound, sweeping policy aimed at reforming the American system


Adewale Troutman,M.D.,M.P.H.Nasanan Health Consultants 1208 Clearbrook DriveAtlanta Georgia 30311adedrum@aol.com404 730 1202404 691 9608