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Social Determinants of Health Disparities Moving the nation to care about social justice. Camara Phyllis Jones, MD, MPH, PhD. Social Determinants of Health and Equity 18 th National Health Equity Research Webcast University of North Carolina Gillings School of Global Public Health

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social determinants of health disparities moving the nation to care about social justice
Social Determinantsof Health DisparitiesMoving the nation to careabout social justice

Camara Phyllis Jones, MD, MPH, PhD

Social Determinants of Health and Equity

18th National Health Equity Research Webcast

University of North Carolina Gillings School of Global Public Health

June 5, 2012www.minority.unc.edu/institute/2012/

Office of Surveillance, Epidemiology, and Laboratory Services

Epidemiology and Analysis Program Office

social determinants of health disparities moving the nation to care about social justice1
Social Determinantsof Health DisparitiesMoving the nation to careabout social justice

The findings and conclusions in this presentation

are those of the author,

and do not necessarily represent the official position of the

U.S. Centers for Disease Control and Prevention.

Office of Surveillance, Epidemiology, and Laboratory Services

Epidemiology and Analysis Program Office

overview
Overview
  • Social determinants of health disparities differ from

social determinants of health

  • Health disparities don’t “just so happen”
    • Definition of racism
    • Generalized definition of structured inequity
  • Health equity and social justice
  • International Convention on the Elimination of all forms of Racial Discrimination
slide17

Addressing the

social determinants of health

Primary prevention

Safety net programs and secondary prevention

Medical care and tertiary prevention

but how do disparities arise
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
slide26

Differences in exposures and opportunities

Differences in access to care

Differences in quality of care

(ambulance slow or goes the wrong way)

slide27

Addressing the

social determinants of health disparities:

Why are there differences

in resources

along the cliff face?

Why are there differences

in who is found

at different parts of the cliff?

slide30

3 dimensions of health intervention

Health services

Addressing social determinants of health

slide31

3 dimensions of health intervention

Health services

Addressing social determinants of health

Addressing social determinants of health disparities

Source: Jones CP et al.J Health Care Poor Underserved 2009.

what is racism1
What is racism?

A system of structuring opportunity and assigning value

what is racism2
What is racism?

A system of structuring opportunity and assigning value based on the social interpretation of how we look (“race”)

what is racism3
What is racism?

A system of structuring opportunity and assigning value based on the social interpretation of how we look (“race”)

  • Unfairly disadvantages some individuals and communities
what is racism4
What is racism?

A system of structuring opportunity and assigning value based on the social interpretation of how we look (“race”)

  • Unfairly disadvantages some individuals and communities
  • Unfairly advantages other individuals and communities
what is racism5
What is racism?

A system of structuring opportunity and assigning value based on the social interpretation of how we look (“race”)

  • Unfairly disadvantages some individuals and communities
  • Unfairly advantages other individuals and communities
  • Saps the strength of the whole society through the waste of human resources

Source: Jones CP. Confronting Institutionalized Racism. Phylon 2003;50(1-2):7-22.

measuring institutionalized racism
Measuring institutionalized racism
  • Scan for evidence of “racial” disparities
    • “Could racism be operating here?”
    • Routinely monitor opportunities as well as outcomes by “race”
  • Identify mechanisms
    • “How is racism operating here?”
    • Structures: the who?, what?, when?, and where?

of decision-making

    • Policies: the written how?
    • Practices and norms: the unwritten how?
    • Values: the why?

Source: Jones CP. Confronting Institutionalized Racism. Phylon 2003;50(1-2):7-22.

what is inequity
What is [inequity] ?

A system of structuring opportunity and assigning value based on [fill in the blank]

what is inequity1
What is [inequity] ?

A system of structuring opportunity and assigning value based on [fill in the blank], which

  • Unfairly disadvantages some individuals and communities
  • Unfairly advantages other individuals and communities
  • Saps the strength of the whole society through the waste of human resources
many axes of inequity
Many axes of inequity
  • “Race”
  • Gender
  • Ethnicity
  • Labor roles and social class markers
  • Nationality, language, and legal status
  • Sexual orientation
  • Disability status
  • Geography
  • Religion

These are risk markers, not risk factors

what is health equity
What is health equity?
  • “Health equity” is assurance of the conditions for optimal health for all people
  • Achieving health equity requires
    • Valuing all individuals and populations equally
    • Recognizing and rectifying historical injustices
    • Providing resources according to need
  • Health disparities will be eliminated when health equity is achieved

Source: Jones CP 2010, adapted from the National Partnership for Action to End Health Disparities.

musings
Musings

Traditional ethics

Integrative bioethics

Collective level

Self-determination

Power to decide

Power to act

Control of resources

Social welfare

Protection

Promotion

Social justice

Distribution of resources among socially assigned groups

Individual level

  • Autonomy
  • Beneficence
  • Justice
social justice
Social justice
  • Evident when there is NO systematic structuring of opportunity or assignment of value based on group membership

Source: Jones CP, Hatch A, Troutman A. Fostering a Social Justice Approach to Health: Health Equity, Human Rights, and an Antiracism Agenda. Health Issues in the Black Community (third edition). San Francisco, CA:  Jossey-Bass, 2009.

barriers in moving the nation to care about social justice
Barriers in moving the nationto care about social justice
  • A-historical culture
    • The present as disconnected from the past
    • Current distribution of advantage/disadvantage as happenstance
    • Systems and structures as givens and immutable
  • Narrow focus on the individual
    • Self-interest narrowly defined
    • Limited sense of interdependence
    • Limited sense of collective efficacy
    • Systems and structures as invisible or irrelevant
  • Myth of meritocracy
    • Role of hard work
    • Denial of racism
    • Two babies: Equal potential or equal opportunity?
moving the nation
Moving the nation
  • Changing opportunity structures
    • Understand the importance of history
    • Challenge the narrow focus on the individual
    • Expose the myth of meritocracy
    • Acknowledge existence of systems and structures
    • View systems and structures as modifiable
    • Break down barriers to opportunity
    • Build bridges to opportunity
    • Transform consumers to citizens
    • Intervene on decision-making processes
  • Valuing all people equally
    • Break out of bubbles to experience our common humanity
    • Embrace ALL children as OUR children
icerd international convention on the elimination of all forms of racial discrimination
ICERD: International Convention on the Elimination of all forms of Racial Discrimination
  • International anti-racism treaty adopted by the UN General Assembly in 1965

http://www2.ohchr.org/english/law/cerd.htm

  • US signed in 1966
  • US ratified in 1994
  • 2nd US report submitted to the UN Committee on the Elimination of Racial Discrimination (CERD) in 2007

http://www2.ohchr.org/english/bodies/cerd/docs/AdvanceVersion/cerd_c_usa6.doc

cerd concluding observations
CERD Concluding Observations
  • 14-page document (8 May 2008) available online

http://www.state.gov/documents/organization/107361.pdf

  • Concerns and recommendations
    • Racial profiling (para 14)
    • Residential segregation (para 16)
    • Disproportionate incarceration (para 20)
    • Differential access to health care (para 32)
    • Achievement gap in education (para 34)
slide49

Camara Phyllis Jones, MD, MPH, PhD

1600 Clifton Road NE

Mailstop E-33

Atlanta, Georgia 30333

(404) 498-1128 phone

(404) 498-1111 fax

cdj9@cdc.gov

Office of Surveillance, Epidemiology, and Laboratory Services

Epidemiology and Analysis Program Office