Health Equity "العدالة الصحية "

What does
"Health Equity" mean?


A basic principle of public health
is that all people have a right to health. Differences in the incidence and
prevalence of health conditions and health status between groups are commonly
referred to as health disparities (see Table 1.1). Most health disparities
affect groups marginalized because
of socioeconomic status,
race/ethnicity, sexual orientation,
gender, disability status,
geographic location, or some combination of these. People in such groups
not only experience worse health but also tend to
have less access to the social determinants or conditions (e.g., healthy food, good housing, good education, safe neighborhoods, freedom
from racism and other forms of
discrimination) that support health . Health disparities are referred to as
health inequities when they are the result of the systematic and unjust
distribution of these critical conditions. Health equity, then, as understood in public health literature and practice, is when everyone has the opportunity to
“attain their full health potential” and no one is “disadvantaged from achieving
this potential because
of their social
position or other
socially determined circumstance.


































Health
equity⁽[1]⁾ is a new idea
for most people. It’s not hard to grasp,
but it does require us to reframe the way in which health differences are
usually presented and perceived.


When the Robert Wood Johnson
Foundation showed focus group participants evidence of glaring socio-economic
and racial disparities in health, many felt that these were “unfortunate but
not necessarily unfair.” People tended to attribute health differences to
behaviors, genes or nature and inevitability: “That’s just the way things are.”
True, some outcomes are random or
result from accidents of nature or individual pathology.


But health equity concerns those
differences in population health that can be traced to unequal economic and
social conditions and are systemic and avoidable – and thus inherently unjust
and unfair.


Most of us can readily see how air
pollution and toxic waste might harm health.
But social structures can also get under the skin and disrupt our
biology. Epidemiologist Sir Michael
Marmot put it this way: "Real
people have problems with their lives as well as with their organs. Those social problems affect their
organs. In order to improve public
health, we need to improve society."


Tackling health inequities requires
widening our lens to bring into view the ways in which jobs, working
conditions, education, housing, social inclusion, and even political power
influence individual and community health. When societal resources are
distributed unequally by class and by race, population health will be
distributed unequally along those lines as well. One way to understand what Marmot calls the
“causes of the causes” is to ask new questions:



Conventional
question: How can we promote healthy behavior?



Health equity question: How
can we target dangerous conditions and reorganize land use and transportation
policies to ensure healthy spaces and places?


Conventional: How
can we reduce disparities in the distribution of disease and illness?


Health equity: How
can we eliminate inequities in the distribution of resources and power that
shape health outcomes?


Conventional: What social
programs and services are needed to address health disparities?


Health equity: What
types of institutional and social changes are necessary to tackle health
inequities?


Conventional: How
can individuals protect themselves against health disparities?


Health equity: What
kinds of community organizing and alliance building are necessary to protect
communities?


Just as the roots of illness and
wellbeing encompass more than individual factors, so too do the solutions.
Historians attribute much of the 30-year increase in U.S. life expectancy over
the 20th century not just to the invention of drugs or new medical technology
but to social reforms. The eight-hour
workday, a minimum wage, universal schooling, prohibitions on child labor,
business regulation, social security and progressive tax policies all helped
ensure that improvements in productivity would be shared, at least in part, by
all Americans. The passage of civil rights laws in the 1960s extended these
benefits to African Americans, whose health also improved in both absolute and
relative terms.


For the past 30 years, however, the
U.S. has been moving in the opposite direction. The top one percent of the
population now holds as much wealth as the bottom 90 percent.


Approximately 22 percent of our
children live in poverty. The United States has by far the greatest inequality
of the industrialized countries—and the worst health.


The good news is that the conditions
that drive health inequities are neither natural nor inevitable but are the
consequence of public policies. We’ve
changed them in the past and can do so now.
A good start is recognizing how other campaigns for social justice
represent opportunities to improve our health and wellbeing. Struggles over jobs and wages, employment
security and working conditions, housing, food security, social supports and transportation
are as much health-promoting initiatives as anti-smoking campaigns, emergency
preparedness and increasing access to health care. Forging alliances with groups working on
these issues can increase everyone’s power and effectiveness, leading to a more
equitable society and better health.


As Dr. David Williams of the Harvard
School of Public Health says in UNNATURAL CAUSES, “Housing policy is health
policy. Educational policy is health policy. Anti-violence policy is health
policy. Neighborhood improvement
policies are health policies.


Everything that we can do to improve
the quality of life of individuals in our society has an impact on their health
and is a health policy.”


Promising state and community-based
policy solutions for reducing disparities include ^([2]):


·
Targeted programs: Initiatives are
often implemented in nontraditional, non-health care settings in communities
where inequities exist.


·
National effort to share successful community programs: Building
on federal grant support available through the Centers for Disease Control and
Prevention’s REACH (Racial and Ethnic Approaches to Community Health) program,
state and local public health departments, health care facilities, universities
and other partners are using and evaluating community-based, targeted
approaches to achieve health equity.

State efforts to
support community programs: States are creating
information systems to monitor and document the health status of their
residents, working to improve the cultural competence of the health care work
force and including goals to reduce health disparities in all health and
education programs

---

[1] www.unnaturalcauses.org






[2] Achieving
Health Equity in States & Communities
"Legislator Policy Brief,2008"

What Can State
Legislators Do to Help Achieve Health Equity?


·
Support and collaborate with
local community programs aimed at eliminating health inequities.


·
Consider legislation to:


1. improve
understanding of disparities through increased data collection;


2. improve access
to care for underserved populations;


3. enhance the
cultural competency of the health care work force;


4.
Adopt health equity as a goal for all public health
programs.


5. Provide
funding and support policies that seek to improve the
environment of communities and encourage citizens to lead healthier lifestyles.


·























·
[1]Health inequality describes
differences in health experience and health outcomes between different
population groups. In contrast, Health Equity Audits (HEA) focus on how fairly
resources are distributed in relation to the health needs of different groups.


·


[2]

---

[1] www.lewishampct.nhs.uk/.../health_equity_audit‎






[2] www.natpact.nhs.uk/cms/50.php‎

Actions for State
Legislators ([1])


1-Support Community
Collaboration


·
Fund outreach and awareness-raising efforts by local
coalitions addressing health disparities including community- and faith-based
organizations, advocacy groups and minority health agencies.


·
Support health disparities research and assist
researchers in developing partnerships with credible local community groups
that serve hard-to-reach populations.


·
Convene forums to foster exchange of best practices
among groups working to achieve health equity.


2-Develop Information
Systems to Monitor Progress


·
Support development of information systems for
monitoring and addressing health disparities.


·
Ensure standardized reporting of race and ethnicity
data across state programs to more accurately assess the extent of existing
disparities.


·
Provide for establishment of baseline data to identify
communities with high rates of death and illness and monitor state progress in
closing the gaps.


·
Fund assessments of state mortality data, the cost of
health disparities and the benefits of achieving health equity. For example, an
estimated 83,000 excess deaths each year could be prevented nationally if the
mortality gap between African-Americans and whites could be eliminated.


3-Enhance State Monitoring
and Support for Communities


·
Adopt health equity as a goal for all state health
programs, set specific targets and identify outcome measures.


·
Ensure state health agency management reflects the
diversity of the state’s population.


·
Fund state offices that address health disparities.
Ensure their ability to coordinate efforts with other public and private
programs and their ability to access health status and outcome data.


·
Provide
support for successful
and promising community-based programs
that foster increased use of screening and prevention
services.


·
Establish a standing commission on reducing health
disparities and achieving health equity that includes both public and private
sector members.


·
Ensure that state agencies (including health and human
services, education, transportation, housing, military affairs and emergency
services) and the health care community are prepared to serve the health needs
of all populations during natural disasters and catastrophic events.





4-Increase Access to
Health Care


·
Reduce the number of uninsured people by expanding
eligibility for Medicaid and the State Children’s Health Insurance Program
(SCHIP).


·
Provide funding to increase community health centers’
ability to provide care in communities with health disparities.


·
Provide funding for more medical interpreters and
other language services in hospitals.


·
Provide funding and support for health information
technology and telemedicine services (the use of communication equipment to
link health care providers and patients in different locations) in
geographically remote areas with provider shortages.


·
Establish policies to encourage use of regular
caregivers—referred to as medical homes rather than hospital emergency rooms
for health care. Include medical home initiatives in the state Medicaid
program. Such initiatives can reduce disparities, research shows.


5-Support Public Information
Campaigns


·
Provide support for ongoing public education campaigns
that encourage people to use preventive services.


·
Support campaigns that are targeted to underserved
populations and coordinated with public schools and community- and faith-based
organizations.


·
Establish a state Web site with culturally appropriate
and linguistically correct health information for the public.


6-Improve Cultural
Competence in the Health Care Work Force


·
Encourage development of cultural and linguistic
competency standards for health care providers to improve availability of
health information and services.


·
Work with colleges and universities to increase
minority enrollment in health care training programs and include cultural
competency training in clinical rotations.


·
Provide financial incentive programs (scholarships,
grants, loans, loan forgiveness, reimbursements, etc.) for minority providers
to practice in underserved communities.


·
Ensure that universities offer continuing education on
culturally appropriate patient communication and improving patient health
literacy.


·
Provide funding for medical interpreter services in
hospitals, medical interpreter training and certification programs, and
language training for health care providers


7-Improve the Environmental
Health of Communities


·
Provide
funding to encourage
healthier lifestyles by
increasing green spaces,
recreational facilities and walk able neighborhoods in communities
without them.


·
Provide financial
incentives for grocery
stores, farmers markets and food suppliers
to increase availability of
nutritious foods in low-income communities.


·
Support policies to prevent harmful environmental
consequences from disproportionately affecting communities with vulnerable
populations. Ensure these communities participate in policy decisions that
could affect their environment and health status.


Eliminating Health Disparities Initiative


·
Individuals’
economic and social characteristics are not related to their health


·
Health disparities exist when health equity has not been achieved

---

[1] http://www.healthystates.csg.org

How are health disparities produced? ^([1])



·
Broader social structure creates the conditions under which health disparities
persist



·
Efforts must target the full spectrum of causes of health disparities in order to



·
Eliminate them



·
Social policy is health policy. Economic policy is health policy.



Factors in Health Equity




























How do we intervene to eliminate health disparities?



·
Intervention in every element
of the diagram is most effective



·
The more ‘up stream
the factor, the
broader reach the intervention will have



·
Example: Eliminating institutional racism will affect more people than providing better medical care for patients Both upstream and downstream work are critical: upstream work is longer‐term, while downstream work provides short‐term results



·
Moving upstream can be challenging



·
Address individual, community, and systems factors that produce health disparities



·
Move closer to the root causes of health disparities (i.e., left side of the framework)



·
Build partnerships and collaborate with
organizations and agencies that are able
to intervene at different levels

---

[1] Understanding Critical Issues in Health Equity
Eliminating Health Disparities Initiative



August 4, 2009

Examples of Health
Disparities by Racial/Ethnic Group or by Socioeconomic Status ^([1])


·
Infant mortality Infant
mortality increases as mother’s level of education decreases. In 2004, the
mortality rate for infants of mothers with less than 12 years of education was
1.5 times higher than for infants of mothers with 13 or more years of education.


·
Cancer deaths In
2004, the overall cancer death rate was 1.2 times higher among African
Americans than among Whites.


·
Diabetes As
of 2005, Native Hawaiians or other Pacific Islanders (15.4%), American
Indians/Alaska Natives (13.6%), African Americans (11.3%), Hispanics/Latinos
(9.8%) were all significantly more likely to have been diagnosed with diabetes
compared to their White counterparts (7%)


·
HIV/AIDS African Americans, who comprise
approximately 12% of the US population, accounted for half of the HIV/AIDS
cases diagnosed between 2001 and 2004.


·
In addition, African Americans were almost 9 times
more likely to die of AIDS compared to Whites in 2004.


·
Tooth decay Between
2001 and 2004, more than twice as many children (2–5 years) from poor families
experienced a greater number of untreated dental caries than children from
non-poor families. Of those children living below 100% of poverty level,
Mexican American children (35%) and African American children (26%) were more
likely to experience untreated dental caries than White children (20%).


·
Injury In
2004, American Indian or Alaska Native males between 15–24 years of age were
1.2 times more likely to die from a motor vehicle-related injury and 1.6 times
more likely to die from suicide compared to White males of the same age.




























Social Determinants by Populations^([2])


·
Access to care In
2006; adults with less than a high school degree were 50% less likely to have
visited a doctor in the past 12 months compared to those with at least a
bachelor’s degree. In addition, Asian American and Hispanic adults (75% and
68%, respectively) were less likely to have visited a doctor or other health
professional in the past year compared to White adults (79%).


In
2004, African Americans and American Indian or Alaska Natives were
approximately 1.3 times more likely to visit the emergency room at least once
in the past 12 months compared to Whites.


·
Insurance coverage In 2007,
Hispanics were 3 times more likely to be uninsured than non-Hispanic Whites
(31% versus 10%, respectively).


·
In 2007, people in families with income below the
poverty level were 3 times more likely to be uninsured compared to people with
family income more than twice the poverty level.


·
Residents of nonmetropolitan areas are more likely to
be uninsured or covered by Medicaid and less likely to have private insurance
coverage than residents of metropolitan areas.


·
Employment
As of December 2007, the
unemployment rate varied substantially by racial/ethnic group (4% among Whites,
6% among Hispanics/Latinos, and 9% among African Americans) and by age and
gender (4.5% among adult men, 4.9% among adult women, and 15.4% among
teenagers).


·
In 2007, African Americans and Hispanics/Latinos were
more likely to be unemployed compared to their White counterparts.


·
Further, adults with less than a high school education
were 3 times more likely to be unemployed than those with a bachelor’s degree.


·
Education Since
the Elementary and Secondary Education Act first passed Congress in 1965, the federal
government has spent more than $321 billion (in 2002 dollars) to help educate
disadvantaged children. Yet nearly 40 years later, only 33% of fourth-graders
are proficient readers at grade level.


·
While the reading performance of most racial/ethnic groups
has improved over the past 15 years, minority children and children from
low-income families are significantly more likely to have a below basic reading
level.


·
According to the National Assessment of Adult
Literacy, African American, Hispanic/Latino, and American Indian/Alaska Native
adults were significantly more likely to have below basic health literacy
compared to their White and Asian/Pacific Islander counterparts.
Hispanic/Latino adults had the lowest average health literacy score compared to
adults in other racial/ethnic groups.


·
The high school dropout rates for Whites, African
Americans, and Hispanics/Latinos have generally declined between 1972 and 2005.
However, as of 2005, Hispanics/Latinos and African Americans were significantly
more likely to have dropped out of high school (22% and 10%, respectively)
compared to Whites (6%)


·
Access to
resources Lower income
and minority communities are less likely to have access to grocery stores with
a wide variety of fruits and vegetables.


·
In spite of recent legislation, many teenagers who go
to a store or gas station to purchase cigarettes are not asked to show proof of
age. African American male students (19.8%) were significantly less likely to
be asked to show proof of age than was White (36.6%) or Hispanic (53.5%) male
students.


·
Housing In
2005, American Indians or Alaska Natives were 1.5 times more likely and African
Americans were 1.3 times more likely to die from residential fires and burns
than Whites.


Homeless
people are diverse with single men comprising 51% of the homeless population,
followed by families with children (30%), single women (17%) and unaccompanied
youth (2%). The homeless population also varies by race and ethnicity: 42%
African-Americans, 39% Whites, 13% Hispanics/ Latinos, 4% American Indians or
Native Americans and 2% Asian Americans. An average of 16% of homeless people
is considered mentally ill; 26% are substance abusers.


·
Transportation Rural
residents must travel greater distances than urban residents to reach health
care delivery sites.


38.9%
of Hispanic/Latinos, 55.2% of African Americans, and 29.6% of Asian Americans
live in households with one vehicle or less compared to 24.5% of Whites.


Low-income
minorities spend more time traveling to work and other daily destinations than
do low-income Whites because they have fewer private vehicles and use public
transit and car pools more frequently.

---

[1] Brennan
Ramirez LK, Baker EA, Metzler M. Promoting Health Equity: A Resource


to
Help Communities Address
Social Determinants of Health. Atlanta:
U.S Department of Health and Human Services, Centers for Disease Control and Prevention; 2008.






[2]
*Social inequities and social
determinants refer to the same resources (e.g., Health care, education, housing)
but social inequities reflect the
differential distribution of these resources by population and by group.