Chicago, 11/3/10

Health Disparities: Health Disparities: Origins and Origins and

OpportunitiesOpportunities

Barry Zuckerman, MDBarry Zuckerman, MDThe Joel and Barbara Alpert Professor and The Joel and Barbara Alpert Professor and

Chairman of PediatricsChairman of PediatricsBoston Medical Center/Boston Medical Center/

Boston University School of MedicineBoston University School of Medicine

Race and HealthRace and Health

Racism

↓ Poverty

↓ Unequal Medical Care↑ Stress

Poor Adult Health

Educational opportunity

Employment opportunity

Stress/violence

Poor diet

Poor learning environment

Medication/other health expenditures

Cigarettes and alcohol

Copyright ©2006 American Public Health Association

Geronimus, A. T. et al. Am J Public Health 2006;96:826-833

FIGURE 1-- Probability of having an allostatic load of 4 or higher, as predicted by race (a) and race and gender (b)

FIGURE 1-- Probability of having an allostatic load of 4 or higher, as predicted by race (a) and race and gender (b)

Copyright ©2006 American Public Health Association

Geronimus, A. T. et al. Am J Public Health 2006;96:826-833

Sickle Cell Sickle Cell Anemia: A Special Anemia: A Special Case Study of Race Case Study of Race

and Healthand Health

Variable SCD Cystic Fibrosis

US prevalence 80,000 30,000

Federal support

NIH fiscal-year 2004 funding, in millions of dollars

NIH funding per person with disease, $

90

1125

128

4267

Private philanthropic support, $

Cystic Fibrosis Foundation 2003 annual review

Sickle Cell Disease Association of America 2003 annual revenue

Revenue per person affected with the disease

498,577

6

152,213,000

5074

Total NIH and private support, in millions, $ 90.4 280.2

Total support per person affected with disease, $ 1130 9340

NIH Research Funding and Private, NIH Research Funding and Private, Nonprofit Association Support of Nonprofit Association Support of

SCD and Cystic FibrosisSCD and Cystic Fibrosis

Number of Federal Government Number of Federal Government Requests for Applications Funded Requests for Applications Funded for Sickle Cell Disease and Cystic for Sickle Cell Disease and Cystic

Fibrosis: 1975-2004Fibrosis: 1975-2004

0

50

100

150

200

250

300

350

400

450

No

. o

f fu

nd

ed R

FA

's

1975 1980 1985 1990 1995 2000 2004

SCD research grants

CF research grants

Race and HealthRace and Health

Racism

↓ Income

↓ Access↑ Stress

Poor Health

Adult Health Disparity Adult Health Disparity by Incomeby Income

Adult Health Adult Health Disparities:Disparities:

Life Course TrajectoryLife Course Trajectory

Adult Health Disparities:Adult Health Disparities:

How Early Experiences Get How Early Experiences Get Embedded in Biology and Embedded in Biology and

Influence HealthInfluence HealthEnvironmentEnvironment →→ Gene- Gene- → → NeurochemicalNeurochemical SocialSocial EnvironmentEnvironment Adaptations &Adaptations & PhysicalPhysical InteractionInteraction DisruptionsDisruptions NutritionNutrition

Poor education & economic Poor education & economic productivityproductivity

↕↕→→ Brain → School failureBrain → School failure Poor health behavior Poor health behavior

↕↕ Poor physical & mental healthPoor physical & mental health

→→ OrgansOrgans

Early experiences are Early experiences are biologically embedded in biologically embedded in development of brain and development of brain and

other organsother organsEarly Early

ExperiencesExperiences

PositivePositive Nurturing and Nurturing and

stimulationstimulation

AdverseAdverse Stress/harmful Stress/harmful

interactionsinteractions Neurotoxic Neurotoxic

exposureexposure Inadequate Inadequate

nutritionnutrition

Child and Adult Child and Adult HealthHealth

Brain DevelopmentBrain Development

Brain DevelopmentBrain Development

Parental Language Addressed to Parental Language Addressed to Child by SESChild by SES

0

500

1000

1500

2000

2500

Wor

ds P

er H

our

PublicAssistance

Working Class Professional

Hart & Risley, (1995)Hart & Risley, (1995)Hart & Risley, (1995)Hart & Risley, (1995)

Early experiences are Early experiences are biologically embedded in biologically embedded in development of brain and development of brain and

other organsother organsEarly Early

ExperiencesExperiences

PositivePositive Nurturing and Nurturing and

stimulationstimulation

AdverseAdverse Stress/harmful Stress/harmful

interactionsinteractions Neurotoxic Neurotoxic

exposureexposure Inadequate Inadequate

nutritionnutrition

Child and Adult Child and Adult HealthHealth

Positive and Tolerable Positive and Tolerable StressStress

Positive and Tolerable Positive and Tolerable StressStress

Toxic StressToxic StressToxic StressToxic Stress

Gianaros, P.J., et al. Neuroimage, 2007.

Direct Effects of StressDirect Effects of StressDirect Effects of StressDirect Effects of Stress

Farah, M.J., et al. Brain Res, 2006

Effect Size Between Low and Middle Effect Size Between Low and Middle Income Children on Neurocognitive Income Children on Neurocognitive

Functioning (N=60)Functioning (N=60)

Stress: Adverse Childhood Stress: Adverse Childhood Events and Adult CV Events and Adult CV

DiseaseDisease

0

0.5

1

1.5

2

2.5

3

3.5

0

1

2

3

4

5,6

7,8

Dong et al, 2004 ACEs

Od

ds

Rat

io

Adverse Childhood Events Adverse Childhood Events and Adult Depressionand Adult Depression

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

0

1

2

3

4

5+

Od

ds

Rat

io

ACEs

Chapman et al, 2004

Caspi, A., et al. Science. 301:386-389 2003

Stress and Genetic Stress and Genetic Vulnerability for Vulnerability for

DepressionDepression

Stress and Genetic Stress and Genetic Vulnerability for Vulnerability for

DepressionDepression

Caspi, A., et al. Science. 297:851-854 2002

Stress and Genetic Stress and Genetic Vulnerability for Antisocial Vulnerability for Antisocial

BehaviorBehavior

Stress and Genetic Stress and Genetic Vulnerability for Antisocial Vulnerability for Antisocial

BehaviorBehavior

What to do: ExamplesWhat to do: Examples

1.1. Society: comprehensiveSociety: comprehensive

2.2. Health careHealth care RaceRace

Regulations tied to new constructionRegulations tied to new construction Target quality improvement of select hospitalsTarget quality improvement of select hospitals Cultural competencyCultural competency Increase racial diversity among physicians, nurses, Increase racial diversity among physicians, nurses,

etc.etc. Interpreters (technology)Interpreters (technology) Use of non-health care settingsUse of non-health care settings

BarbersBarbers ChurchesChurches salonssalons

Use Health Care to Disrupt Use Health Care to Disrupt Link Between Poverty and Link Between Poverty and

Poor HealthPoor Health

Reach Out and ReadReach Out and Read Medical-Legal PartnershipMedical-Legal Partnership Project HEALTHProject HEALTH

Reach Out and ReadReach Out and ReadReach Out and ReadReach Out and Read

Advice and books given at pediatric well child visits until age 5

Frequency of Reading Aloud

(High et. al., 2000)

0

2

4

6

Num

ber

of d

ays

and

nigh

ts

per

wee

k

Days/ week Nights/ week

InterventionControl

Children’s Expressive and Children’s Expressive and Receptive Language Receptive Language

CompetenciesCompetencies

74

76

78

80

82

84

86

88

90

92

94

Vo

cab

ula

ry s

core

s

Receptive language Expressive language

Intervention

Comparison

Mendolsohn, et al., Mendolsohn, et al., 19951995

Mendolsohn, et al., Mendolsohn, et al., 19951995

Reach Out and Read Reach Out and Read StatisticsStatistics

● Founded in 1989 at Boston City Founded in 1989 at Boston City HospitalHospital

● Over 4,500 sites Over 4,500 sites

● Over 3.5 million children from low-Over 3.5 million children from low-income families reached last yearincome families reached last year

● Over 5 million books distributed last Over 5 million books distributed last yearyear

Social Determinants of Social Determinants of Healthy Development: Healthy Development:

MechanismsMechanisms1.1. Direct:Direct:

DeprivationDeprivation FoodFood MoneyMoney HealthHealth medicationsmedications

ExposuresExposures caloric foodcaloric food LeadLead Asthma triggersAsthma triggers

2.2. Indirect: StressIndirect: Stress

Specialist saves the Specialist saves the dayday

A 11 yr old boy arrives for an urgent care visit. In the A 11 yr old boy arrives for an urgent care visit. In the past 2 months, he has needed several courses of oral past 2 months, he has needed several courses of oral steroids despite an appropriate medication regimen and steroids despite an appropriate medication regimen and an asthma action plan which his mother follows. an asthma action plan which his mother follows. However, the landlord has refused to do the needed pest However, the landlord has refused to do the needed pest control measures you suggested. control measures you suggested.

The patient has missed school repeatedly and is at risk of The patient has missed school repeatedly and is at risk of failing.failing.

A new specialist was consulted and within 6 weeks, the A new specialist was consulted and within 6 weeks, the teen was weaned off steroids and was back in school.teen was weaned off steroids and was back in school.

NICU Babies Have NICU Babies Have Legal NeedsLegal Needs

Baby Isabel, born 28 wks. Parents Baby Isabel, born 28 wks. Parents are legal immigrants from the are legal immigrants from the Dominican Republic. Dominican Republic.

As a NICU patient, Isabel is eligible As a NICU patient, Isabel is eligible for many benefits and services that for many benefits and services that will protect her health and prevent will protect her health and prevent re-hospitalization: SSI, early re-hospitalization: SSI, early intervention, etc.intervention, etc.

Parents don’t understand if and how Parents don’t understand if and how Isabel’s access to benefits impact their Isabel’s access to benefits impact their immigration status. Front-line and immigration status. Front-line and hospital staff – nurses, case managers, hospital staff – nurses, case managers, pediatricians – don’t know how to pediatricians – don’t know how to advise them.advise them.

Parents decide not to pursue benefits. Parents decide not to pursue benefits. Isabel is seen in the ED 3 months later Isabel is seen in the ED 3 months later with fever, secondary infection of with fever, secondary infection of diaper rash due to diarrhea and FTT.diaper rash due to diarrhea and FTT.

Medical-Legal Medical-Legal Partnership for Disparity Partnership for Disparity

ReductionReduction

Social

Doctors

Lawyers

Childhood Illness

Biological

The MLP Network – March The MLP Network – March 20092009

81 partnerships in over 180 hospital and health centers

Perry Preschool Project:Perry Preschool Project:

0

20

40

60

80

100

H.S. graduate (orequivalent)

Average or betterliteracy at age 19

90 or higher IQ atage 5

Ever in program foreducable mental

impairment

InterventionControl

Perry Preschool Project:Perry Preschool Project:

00.5

11.52

2.53

3.54

4.55

All arrests Arrests forviolence

Drug dealing

InterventionControl