The William T. Small Keynote Lecture

School of Public HealthUniversity of North Carolina-Chapel Hill

March 1, 2002

UNC School of Public Health 1973-74

Social Determinants of Health

Implications for Intervening on Racial and Ethnic Disparities

Sherman A. James, Ph.D.University of Michigan

SOCIAL DETERMINANTS

Life enhancing resources - the food supply, economic and social relationships, educational opportunities, housing, medical care, transportation, the built environment, etc. - whose distribution across populations effectively determines inter-population differences in length and quality of life.

Why is the elimination of racial and ethnic health disparities of such vital importance to the country?

What are some important factors that underlie persistent racial and ethnic disparities in health?

What standards are appropriate for measuring progress in eliminating racial and ethnic health disparities?

How might we organize our work so that real progress toward this goal is made during this decade?

Projected Racial/Ethnic Composition of the U.S. Population

0

10

20

30

40

50

60

70

80

90

100

1995 2000 2005 2010 2015 2020 2025

Year

Per

cen

t

WhitesBlacksLatinosAsians

Source: Smith and Edmonston 1997 (National Research Council Report)

1998

Rate2 RR

855

1136 1.33

705 0.83

517 0.60

596 0.70

and 1998All Cause Age-adjusted1 Death Rates and Rate Ratios by Race/Ethnicity: United States, 1990

Race/Ethnicity 1990

Rate2 RR

White

Black

AmericanIndian/NativeAlaskan

Asian/PacificIslander

Hispanic

910

1250 1.37

716 0.79

582 0.64

692 0.76

1Direct Method, 2000 US population as standard; 2deaths per 100,000 Source: Health, United States 2001

Complications - eye disease, kidney disease,heart disease, and nervous system damage

Preventable through healthy eating, regular exercise and weight control

Costs US economy ~ $100 billion/year

DIABETES MELLITUS

A complex metabolic disorder - poorlyunderstood and poorly managed

Source: J. McKinley, L. Marceau, Lancet 2000; 356: 757-61

Men’s FitnessFebruary 2002, p. 69

Diabetes Age-adjusted1 Death Rates and Rate Ratios by Race/Ethnicity: United States, 1990

Race/Ethnicity 1990

Rate2 RR

White 18.8

Black 40.5 2.15

AmericanIndian/NativeAlaskan

34.1 1.81

Asian/PacificIslander

14.6 0.78

Hispanic 28.2 1.50

1998

Rate2 RR

21.9

48.4 2.21

45.9 2.10

16.9 0.77

32.1 1.47

and 1998

1Direct Method, 2000 US population as standard; 2deaths per 100,000 Source: Health, United States 2001

HEALTHY PEOPLE 2010

“Our goal is to eliminate disparities in

health among all population groups by 2010…”

Hon. Tommy G. ThompsonUS SecretaryHealth and Human Services

Press Release: January 24, 2002

Participating communities will match federal resources to develop coalitions between privateand public organizations... in prevention, medical, social, educational, business, religious and civic services

HEALTHY COMMUNITIES INITIATIVE

...demonstration projects in 5 communities to enhance access to services and encourage positive behavioral changes...

Source: HHS Press Release, February 6, 2002

Census tractSocioenvironmentScore

IncomeEducation

Mortality 50-60%highermortality inpoorer areas

LEVEL

Authors Neighborhood Individual Outcome Findings

Yen &KaplanAJE, 1999

Setting

AlamedaCounty, CA

1983-94follow up

Multi-level Socioeconomic Effects on Health, Health Behaviors and Health Resources

Census BlockSocioenvironmentScore, 1990

IncomeEducationOccupation

CHDincidence

2-3 fold Higherincidencein poorneighborhoods

LEVEL

Authors Neighborhood Individual Outcome Findings

Diez Rouxet alNEJM, 2001

ARICCommunities

Setting

1987-97follow up

Multi-level Socioeconomic Effects on Health,Health Behaviors and Health Resources

LEVEL

Authors Neighborhood Individual Outcome Findings

Diez Rouxet alJECH, 1999

ARICCommunities

Setting

1987-97follow up

Census blockmedian householdincome, 1990

FamilyIncome

Higher incomeassociated withhealthier diets

Daily F/V/M*

consumption

*Fruits/Vegetables/Meat

Multi-level Socioeconomic Effects on Health,Health Behaviors and Health Resources

Census tractmedian homevalue, 1990

NA

Prevalenceof food stores

More foodstores in wealthier areas

AJPM, 2002

Authors Neighborhood Individual Outcome Findings

LEVEL

Morland et al

Setting

216 censustracts in ARICcommunities

Multi-level Socioeconomic Effects on Health,Health Behaviors and Health Resources

Authors Neighborhood Individual Outcome Findings

LEVEL

Morland et alAJPM, 2002

Setting

216 censustracts in ARICcommunities

Census tract% Black residents, 1990

NA

Prevalenceof food stores

Fewer food stores in predominatelyBlack areas

Multi-level Socioeconomic Effects on Health,Health Behaviors and Health Resources

Racial/Ethnic Differences in Access to Medical Care?

Yes YesYes Yes

? ?

1985 2000

CANCER

BreastProstate

DIABETES

HEART DISEASE Yes Yes

Sources: Mayberry et al, 2000; Kaiser Family Foundation Report, October 1999

White

Black

80%

60%

40%

20%

0%Mild Disease

Severe Disease

25%

35%

61%

45%42%

31%

SOURCE: Peterson, et al., 1997

Percent Receiving Coronary Artery Bypass Graft Surgery

>1 Year LifeExtension Expected

with Surgery

Differences in Heart Surgery Rates by Race,Disease Severity, and Survival Benefit

CDC’S REACH1 2010 INITIATIVE

Eliminate Racial/Ethnic Disparities in Six Areas:

Infant Mortality

Cancer Screening and Management

Cardiovascular Disease

Diabetes

HIV Infection/AIDS

Child and Adult Immunizations

1Racial and Ethnic Approaches to Community Health

Washtenaw Co.

C a n a d aCanada

LakeSt. Clair

LakeErie

OaklandOaklandOaklandOaklandOaklandOaklandOaklandOaklandOaklandCounty

MacombMacombMacombMacombMacombMacombMacombMacombMacombCounty

WayneWayneWayneWayneWayneWayneCounty

Detroit

Metro Detroit Area

OAKLAND COUNTY

“Oakland county ranks in the top five in the country in many areas crucial to reading a County’s success. Our mix of economic activity and quality of life programs and resources make Oakland County an ideal destination for families and businesses…Oakland County ranks second in per capita income for counties with over one million people, and we have a coveted triple AAA bond rating by both Standard and Poors and Moody’s, putting the County in the top one percent of all counties…”

Source: http://www.co.oakland.mi.us/aboutcommunity/

Total Number of Jobs by Location in Metro Detroit, 1960 - 1990

0100200300400500600700800900

1,0001,1001,2001,3001,4001,500

City of Detroit

Suburban Ring

Nu

mb

er o

f Jo

bs

(Th

ousa

nd

s)

1960 19801970 1990

Source: Farley et al Detroit Divided, 2000

Majority Race by Census TractMetro Detroit, 2000

Health Status and Health Behaviors, Tri-County Metro Detroit

Oakland Macomb Wayne

%Fair/PoorHealth

9.4 11.6 18.1

Overweight 28.3 33.3 37.1

No LeisureTime PhysicalActivity

18.7 22.8 29.5

Source: Michigan Behavioral Risk Factor Surveys, 1995-99

1

Primary CarePhysicians1

168.0 52.2 75.1

Sources: Michigan Behavioral Risk Factor Surveys, 1995-992

Fitness Centers2

10.5 7.0 4.6

Michigan Economic Development Corporation, 19993

4.8 5.2 4.96(Out-Wayne)

0.76

Metro Detroit yellow pages, 2002

Oakland Macomb Wayne Detroit

Health Promotion Resources Per 100,000Residents in Metro Detroit

MajorSupermarkets3

Men

Suburbs1 Rate2 RRWhite 392

Black 793 2.0

DetroitWhite 968 2.47

Black 1124 2.87

1Oakland, Macomb, and Out-Wayne Counties2Per100,000 Age-adjusted by Direct Method, sex-specific standard population of 25-64 year olds in Tri-County Suburbs

All Cause Death Rates for 25-64 Yr. Old Persons by Race and Place, Metro Detroit 1999/2000

1 2

Women

Suburbs Rate RRWhite 237

Black 472 1.99

DetroitWhite 522 2.20

Black 564 2.38

All Cause Death Rates for 25-64 Yr. Old Persons by Race and Place, Metro Detroit 1999/2000

1Oakland, Macomb, and Out-Wayne Counties2Per100,000 Age-adjusted by Direct Method, sex-specific standard population of 25-64 year olds in Tri-County Suburbs

Source: The New Yorker Magazine

COALITIONS WITH MULTI-LEVELPROBLEM SOLVING SKILLS

increase goods and services in poor communities

advocate for healthy public policies

design/evaluate interventions

Source: J. McKinlay and L. Marceau, Lancet, 2000; 356: 757-61

PARTNERS WHO CAN

treat health problems effectively promote healthy behaviors amongindividuals and families

REACH DETROIT*

Towards a Social Ecology of Health

*Funded by CDC grant number CCU517264

Health Care Systems

20 MD’s

CHA’s4 Black4 Hispanics

Detroit Hlth Dept.Education Programs

UMSPHEvaluation

Families 150 Black 150 Hispanics

Communities

FHA’s 5 Black 5 Hispanics

CONCLUSIONS

US racial/ethnic disparities in health remain unacceptably large

These disparities are largely socially determined,reflecting structural inequalities in neighborhood resources and access to quality medical care

Elimination of racial/ethnic health disparities requires broad-based coalitions - including strong governmental leadership - capable of solving problems at multiple levels

ACKNOWLEDGEMENTSUNIVERSITY OF MICHIGAN

School of Public Health

Debbie BarringtonMiwon ChoeLynda FuerstnauArline GeronimusTrevillore RaghunathanAnita VashiAmanda Wobbema

Institute for Social ResearchJohn VanHoewyk

Hatcher Graduate LibraryJoAnn Dionne