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Rex Archer, MD, MPH, Director, Kansas City Health Department | Learn more about health equity in Missouri by visiting: http://www.mohec.org/
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Creating a Culture of Health Equity
KC Community Conversation
November 14, 2014 Rex Archer, MD MPH
Saving Lives, Protecting People from Health Threats,
Saving Money through Prevention
"The reason we have government is to solve
problems collectively that we can not solve
individually." Dr. Thomas Farley, NYC Health Commissioner (from
the HBO May, 2012 Documentary, "Weight of the Nation"
Saving Lives, Protecting People from Health Threats,
Saving Money through Prevention
“Public health is what we, as a society, do collectively through organized actions to assure the conditions in which all people
can be healthy.”
-Institute of Medicine (1988), Future of Public Health
79.1
74.6 73.8
65.7
80.3
77.1 75.2
68.7
60
65
70
75
80
85
White female Black female White male Black male
Life expectancy (year)
Life expectancy, KCMO 1999-‐2003 vs. 2009-‐2013 1999-‐2003 2009-‐2013
*Non-‐Hispanic white male and female and non-‐Hispanic black male and female.
+1.2 years +2.5 years
+3.0 years +1.4 years
14.6
12.1
6.8 5.5
11.2
7.2 6.4
4.0
0
2
4
6
8
10
12
14
16
Black male Black female White male White female
No. of infan
t deaths p
er 1,000 births)
Infant mortality rate, KCMO 1999-‐2003 vs. 2009-‐2013 1999-‐2003 2009-‐2013
*Non-‐Hispanic white male and female and non-‐Hispanic black male and female.
-‐27.2%
-‐40.6%
-‐23.4%
-‐5.9%
POPULATION APPROACH VS. INDIVIDUAL APPROACH
Life expectancy by zip code, Kansas City, MO 2008-‐2012
Life expectancy Nonwhite
Below poverty@
Median family@
(year) % % income ($) 81-‐83 years 11.3 8.0 92,258 73-‐79 years 35.6 21.3 53,264 70-‐72 years 82.4 37.4 27,899
*Too small popula+on to calculate life expectancy
64153 64154 64156
64163
64155
6411964151
64134
64129
64120
64157
64161
64132
64138
64149
64131
64116
64130
64137
64117
64136
64118
64160
64164
64139
64133
64127
64165
64133
64108
64133
64128
64147
64111
64158
64109
64126
64118
64112
64124
64114
6414664145
64110
64113
64152
64079
64106
64166
6412364125
64012
64152
6410564101
64102
64167
64030
64079
64081
64079
64152
Life expectancy
80-83 years
73-79 years
70-72 years
Too small pop.*
@ 2008-2012 American Community Survey 5-Year Estimates
240 226
66 58 53 52 51 46 41 37
126 108
3 28 24 29 34 28
12 10 0
50
100
150
200
250
Rate per 100,000 pop
ulaQ
on Shortest life expectancy Longest life expectancy
Leading Causes Crude Mortality Rates in Two Areas, KCMO 2008-‐2012
6zipcodes include zip code 64109, 64126, 64127, 64128, 64130, and 64132, which are the shortest life expectancy; 11zipcodes include zip code 64112, 64113, 64116, 64118, 64151, 64152, 64153, 64154, 64156, 64157, and 64158, which are the longest life expectancy.
EsSmated Deaths AVributable to Social Factors U.S* KCMO**
• Less than High School graduaSon 245,000 234 • Racial segregaSon 176,000 561 • Low social support 162,000 232 • Individual level poverty 133,000 236 • Income inequality 119,000 222 • Community level poverty 39,000 349
_____________________________
~47% of annual KCMO deaths (41-‐53%) Total 1,834***
*Galea, et.al., American Journal of Public Health August 2011, Vol 101 no. 8 **ConservaSve esSmate for Kansas City, MO based on Galea, et.al. ***ConservaSve esSmates that assume factors are not synergisSc
Social and Economic
Factors 40%
Health Behaviors 30%
Clinical Care 10%
Physical Environment
10%
Genes and Biology
10%
What Creates Health? What are the Determinants of Health?
Tarlov AR. Public policy frameworks for improving population health. Ann N Y Acad Sci 1999; 896: 281-93.
Through inequities H
ow d
o di
spar
ities
aris
e?
Access to care
Quality of care
Exposures
and opportunities
Achieving Health Equity by Addressing the Social Determinants of Health
• It is Sme to stop thinking of health as something we get at the doctor’s office
• Health starts—long before illness-‐-‐ in our homes, neighborhoods, schools and jobs.
• All residents should have the opportunity to make the choices that allow them to live a long, healthy life, regardless of their income, educaSon or ethnic background.
• Your neighborhood or job shouldn’t be hazardous to your health.
• The more we see the problem of health this way, the more opportuniSes we have to improve it.
12
The Cost of a Long Life 13 Japan
We need to restructure our investments
Hospitalization
Chronic Disease Care
Public Health KC-CHIP Our goal is to
work upstream to keep Kansas Citians from falling in the river of medical care and going over the waterfall of hospitalization.
Healthy Communities Healthy Living
Medical System
We Have to Change! • The “System” is broken • We need to address inequities/injustices • How can we do things differently?
Refocusing Upstream
Fam
ily &
C
ultu
re
Fam
ily &
C
ultu
re
Health
Inequities
Health
Disparities
Fam
ily &
C
ultu
re
Place Policy Narrative
Examples Condoms, eat healthy, be physically active
Rx for high blood pressure, high cholesterol
Poverty, education, housing, inequality
Immunizations, brief intervention, cessation treatment, colonoscopy
Fluoridation, 0g trans fat, iodization, smoke-free laws, tobacco tax
Religious, moral teachings, beliefs
Largest Impact
Smallest Impact
Contributory/Distributive (Social) Justice
Changing the Context to make individuals’ default
decisions healthy
Long-lasting Protective Interventions
Clinical Interventions
Counseling & Education
Socioeconomic Factors
Factors that Affect Health
Frieden, Archer
Social Structure
Power and Wealth Imbalance LABOR
MARKETS
GLOBALIZATION &
DEREGULATION HOUSING POLICY
EDUCATION SYSTEMS
TAX POLICY
Social Determinants of Health
Disparity in the Distribution of Disease, Illness, and Wellbeing
Institutional Racism
Class Oppression
Gender Discrimination
and Exploitation
SOCIAL NETWORKS
SOCIAL SAFETY
NET
Safe Affordable Housing
Social Connection
& Safety
Quality Education
Job Security
Living Wage
Transportation Availability of Food
Psychosocial Stress / Unhealthy Behaviors
Definitions
Social Justice Health Equity
The absence of unfair, unjust advantage or privilege based on race, class, gender, or other forms of difference.
A fair, just distribution of the social resources and social opportunities needed to achieve well-being.
Health Disparity
“A disproportionate difference in health between groups of people.”
By itself, disparity does not address the chain of events that produces it.
Health Inequity “Differences in population health status and mortality rates that are systemic, patterned, unfair, unjust, and actionable, as opposed to random or caused by those who become ill.” Margaret Whitehead
Deaths Prevented And Change In Health Care Costs Plus Program Spending, Three Intervention Scenarios, At Year 10 And Year 25.
Milstein B et al. Health Aff 2011;30:823-832
WE KNOW HOW TO
REVERSE EPIDEMICS
Your Kansas City, MO
Health Department
87
20
9
62
3 0 10 20 30 40 50 60 70 80 90
100
City Aim4Peace target area
Num
ber o
f hom
icides
Number of homicides between city and Aim4Peace target area, YTD October 17, 2014
YTD2013
2010-‐2012*
2013
YTD2014
*2010-‐2012 in target area means average number of homicides among 2010-‐2012
-‐29% reducSon
-‐85% reducSon
Seeing a Wider Set of Relationships
Centers for Disease Control and Prevention, Bobby Milstein
Public Health As A Social Justice Enterprise
JUSTICE = TRUTH + POWER
Public Health Practice Research + Data
Community Organizing
=
Aligned Campaigns (PH&CO) • 2012: Cap the Rate, Raise the Wage
• 2013: Ban the Box • 2013-2014: Low Wage Worker Actions/
Living Wage • 2014: Ban the Ban • 2014: Raising of America Kansas City • 2014: Advance KC Development Scoring • Other Ongoing: Medicaid Expansion, Early
Voting, Violence/Homicide Prevention
Questions?
Your Nationally Accredited
Kansas City, Mo., Health Department
Improving Service. Protecting People. Saving Lives.
Rex Archer, MD, MPH
Director of Health
Prepared by: T.Cole
We are focused on prevention of gun-related violence that is primarily related to arguments and
retaliation in targeted areas of East Patrol, but we seek to expand to the entire Metro Area.
A4P Current Target Zone: KCMO Police Sector 330, parts of 320 & 340
KCPD Beats
2010 (Jan-Dec)
2011 (Jan-Dec)
2012 (Jan-Dec)
2013 (Jan-Dec)
diff % change
2014 (Jan-
Oct. 16)
diff % change
331 4 4 3 3 0 0% 1 -2 -67% 332 3 3 7 1 -6 -86% 0 -1 -100% 333 0 5 2 0 -2 -100% 1 1 0% 334 6 3 4 3 -1 -25% 1 -2 -67%
Total 330
13 15 16 7 -9 -56% 3 -4 -57%
324 4 7 4 2 -2 -50% 0 -2 -100%
Total 17 22 20 9 -11 -55% 3 -6 -67%
To Achieve the Vision Participants Reached Consensus on Six KC-CHIP Strategic
Issues/Goals
Safe and Healthy Community Encourage
AcQve Living and Healthy
EaQng
Reduce health dispariQes/social determinants of
health
Ensure Every Child has a Healthy Start
Access to Clinical
PrevenQve Services,
Illness Care, & Public Health
Services & IntervenQons
Live Tobacco Free in KC Thriving
people living, learning and working in a
healthy, active, vibrant, and safe community,
where there is equitable access to jobs, quality health, education and
social services
34
Develop and Sustain a High Performing OrganizaQon
Increase Public Health EffecQveness and Promote PrevenQon Strategies that Reduce Health InequiQes
and Improve the Health of the Community
Increase Stakeholder Awareness, and Support of Mission & Activities
Updated as of 5/16/13
Kansas City, Missouri Health Department Strategic Map: 2013-‐2016
Enrich and Support Community Partnerships
Lead Policy and Advocacy
Development
Review Current Programs, Services And IdenSfy
Gaps
Implement QI Focus into
All Programs
Incorporate an EvaluaSon Component into All Programs
Align Partnerships with Emerging Changes in Public Health Issues
Leverage CommunicaSons To AcSvate Partners and
Improve Efficiency
Ensure ConSnuing Face-‐to-‐Face (1 on 1s)
InteracSons
Assure Quality of Services Delivered or Contracted For
Develop Departmental Capacity and
Technical ExperSse
Determine Framework for Policy and
Advocacy Issues
IdenSfy & PrioriSze Department & Community
Health PrioriSes
Develop Public and Private Strategic
Alliances to Advocate for RecommendaSons
Develop & Enforce Agency CommunicaSon Plan Including an Integrated Brand Framework
IdenSfy & Respond to CommuniSes’ Perceived
Value of KCHD
Increase Visibility Of KCHD Services
Engage & Inform Key Decision-‐
Makers & Influencers on Policy RecommendaSons
Strengthen Internal ProgrammaSc awareness
And Linkages
Pursue and Maintain NaSonal Public Health
AccreditaSon
Update and & Implement a Staff Training Plan
IdenSfy & OpSmize Technology to Innovate
Public Health
Recruit, Retain, and Invest in Quality Staff
Strengthen the Impact of Programs and
Services
Assure RecogniSon of KCHD/KCMO for all Funded AcSviSes (Co-‐Branding)
Use Data, and Evidence-‐Based PracQces as Tools to Drive Decision-‐Making
Communicate the Meaning and Importance of
Public Health
1
2
3
4
5
6
F
A B DC E
Tracks of Work for Year 2: ProgrammaSc Linkages (Yellow), Performance Management (Pink), IntegraSng Technology (Orange), Workforce Development (Green), Stakeholder Awareness (Blue), Cultural Competency (Purple) will be added as TA progresses
Work with Community Organizing Agencies to address
health inequiSes
Become an Academic Health Department
Cultural Competency
Expand and Sustain Funding and Investment
Arenas of Power
Power is the ability to act or produce an effect • Directly impacting decisions makers • Developing deeper relationships and
aligning interests • Consciously shifting the narrative
Working with Faith-based Organizations
We believe: • Everyone has a story • In the potential of transformation
(individual, community, society at large) • Power is a product of relationships • We get as much justice as we have
power to compel
Three Principles of Community Organizing
v Win concrete improvements in people's lives
v Make people aware of their own power
v Alter the relations of power: § Build strong organizations § Pass new laws and regulations § Elect good people who recognize
your power