Transcript National Network of Centers for Public Health Preparedness

Community Health and Health Disparities:
A Shared Responsibility
Saint Louis University School of Public Health
Greater St. Louis Community Health Speaker Series
Thursday, January 14, 2010
Deborah Prothrow-Stith, MD
Consultant, SpencerStuart
Adjunct Professor, Harvard School of Public Health
There Are Many Indicators of Poor Health Outcomes
Among U.S. Minorities
• Incidence rate of hypertension is 11 % higher for African Americans
as for whites
• Black infant mortality is more than twice white infant mortality: 14
per 1,000 vs. 6 per 1,000 births
• Life expectancy for black men (67.8 yrs) is seven years less than
that for white men (74.6)
• Blacks, Hispanics, and Asian Americans are also more likely to be
uninsured
• Approximately 39% of blacks, 46% of Hispanics, compared with
26% of whites do not have a regular doctor
• Approximately 45% of Hispanics, 41% of Asians, 35% of blacks
report difficulty paying for medical care, vs. 26% of whites
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National Center for Health Statistics
MLK Quote
“Of all the forms of inequality, injustice in health
is the most shocking and the most inhuman.”
Martin Luther King Jr.
March 25, 1966
Chicago
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Effective Strategies for Community Health Require
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I.
Increasing the knowledge base
Example: race and racism
II.
Eliminating turf wars
Example: Medicine and Public Health
III.
Thinking outside the box
Example: CBPR
IV.
Yielding decision-making power
Example: Boxing Out the Violence
I. Increasing Knowledge
Example: Racism and Health
• “Race” is not a biological construct that reflects innate
differences, but a social construct capturing the social
classification of people in our race-conscious society.
• Race-associated differences in health outcomes may in
fact be due to the impacts of racism.
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Census Irregularities
• 1790 to 1850, the only categories recorded were White and Black
(Negro), with Black designated as free and slave.
• 1850 to 1870, 1890, 1910, and 1920, enumerators were instructed
to identify Mulattoes (and Quadroons and Octoroons in 1890)
among the Black population .
• 1860, with much of the West region of the United States being
counted, American Indians (excluding those not taxed) and
Chinese (in California only) were identified separately. Japanese
were identified separately starting in 1870.
• 1910 -1940 census, Asian and Pacific Islander categories other
than Chinese and Japanese were identified for the first time in
decennial census reports, including, for example, Filipino, Hindu,
and Korean.
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Census Irregularities
• 1930 census only, there was a separate race category for Mexican.
The race category of Mexican was eliminated in 1940, and 1930
race data were revised to include the Mexican population with the
White population.
• 1950, an attempt was made for the first time (and with limited
success) to identify individuals of mixed American Indian, Black,
and White ancestry living in certain communities in the eastern
United States.
• 1950-1960 -Other individuals who were Asian and Pacific
Islanders and individuals of mixed American Indian, Black, and
White ancestry were grouped together as "Other race.“
• 1970 - Koreans were identified in tabulations for the conterminous
United States and Hawaii, and Eskimos and Aleut were again
identified only in Alaska.
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Three Levels of Racism
• Institutionalized: Differential access by race to goods,
services, and opportunities of society.
– inherited disadvantage
– material conditions, access to power
• Interpersonal or Personally mediated: Prejudice and
discrimination.
• Internalized: Acceptance by members of stigmatized
races of negative messages about our own abilities and
intrinsic worth.
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AFRICAN AMERICAN CITIZENSHIP STATUS & HEALTH EXPERIENCE
FROM 1619 TO 2010
TIME
SPAN
16191865
18651965
19652010
16192010
CITIZENSHIP
STATUS -YRS
246
100
45
391
PERCENT U.S.
EXPERIENCE
63%
26%
11%
100.00%
STATUS
HEALTH & HEALTH
SYSTEM EXPERIENCE
Chattel
slavery
Disparate/inequitable treatment;
poor health status & outcomes.
“Slave health deficit” & “Slave
health sub-system” in effect
Virtually no
citizenship
rights
Absent or inferior treatment and
facilities. De jure segregation/
discrimination in South, de facto
throughout most of health system.
“Slave health deficit” uncorrected
Most
citizenship
rights
Southern medical school desegregation
[1948], Imhotep Hospital Integration
Conferences [1957-1964], hospital
desegregation in federal courts [1964].
Disparate health status, outcomes, and
services with apartheid, discrimination,
institutional racism and bias in effect.
The struggle
continues
HEALTH DISPARITIES/
INEQUITIES
Source: Byrd, WM, Clayton, LA. An American Health Dilemma, Volume 1, A Medical History of African
Americans
and the Problem of Race: Beginnings to 1900, New York, NY: Routledge. 2000.
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Anti-Racism Curriculum
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II. Eliminating the Turf Wars
Example: Medicine and Public Health
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Medicine
Anatomy
Establishing a Relationship
Histology
Building Trust
Biochemistry
Taking a History
Physiology
Patient Education
Pathophysiology
Developing a Rx plan
Pharmacology
Receiving Feedback
Soliciting Cooperation
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Excellence in clinical care requires merging the “art” and “science” medicine
Public Health
Excellence in public health practice requires merging of the “art” and “science”
of public health
Epidemiology
Biological Sciences
Biostatistics
Behavioral Science
Political Science
Economics
Environmental Science
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Assessment
Policy development
Assurance
Program Development
Design
Implementation
Management
Evaluation
Communication
Leadership
Cultural competency
Degree of Discipline Involvement
in Interventions
Proposed Relationship Between
Public Health and Medicine
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Primary Prevention Secondary Prevention
Education & Policy
Risk Reduction
Type of Intervention
Tertiary Prevention
Treatment
III. Thinking outside the box
Example: Community Based Participatory Research
CBPR is a collaborative approach to research that
equitably involves all partners in the research
process and recognizes the unique strengths that
each brings. W. K. Kellogg Foundation
Community Health Scholars Program (2001)
“participatory research fundamentally is about who
has the right to speak, to analyze, and to act.”
Budd Hall, 1992
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Similar Activities and Labels
•
•
•
•
PR –Participatory Research
PAR Participatory Action Research
Collaborative Action Research
Action Research – now a more overarching term describing
participatory inquiry and PRACTICE
• Mutual Inquiry
• FPR –Feminist Participatory Research
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What Created the CBPR Movement
• 21st century’s problems (e.g.HIV, Homelessness,
environmental injustice, violence) are too complex
for a traditional “outside expert” approach.
• Greater community and political demands for
accountability within the research arena.
• Considerable community and funder
disappointment with traditional research
paradigms.
• Scholars of color and feminist scholars paying
attention to issues of race, class, culture as these
influence research enterprises.
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Fundamental Characteristics of CBPR
• It is participatory (from beginning to end).
• It is cooperative, engaging community members and researchers in
a joint process in which both contribute equally.
• It is a co-learning process.
• It involves systems development and local community capacity
building.
• It is an empowering process through which participants can
increase control over their lives.
• It achieves a balance between research and action (a shift in the
power equation).
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CBPR Guiding Principles
CBPR begins with a
research topic of
importance to the
community with the aim of
combining knowledge and
action for social change to
improve community health
and eliminate health
disparities.
 Community Benefit
 Mutual Benefit
 Mutual Investment
 Career Development
Can Research become an organizing theme for a social change
movement in a community that has been abused by research in the past?
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IV: Yielding Power
Example: Boxing Out the Violence
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Optimism is a MUST
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I.
Increasing the knowledge base
Example: race and racism
II.
Eliminating turf wars
Example: Medicine and Public Health
III.
Thinking outside the box
Example: CBPR
IV.
Yielding decision-making power
Example: Boxing Out the Violence
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