Advancing Health in New York City:

Transcription

1 Advancing Health in New York City: Channeling the Tides to Lift All Boats Marc N. Gourevitch, MD, MPH Department of Population Health, NYU School of Medicine Intersectoral Forum on Advancing Health and Equity in NYC March 26, 2014 Presentation Title Goes Here 1

2 Overview Net gains in NYC health over last yrs are substantial and must be preserved and extended Unacceptable inequalities persist, some worsening Further gains require specific efforts to inequalities, by: o Sharpening focus on most disadvantaged communities o Engaging other sectors that also produce health o Optimizing impact of healthcare sector on health 2

3 Current smoking, 18 years old, NYC Dowell & Farley, Lancet 2012

4 4

5 Change in life expectancy, Females, IHME, 2013

6 Life expectancy, by Borough, Alcorn, Lancet 2012

7 NYC DOHMH, Bureau of Vital Statistics, March

8 NYC DOHMH, Bureau of Vital Statistics, March

9 NYC DOHMH,

10 10

11 What produces health? 11

12 Median household income & life expectancy, US counties NY Times, March 16,

13 Spending on social programs vs. healthcare: impact on health ratio of social : health expenditures in OECD countries infant mortality life expectancy potential life years lost (after adjusting for level of health expenditures, GDP) Bradley, Elkins, Herrin, Elbel. BMHJ Qual Saf,

14 Mortality, USA Yr 2000: Dx d vs underlying causes Underlying Behavioral Causes N = 1.2 million Diagnosed Causes N = 2.4 million Smoking Obes/inact Alcohol MVA Guns Unprot'd sex Drugs Heart Cancer Stroke Resp Injury Diabetes Flu/Pneu Other Mokdad JAMA 2004

15 Mortality, USA Yr 2000: Social factor attribution Galea, Tracy, Hoggatt, DiMaggio, Karpati, AJPH

16 Education: Bachelor s Degree & Higher, NYC, % NYC adults White Black Hispanic Asian Furman Center Annual Report

17 Poverty rate, NYC, % households < poverty White Black Hispanic Asian Furman Center Annual Reports, 2006 and

18 Severe crowding: % of rental households, NYC, (>1.5 household members/room) White Black Hispanic Asian Furman Center Annual Reports, 2006 and

19 NYC DOHMH,

20 Inequalities in income: Gini coefficients* by borough *measure of income dispersion in geographic area

21 Inequalties in health: which way forward? Furman Center Annual Reports, 2006 and

22 Inequalties in health: which way forward? Furman Center Annual Reports, 2006 and

23 Inequalties in health: which way forward? Furman Center Annual Reports, 2006 and

24 Inequalties in health: which way forward? Furman Center Annual Reports, 2006 and

25 House lights and spotlights City-wide approaches o Public health and healthcare sectors Ø Regulatory initiatives, prevention: continued promise o Other sectors Ø Downstream impact could be even greater Community/neighborhood/population grounded approaches o Fundamental to eliminating health inequalities 25

26 Complementary approaches: policy and community A B C D E 26

27 Complementary approaches: policy and community A B C D E 27

28 Complementary approaches: policy and community A B C D E 28

29 Complementary approaches: policy and community A B C D E 29

30 Complementary approaches: policy and community A B C D E 30

31 Smoking rates NYC, White, M Black, M Hispanic, M Asian, M White, F Black, F Hispanic, F Asian, F NYC DOHMH, EpiQuery 31

32 Strategies forward 1. City-wide health policy approaches Legislation Regulation Procurement 2. Bridge other sectors to tackle upstream determinants Health in All Policies 3. Deepen focus on / partnership with highest need communities 4. Extend the population impact of healthcare 32

33 City-wide health policy approaches Legislation Regulation Procurement Examples: o Sugar-sweetened beverage portion size o age of cigarette purchasing to 21 33

34 Bridging other sectors to tackle upstream determinants Health in all Policies (HIAP) Transportation Education Housing Built environment 34

35 L Brotman, 2014

36 Moving to Opportunity demonstration 4248 families in Boston, Baltimore, Chicago, LA, NYC Randomly assigned ( ) to: 1. housing voucher that could be used to move to a low poverty (<10%) neighborhood 2. housing voucher with no geographic restrictions 3. control group In 2002, one adult (98% female) from each family was followed up by interview Kling JR, Liebman JB, Katz LF. ( MTOcomprehensivejune2005.pdf)

37 Obesity Outcomes in MTO % Obesity P =.04 P =.09 Low poverty Traditional Control Kling JR, Liebman JB, Katz LF. ( MTOcomprehensivejune2005.pdf)

38 Deepening partnerships w/ communities at highest risk: Hypertension inequalities in NYC Percentage of residents reporting high blood pressure ever and currently taking HTN medications by race (age-adjusted) NYC Community Health Survey Black White 0 HBP Ever Currently taking BP Meds

39 Deepening partnerships w/ communities at highest risk: Health Ministry-based BP Dashboard

40 Extending the population impact of healthcare delivery Healthcare system: a minor actor? But:» Resource-rich» Concentrated focus on health» Strong evidence behind preventive interventions New opportunities» Payment mechanisms favoring population-oriented approach» Primary care» CHWs» Community benefit 40

41 Total area popula+on Pop n for which delivery system at risk Total area popula+on Pop n for which delivery system at risk

42 Jacobson & Teutsch,

43 Delivery system? Jacobson & Teutsch,

44 2020 look-back? Community-grounded, sector-bridging Premature Mortality Affordable housing Univ pre-k Minimum wage Green carts ubiquitous; Safe, well-lit stairwells Narcan Accountable partnership organizations (APOs)

45 Moving forward Don t dim the house lights Intensify focus on and deepen partnerships with communities at greatest disadvantage Broaden interface of healthcare and community health Actively adopt health strategies in key health-producing sectors Address income inequality Tax policy; affordable housing policy; new entry level jobs 45