How Inequality Kills:

Transcription

1 How Inequality Kills: Social Medicine as a Core Med Ed Competency David Ansell, MD, MPH Michael E. Kelley Professor of Internal Medicine SVP and Associate Provost for Community Health Equity Rush University Medical Center

2 I have no disclosures

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4 A Talk in 3 Parts Part 1: Why Social Medicine? Part 2: How Inequality Kills: Structural Violence Part 3: Social Medicine as a Core Competency for Med Education

5 Part 1: Why Social Medicine?

6 If Health is a Human Right Then what are the implications for Medical Education?

7 One street, two worlds

8 Doctors within Borders

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10 Part 2: How Inequality Kills: Equity and Structural Violence

11 Healthy Chicago 2.0 Map of Communities with Hardship Z Source: Healthy Chicago 2.0 Plan,

12 Chance of a 16 year Black teen on the South Side of Chicago living to 65? 50%

13 Deaths per 100,000 women Chicago Black Women 62% More Likely 50 To Die Of Breast Cancer Black White per 100,000 is 62% more deaths than 24 per 100, Age-Adjusted Female Breast Cancer Mortality for Chicago, Per 100,000 Population. Prepared by The Sinai Urban Health Institute

14 Geography Of the Death Gap Chicago Community Areas with the Highest Annual Breast Cancer Mortality Rates Predominately African American Communities Non- African American Communities Hospitals with American College of Surgeons Approved Cancer Programs

15 6 Ways Structural Racism Kills Concentration of Black Disadvantage (White Advantage)- location effect Structural racism: police, incarceration, schools, housing, jobs, food Embodiment of Racism (Embodiment of Privilege) Bias (Implicit and Explicit) Inequality in quality of health care delivery Inequity in health outcomes

16 Equity and Equality: The social, structural and political determinants of health

17 Worldwide life expectancy growing

18 20 year life expectancy gap between rich and poor

19 Average life expectancies hide large societal death gaps

20 2003 RUSH University Medical Center

21 Global Income Inequality 2003 RUSH University Medical Center

22 National Income Inequality Gaps

23 Income Inequality Income inequality in OECD countries is at its highest level for the past half century. The average income of the richest 10% of the population is about nine times that of the poorest 10% across the OECD, up from seven times 25 years ago.

24 How Does Health Care Influence Life Expectancy? Lifespan Growing Faster for Canadians than Americans Canada USA

25 Mortality Gap by Income is Shrinking in Canada Poorest Q2 Q3 Q4 Richest Remaining life expectancy at age 25

26 The gap is growing in the US Dramatic gains for the wealthy; losses for lower income 45 Remaining life expectancy at age Turned 50 in 1980 Turned 50 in 2010 Poorest Q2 Q3 Q4 Richest Growing Gap in Life Expectancy by Income National Academy of Sciences, 2015

27 2013 healthcare spending per capita It is not just about spending $10,000 $9,160 $8,000 $6,000 $3,398 $6,470 $6,292 $4,000 $2,000 $3,240 $3,710 $4,120 $4,430 $4,720 $5,000 $5,220 $- UK JAP FRA CAN GER SWE HOL SWI USA Total US Public US Private Public includes benefit costs for govt. employees & tax subsidies for private insurance Data are for 2014 or most recent year Sources: OECD 2015; NCHS; Health Affairs (4)88

28 Physician Views of their Health Systems System Works Well, Only Minor Changes Needed Percent AUS CAN FR GERNETH NZ NOR SWE SWIZ UK US Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians. 29

29 Part 3. Social Medicine as a Core Competency I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm. Hippocratic Oath

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31 The physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction.

32 Narrative + Data+ Public Action= Change

33 White Coats for Black Lives

34 7 Social Medicine Competencies Respect for History/ Cultural Humility/Privilege Narrative as a tool for seeing the invisible Improvement skills for mitigating health inequities Skills to conduct a structural inequity analysis- social, structural and political determinants of health- how does structural racism work here? Structured mentored clinical experiences with marginalized populations with reflection Advocacy and activism training- teach speech Tools to manage empathetic distress

35 Differential Incentives leads to Inequality

36 Health care is a human right