Social Determinants of Disparities in Health: Before, During, and After the Storm

Social Determinants of Disparities in Health: Before, During, and After the Storm 2008 Fulbright Symposium Flinders University Adelaide, Australia July 11, 2007 David Satcher, M.D., PhD Director, The Satcher Health Leadership Institute and The Center of Excellence on Health Disparities Poussaint-Satcher- Cosby Professor of Mental Health Morehouse School of Medicine 16th U.S. Surgeon General

Satcher Health Leadership Institute Mission The mission of the Satcher Health Leadership Institute is to develop a diverse group of public health leaders, foster and support leadership strategies, and influence policies toward the reduction and ultimate elimination of disparities in health. www.satcherhealthleadershipinstitute.org

Reports of the 16 th Surgeon General Best available science

Healthy People 2010: Overarching Goals Increase Years and Quality of Healthy Life Eliminate Racial and Ethnic Health Disparities

Infant Mortality Rates, by Maternal Race/Ethnicity --- United States, 1995 and 2003

What If We Had Eliminated Disparities in the Last Century? Fewer Black Deaths In 2000 83,500 overall 24,000 from heart disease 7,000 from HIV / AIDS 4,700 infant deaths 22,000 from diabetes 2000 fewer Black women from breast cancer More Health Insurance Coverage 2.5 million Blacks, including 620,000 children Source: D. Satcher et al, Health Affairs, March/April 2005

Determinants of Health Source: Health People 2010

Leadership Challenge: Selected Health Status Characteristics of Pre- Katrina Louisiana Compared to the U.S. 40.8 25.3 10.3 21.2 14 Louisiana United States 7 Infant Mortality AIDS Case Rate Diabetes Mortalitly Per 1,000 live births AIDS Cases per 100,000 Deaths per 100,000 Note: Rankings include DC. Source: Kaiser statehealthfacts. Org 2006 Infant Mortality data for 2002, Diabetes Mortality for 2003, and AIDS Case Rate for

Leadership Challenge: Key Characteristics of Pre-Katrina Louisiana Compared to the U.S., 2004-2005 28% 31% 32% 23% 23% 24% 17% 12% Louisiana United States % living in poverty % of Children living in Poverty Medicare Enrollees <150% Poverty Percent African American Source: Kaiser statehealthfacts. Org 2006 Data is from the Census Bureau s March 2005and 2006 Current Beneficiary Survey

Leadership Challenges More Than 1400 Lives Lost. 900,000 People Displaced. 18,750 Businesses Destroyed. 200,000 Homes Damaged or Destroyed 220,000 Jobs Lost. Source: Louisiana Recovery Authority, August 2006

Cumulative Effect of Hurricane Katrina on Underserved Community Baseline health status Support system Trauma & Stress Survivor character, coping skills Resource Content Evacuee Status Mental Illness Health Disparities Fractured Healthcare System for the Underserved

Leadership Challenge: The Health of Children Displaced by Hurricane Katrina Chronic Health Conditions Asthma Learning disabilities Behavioral /conduct problems Developmental delay/physical impairment Depression/anxiety Any chronic condition Displaced Children (2006) 18% 18 15 9 9 34 Urban LA Children (2003) 14% 10 7 4 4 26 Medical Equipment Children who need special medical equipment 16% 10% Source: The New York Times/2006

Leadership Challenge: The Health of Children Displaced by Hurricane Katrina Medication Children who did not receive all the medications they were prescribed in the last three months School Absenteeism School-age children not currently in school Displaced Children (2006) 14% 10% Urban LA Children (2003) 2% 2% School-age children not currently in school or who missed 10 or more days in the last month Source: The New York Times/2006 23 N.A.

Leadership Challenge: Healthcare Infrastructure After Katrina Plight of public hospitals damaged by hurricane Charity Hospital, 275-year history of treating patients regardless of ability to pay; major trauma center; teaching hospital. Served 62% of New Orleans residents before Katrina Provided psychiatric, substance abuse, and HIV/AIDS care Provided free medical detox services to the city's poor and uninsured Closed and no plans to reopen.

Leadership Challenge: Healthcare Infrastructure After Katrina 2038 physicians Pre-Katrina and 510 physicians as of 2006 * Source: Blue Cross/Blue Shield Lost medical professionals 77% of primary care doctors 70% of dentists 89% of psychiatrists Increased stress, anxiety, depression, and substance abuse. Problems finding medical care Problems finding care for Pre-Katrina physical and mental health conditions.

The Regional Coordinating Center for Hurricane Response National Center for Primary Care Morehouse School of Medicine Balanced Healthcare Information Technology/ EHR,CCR Telemedicine Psychiatry Strategic Response Infrastructure Phase I Research Network Community based screening and surveillance

How Do We Define Primary Care? Primary care is the provision of: First contact care of the often undifferentiated patient Comprehensive care responding to most of the health care needs of patients Continuous, coordinated care serving as patients medical home with recordkeeping, consultation and referral as needed Integration of services into the context of family and community. Reference: Millis Report, 1966/ Institute of Medicine 1994

Commission on Social Determinants of Health The Commission on Social Determinants of Health fosters a global movement that places fair health fairer distribution of health and better overall population health - at the head and the heart of governance. www.who.int/social_determinants/en

CSDH The goal is not an academic exercise, but to marshal scientific evidence as a lever for policy change aiming toward practical uptake among policymakers and stakeholders in countries. WHO Director-General Lee Jong-Wook, World Health Assembly, 2004 Former DG of WHO Lee Jong-Wook at World Health Assembly 2004

180 San Marino 160 140 120 100 80 Cape Verde 60 40 20 A ndorra Japan Singapore Australia Samoa Morocco Lithuania Nicaragua Angola Zimbabwe 0 Malawi Mozambique Zambia Inequalities: Between & Within Countries Under-5 Mortality Rate by Income Quintile 81.1 80.7 80.1 79.8 69.2 69.1 69.1 68.9 68.7 38.3 37.8 37.6 37.5 37.2 Indonesia Brazil India Kenya 83.5 0 10 20 30 40 50 60 70 80 90 LE at Birth, years Poorest fifth 2nd poorest fifth Middle fifth 2nd richest fifth Richest fifth

Health Equity & Core Values Health inequities, within and between countries, are socially unjust; Social, economic, political, cultural and environmental factors are the key drivers of health inequities; Tackling health inequities requires action on SDH; Health equity is the responsibility of a diverse social actors.