Massachusetts Department of Public Health The Elimination of Racial and Ethnic Disparities A Public Health Priority September, 2009
The Elimination of Racial and Ethnic Disparities is a Core Public Health Goal Data clearly indicate that it needs to a priority to address a wide range of health issues There is unevenness within public health with regard to whether this is a top priority Positive examples exist that demonstrate what public health can do to have an impact on disparities even in difficult economic ties 2
Why Should this be a Priority?
Racial Disparities in Boston Health Indicator Black White Black vs. White Asthma (< 5, hosp) 12.5 per 1000 3.6 3.5 x Birth Weight (Less than 3.3lbs) 3.4% of births 1.5 2.3 x Body Weight (Overweight or 65% 47% 1.4 x Breast Cancer (Morality) 33.9 per 100,000 16.3 2.1 x Cervical Cancer (Mortality) 2.4 per 100,000 1.3 1.8 x Death Rate (Mortality) 1010.3 per 100,000 727.9 1.4 x Diabetes (Mortality) 41.1 per 100,000 18.1 2.3 x Drug Related Mortality 27.9 per 100,000 36.3 (1.3x) Heart Disease (Mortality) 182.1 per 100,000 148.8 1.2x High Blood Pressure 27% 20% 1.4 x HIV / AIDS (Mortality) 20.9 per 100,000 2.4 8.7x Homicide 31.3 per 100,000 n<5 >8 x Hospitalization 173.6 per 1,000 99.4 1.75 x Infant Mortality (Mortality) 11.3 per 1,000 3.4 3.3 x Lung Cancer (Mortality) 57.5 per 100,000 50.5 1.14 x Prostate Cancer (Mortality) 80.5 per 100,000 27.0 2.9 x Smoking during pregnancy 3.4% 4.9% (1.4 x) Suicide (Mortality) 4.3 7.3 (1.7 x) Teen Birth Rate (15-17) 26.2 per 1,000 10.9 2.4 x Uninsured 11.1% 5.8% 1.9 x 4
Ratio of All Cause Mortality Rates Compared to White non-hispanics Massachusetts: 1996-2006 2.0 1.8 Ratio of Rates 1.6 1.4 1.2 1.0 0.8 0.6 0.4 1.3 Worse Off Better Off 0.6 0.5 + 10.9%* APC Blacks to Whites -1.5%* APC Hispanics to Whites -1.0%* APC Asians to Whites 1.2 0.7 0.5 0.2 0.0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 * Statistically Significant (p.05) APC = Annual Percentage Change 5
Infant Mortality Rates by Race/Ethnicity Western Region and Massachusetts: 2002-2005 16 15.1* White^ Black^ Hispanic Asian^ 14 Deaths per 1000 live births 12 10 8 6 4 4.5 8.0* State Overall: 4.9 4.1* 11.3 * 7.0 * 3.0* 2 NA 0 Western Region Massachusetts NA= Calculations based on less than 5 events are excluded (*) Statistically different from State (p.05) ^ = Non-Hispanic Source: MDPH, Bureau of Health Information, Statistics, Research, & Evaluation Bureau, Division of Research & Epidemiology 6
HIV/AIDS Death Rate by Race/Ethnicity Western Region and Massachusetts: 2003-2005 35 30 White non-hispanic Hispanic 29 * Black non-hispanic Asian non-hispanic Deaths per 100,000 25 20 15 10 19 16 13 5 0 1 NA 2 Western Region Age-adjusted to the 2000 US standard population. Health Information, Statistics, Research & Evaluation Bureau, Research & Epidemiology Program Massachusetts 1 Source: MDPH, 7
Asthma Emergency Department Visit Rates Children Ages 0-14 Western Region and Massachusetts: 2005 White non-hispanic Hispanic Black non-hispanic Asian non-hispanic 2,500 2,196 * 2,096 Visits per 100,000 2,000 1,500 1,000 500 1,683 ** 569 516 238 1,573 356 0 Western Region Massachusetts Statistically different from State (p.05) Red (*) = Statistically higher; Green (**) = Statistically lower Age-adjusted to the 2000 US standard population. Source: Division of Health Care Finance and Policy. Calendar Year 2005. Emergency Department Visits 8
Diabetes An Example of a Growing Health Problem with Racial and Ethnic Disparities 9
Prevalence of Diabetes in Massachusetts Varies Significantly by Race/Ethnicity 225 200 Age adjusted rate per 1000 175 150 125 100 75 50 32 123 121 54 64 25 0 2005 Asian Hispanic Black (NH) White Total SOURCE: Mass DPH. 10
Diabetes Hospital Discharges, 2003-2005 MA White Black Hispanic Asian 400 350 368 Rate per 100,000 300 250 200 150 100 50 133 114 242 45 0 Hospital discharge rate Source: Division of Health Care Finance and Policy, Inpatient Hospital Discharge Database 11
Mortality Rates are Much Higher for Blacks and Hispanics Mortality Rates for Diabetes as the Primary Cause of Death, by Race, 1994-2004 Rate p er 100, 000 60 50 40 30 20 10 0 54.5 47.8 43.9 43.0 46.1 42.9 44.6 42.6 45.7 42.4 41.0 36.1 34.3 34.7 30.7 23.8 23.5 26.8 25.9 25.8 26.8 20.5 16.7 19.7 19.2 22.2 12.7 15.1 16.7 19.7 17.9 11.7 11.3 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Years Source: Mass Dept of Public Health White, NH Black, NH Hispanic Asian/Pacific Islander, NH 12
And then there is H1N1
Race/Ethnicity of Novel H1N1 Cases Compared to the Boston Population 14
Race/Ethnicity of Hospitalized Novel H1N1 Influenza Cases 77% of cases vs. 51% of population Black 35 (49%) Hispanic 20 (28%) Other 5(7%) White 11 (15%) 15
What Causes These Disparities? 16
Substantial Variation in Diabetes Rates by Household Income <$25,000 3+ fold variation $75,000 + Source: NEHI/Boston Foundation: Boston Paradox 17
Diabetes by Education, 2006 25 20 Percent 15 15.6 10 5 7.9 5.4 4.4 6.4 0 < HS HS grad 1-3 years college 4+ years college MA Statistically different from state (p.05) Red (*) Statistically worse than state- Green (**) statistically better than state Source: MDPH, Bureau of Health Information, Statistics, Research and Evaluation, Health Survey Program 18
Racial & Ethnic Disparities Infant Mortality & Education, 2003 10.2 6.5 DATA SOURCE: Infant Mortality Statistics from the 2003 Period Linked Birth/Infant Death Data Set, National vital statistics reports; vol. 54, no. 16. Hyattsville, MD; National Center for Health Statistics, 2006 19
The Experience of Racism and Discrimination Boston Adults Who Report Having Been Treated Worse Than People of Other Races When Seeking Health Care During the Previous Year, By Race/Ethnicity Percentage of resp ondents 40.0% 30.0% 20.0% 10.0% 0.0% 8.3% 4.0% 1.9% Black Latino White 20
Leading Occupations in Massachusetts by Race/Ethnicity HISPANIC ASIAN Nursing aides aides Janitors & cleaners Grounds maintenance Maids Maids Truck Truck drivers drivers BLACK Nursing aides aides Janitors & cleaners RNs RNs Cashiers Maids Maids ASIAN Computer engineers Medical scientists Waiters & waitresses Physicians Cashiers WHITE Secretaries Managers & admin. admin. Supervisors in in retail retail sales sales RNs RNs Salespersons 21 Source: Current Population Survey: 2005-07
Hispanic workers are at high risk of fatal occupational injury in Massachusetts 5 Deaths per 100,000 workers 4 3 2 1 2.1 3.4 0 White Hispanic Source: Massachusetts Census of Fatal Occupational Injuries, 2003-06 22
Minority workers experience higher rates of hospitalizations for some work-related injuries White Black Hispanic Asian Hospitalizations per 100,000 workers 10 0 1.2 4.6 2.4 Amputations 1.8 1.9 8 1.7 Burns 5.3 Source:: DHCFP Hospital Discharge Data Set: 1996-2000; Hospitalization Rates for Work-Related Injuries 23
What Can be Done in Public Health to Address the Issue?
Leadership at the Highest Levels Helps The Elimination of Disparities is an Explicit Priority of the Patrick Administration 25
Hire Diverse Leadership After years of little diversity in leadership 26
Focus Attention at the Highest Levels Creation of DPH Health Equity Office Management of disparities and other grants Involvement in senior policy inside and outside of DPH Use of the position as a bully pulpit 27
Provide Information on Disparities Regulatory mandate that hospitals collect and report accurate, consistent patient race and ethnicity data 28
Guarantee Interpreter Services Chapter 66 of the Acts of 2000 Emergency Room Interpreters Law (ERIL) every acute care hospital shall provide competent interpreter services in connection with all emergency room services provided to every non-english speaker who is a patient or who seeks appropriate emergency care or treatment. DPH Releases the 1 st Annual Hospital Interpreter Services Report 1.2 million interpreter sessions completed in Massachusetts in over 100 different languages in a one year period. 29
Issue Special Reports 30
Promote Higher Quality Services Making CLAS Happen CLAS (Culturally and Linguistically Appropriate Services) Standards (US DHHS, 2001) contribute to the elimination of racial and ethnic health disparities make services more responsible to the individual needs of clients are inclusive of all cultures, while specifically designed to address the needs of racial, ethnic, and linguistic minority groups. 31
Provide Specialized Funding Release of $1M dollars to support innovative efforts throughout the state *42 grantees across the state *Workforce development, quality improvement, social determinants 32
Work with Local Communities Supporting local screenings of Unnatural Causes* to build awareness about health disparities. Working with communities to develop goals to eliminate disparities in health. *Unnatural Causes Produced by California Newsreel www.californianewsreel.org 33
Change Internal DPH Efforts Increase programming for health issues affecting communities of color ($2 M in violence prevention) Adapt existing DPH programs to reflect focus on racial and ethnic disparities (new RFP criteria) 34
Develop Targeted Campaigns 35
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Wellness Promotion/Obesity Prevention Initiative Mass In Motion 37
Consider Needed Policy Changes Example: Passage of Menu Labelling Regulation New regulations require fast food chain restaurants to post the calorie content of their food Such restaurants are more likely to be located in neighborhoods of color 38
Example of disproportionate impact low income residents of color 39
Low income neighborhoods are less likely to have Supermarkets with large produce sections Farmers markets Accessible recreational facilities Safe, walkable neighborhoods 40
An Example of the Adaptation Process Support the Successful Implementation of Health Care Reform
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Percentage of males who reported that they did not have Health Insurance, by Race/Ethnicity, 1991-2008 40 30 % 20 10 0 1991 1993 1995 1997 1999 2001 2003 2005 2007 2 per. Mov. Avg. (Black NH) 2 per. Mov. Avg. (Hispanic) 2 per. Mov. Avg. (White NH) 43
Latinos and other people of color less likely to have health insurance 44
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Additional Areas of Health Disparity Often intensifying racial and ethnic disparities
Income 47
Education : Prevalence of serious mental health distress *Significant at the p<.05 level 48
Disabilities 49
Age Suicides by Gender and by Age Massachusetts: 2007 160 159 140 141 Female Male 120 Number of Deaths 100 80 60 40 20 0 48 43 34 24 11 13 16 7 6 0 15-24 25-44 45-64 65-74 75-84 85+ 50
Gender Men s Health: Life Expectancy by Gender and Age Massachusetts: 2007 100 Life Expectancy in Years 90 80 70 60 50 40 30 20 10 77.6 82.5 18.1 Male 21.1 Female 11.3 13.5 0 At Birth At Age 65 At Age 75 51
Sexual Orientation 52
Jobs Soldiers and Veterans Face Higher Health Risks 441,000 veterans in Massachusetts 53,000 with disabilities 12,000 inpatient admissions per year in Mass. to VA hospitals Physical injuries and post traumatic stress disorder 53
The Common Occurrence: Racial/Ethnic Disparities combined with others disparities 54