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
Overview Net gains in NYC health over last 10-15 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
Current smoking, 18 years old, NYC 1993 2010 Dowell & Farley, Lancet 2012
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Change in life expectancy, Females, 1985-2010 IHME, 2013
Life expectancy, by Borough, 1985-2009 Alcorn, Lancet 2012
NYC DOHMH, Bureau of Vital Statistics, March 2013 7
NYC DOHMH, Bureau of Vital Statistics, March 2013 8
NYC DOHMH, 2014 9
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What produces health? 11
Median household income & life expectancy, US counties NY Times, March 16, 2014 12
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, 2011 13
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
Mortality, USA Yr 2000: Social factor attribution Galea, Tracy, Hoggatt, DiMaggio, Karpati, AJPH 2011 15
Education: Bachelor s Degree & Higher, NYC, 2000-2012 60 50 % NYC adults 40 30 20 10 White Black Hispanic Asian 0 2000 2012 Furman Center Annual Report 2012 16
Poverty rate, NYC, 2000-2012 35 % households < poverty 30 25 20 15 10 5 0 2000 2012 White Black Hispanic Asian Furman Center Annual Reports, 2006 and 2012 17
Severe crowding: % of rental households, NYC, 2006-2012 9 8 7 (>1.5 household members/room) 6 5 4 3 2 White Black Hispanic Asian 1 0 2006 2012 Furman Center Annual Reports, 2006 and 2012 18
NYC DOHMH, 2010 19
Inequalities in income: Gini coefficients* by borough *measure of income dispersion in geographic area
Inequalties in health: which way forward? Furman Center Annual Reports, 2006 and 2012 21
Inequalties in health: which way forward? Furman Center Annual Reports, 2006 and 2012 22
Inequalties in health: which way forward? Furman Center Annual Reports, 2006 and 2012 23
Inequalties in health: which way forward? Furman Center Annual Reports, 2006 and 2012 24
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
Complementary approaches: policy and community 2014 2024 2034 A B C D E 26
Complementary approaches: policy and community 2014 2024 2034 A B C D E 27
Complementary approaches: policy and community 2014 2024 2034 A B C D E 28
Complementary approaches: policy and community 2014 2024 2034 A B C D E 29
Complementary approaches: policy and community 2014 2024 2034 A B C D E 30
Smoking rates NYC, 2002-2012 30 25 20 15 10 5 White, M Black, M Hispanic, M Asian, M White, F Black, F Hispanic, F Asian, F 0 2002 2012 NYC DOHMH, EpiQuery 31
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
City-wide health policy approaches Legislation Regulation Procurement Examples: o Sugar-sweetened beverage portion size o age of cigarette purchasing to 21 33
Bridging other sectors to tackle upstream determinants Health in all Policies (HIAP) Transportation Education Housing Built environment 34
L Brotman, 2014
Moving to Opportunity demonstration 4248 families in Boston, Baltimore, Chicago, LA, NYC Randomly assigned (1994-97) 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. (http://www.ksg.harvard.edu/jeffreyliebman/ MTOcomprehensivejune2005.pdf)
Obesity Outcomes in MTO % Obesity 50 45 40 35 30 25 20 15 10 5 0 P =.04 P =.09 Low poverty Traditional Control Kling JR, Liebman JB, Katz LF. (http://www.ksg.harvard.edu/jeffreyliebman/ MTOcomprehensivejune2005.pdf)
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 2012 70 60 50 51.2 60.2 40 30 20 10 36.7 22.2 Black White 0 HBP Ever Currently taking BP Meds
Deepening partnerships w/ communities at highest risk: Health Ministry-based BP Dashboard
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
Total area popula+on Pop n for which delivery system at risk Total area popula+on Pop n for which delivery system at risk
Jacobson & Teutsch, 2012 42
Delivery system? Jacobson & Teutsch, 2012 43
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) 2013 2014 2015 2016 2017 2018 2019 2020
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