Making a World of Difference Health Disparities in Memphis and Beyond: Does inequality make us sick? Marian Levy, DrPH, RD Assistant Dean School of Public Health Interdisciplinary Community Education Workshop March 29, 2016 Learning Objectives 1. Identify examples of racial and socioeconomic disparities in the U.S. and Memphis 2. Recognize how the social environment, including neighborhood factors, income inequality, and discrimination affect health status 3. Reflect on potential solutions to reducing disparities A Tale of Two Cities.. 1
Health Disparities Communities of Color are Disproportionately Affected Kawachi 2004 2
Life Expectancy At Birth, By Race & Gender U.S. Census Bureau. 2007. Statistical Abstract of the United States: 2007. Source: Health, United States, 2007. http://www.cdc.gov/nchs/data/hus/hus07.pdf#029 Table 29. All Causes Age-Adjusted Death Rates per 100,000 Persons by Race & Hispanic Origin: U.S., 2005 Source: Health, United States, 2007. http://www.cdc.gov/nchs/data/hus/hus07.pdf#029 Table 29. 3
Heart Disease Age-Adjusted Death Rates per 100,000 Persons by Race & Hispanic Origin: U.S., 2005 Source: Health, United States, 2007. http://www.cdc.gov/nchs/data/hus/hus07.pdf#029 Table 29. Cancer Age-Adjusted Death Rates per 100,000 Persons by Race & Hispanic Origin: U.S., 2005 Source: Health, United States, 2007. http://www.cdc.gov/nchs/data/hus/hus07.pdf#029 Table 29. 4
Stroke Age-Adjusted Death Rates per 100,000 Persons by Race & Hispanic Origin: U.S., 2005 Source: Health, United States, 2007. http://www.cdc.gov/nchs/data/hus/hus07.pdf#029 Table 29. Human Immunodeficiency Virus (HIV) Disease Age-Adjusted Death Rates per 100,000 Persons by Race & Hispanic Origin: U.S., 2005 Source: Health, United States, 2007. http://www.cdc.gov/nchs/data/hus/hus07.pdf#029 Table 29. Diabetes Age-Adjusted Death Rates per 100,000 Persons by Race & Hispanic Origin: U.S., 2005 Source: Health, United States, 2007. http://www.cdc.gov/nchs/data/hus/hus07.pdf#029 Table 29. 5
Age-Adjusted Maternal Mortality Rate per 100,000 Persons Maternal Mortality for Complications of Pregnancy, Childbirth, & the Puerperium Age-Adjusted Death Rates per 100,000 Persons by Race & Hispanic Origin: U.S., 2005 35 30 25 20 15 10 5 0 12.4 All Races 9.6 9.1 Non-Hispanic White White 31.7 African American 8.2 Hispanic Source: Health, United States, 2007. http://www.cdc.gov/nchs/data/hus/hus07.pdf#029 Table 29. Sudden Infant Death Syndrome (SIDS) Rates per 100,000 Live Births by Race & Hispanic Origin: U.S., 2006 Source: Health, United States, 2007. http://www.cdc.gov/nchs/data/hus/hus07.pdf#029 Table 29. Infant Death Under 1 Year Rates per 1,000 Live Births by Race & Hispanic Origin: U.S., 2005 Source: Health, United States, 2007. http://www.cdc.gov/nchs/data/hus/hus07.pdf#029 Table 29. 6
Age-adjusted death rates, by race: United States, 1980 2013 National Vital Statistics Reports, Vol. 64 No. 2, February 16, 2016 http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdf Why do these disparities exist? Is it genetics? 7
Hypertension, 7 West African Origin Groups (%) Source: International Collaborative Study of Hypertension in Blacks, 1995 Why do these disparities exist? Genetics? no Social status? What we know about the link between socioeconomic status and health Socioeconomically disadvantaged men and women have higher overall mortality, higher mortality from almost every cause of death, and lower self-rated health than persons with a higher socioeconomic status. These associations seem universal, which is remarkable given differing disease prevalence and risk factors across time and place. 8
Relative Risk 3/31/2016 In the Whitehall Study, 17,000 British civil servants were classified according to their social position, as reflected by occupational class, and followed for 7.5 years MG Marmot et al., J Epi Comm Health, 1978, 32, 244-249 MG Marmot et al., J Epi Comm Health, 1978, 32, 244-249 Relative Risk of Premature Death by Family Income (U.S.) Family Income in 1980 (adjusted to 1999 dollars) 9-year mortality data from the National Longitudinal Mortality Survey 9
Why do these disparities exist? Genetics? Social status? Environment? no Yes, but not the full story Pop Quiz! What is the greatest difference in life expectancy observed between U.S. counties? A. 4 years B. 7 years C. 15 years D. 22 years E. 33 years ANSWER: C. 15 years Our zip code is a strong indicator of our health. Asian American women in Bergen County, New Jersey, live 33 years longer than Native American men in South Dakota. Health expert Sir Michael Marmot noted that on a subway ride from southeast Washington, D.C. to Montgomery County, Maryland, life expectancy of the surrounding communities rises about a year and a half for every mile traveled amounting to a 20-year gap. Despite being the wealthiest country in the world, the US ranks 50th in life expectancy behind several developing countries. Sources: (1) Murray, C.J.L. et al. (2006). Eight Americas: Investigating Mortality Disparities across Races, Counties, and Race- Counties in the United States. PLoS Med 3(9): e260. doi:10.1371/journal.pmed.0030260 (2) Marmot, Michael. (2004). Status Syndrome. New York: Henry Holt and Company.; CIA Fact Book, 2010 data 10
How many more supermarkets are there in white neighborhoods compared to Black and Latino neighborhoods? 1. About the same 2. 1.5 times as many 3. 2 times as many 4. 4 times as many 5. 6 times as many Answer: 4 times as many Predominantly Black and Latino neighborhoods have more fast-food franchises and liquor stores, yet often lack stores that offer fresh, affordable fruits and vegetables. Residents tend to rely more on public transportation, further compounding problems of access. A 2005 Chicago study found that people living in such food deserts died early in greater numbers and had more diabetes, obesity and high blood pressure. White neighborhoods in west LA contain ~31.8 acres of Park space per 1000 residents. How Much in Black & Latino Neighborhoods? 1. 28.7 acres 2. 17.2 acres 3. 14.6 acres 4. 5.8 acres 5. 1.7 acres 11
Answer: 1.7 acres That s almost 19 times more green space in white neighborhoods than Black and Latino neighborhoods. More parks mean cleaner air, room to exercise and play, a place for community members to gather, and also higher property values and increased desirability Place Matters! Communities of Opportunity Good Health Status Low- Income Communities Parks Sidewalks Grocery Stores Better Performing Schools Living Wage Jobs Good Public Transportation Poor Health Status contributes to health disparities: Obesity Diabetes Asthma Infant mortality Fast Food Restaurants Liquor Stores Unsafe/Limited Parks Lack of jobs Increased Pollution and Toxic Waste Sites Limited Public Transportation Tips for Staying Healthy: A Social Determinants Approach 1. Don t be poor. If you can, stop. If you can t, try not to be poor for too long 2. Don t have poor parents 3. Don t live in a poor neighborhood 4. Own a car but use only for weekend outings 5. Walk to work 6. Practice not losing your job and don t be unemployed 7. Don t be illiterate 8. Avoid social isolation 9. Try not to be part of a socially marginalized group 12
Why do these disparities exist? Genetics? Social status? Environment? Discrimination? no Yes, but not the full story Yes, but also not the full story The mark of a criminal record Pairs of young, well-groomed, well-spoken college men with identical resumes apply for 350 advertised entry-level jobs in Milwaukee, Wisconsin. Two teams were black and two were white. In each team, one said that he had served an 18-month prison sentence for cocaine possession. Pager, D., American Journal of Sociology, 2003 13
It was easier for a white male with a felony conviction to get a job than a black male whose record was clean (% of Job Applicants Receiving a Callback) Criminal Record White Black No 34% 14% Yes 17% 5% Source: Devan Pager; NYT March 20, 2004 Are Emily and Greg more employable than Lakisha and Jamal? A field experiment on labor market discrimination Fictitious resumes sent in respond to helpwanted ads in Boston and Chicago newspapers. To manipulate race, resumes are randomly assigned African American or White sounding names (e.g., Lakisha vs. Emily) White names received 50% more callbacks for interviews Bertrand, M., & Mullainathan, S. American Economic Review, 2004, 94, 991-1013. Why do these disparities exist? Genetics? Social status? Environment? no Yes, but not the full story Yes, but also not the full story Discrimination? Yes, another part of the story So, what do we do to solve these inequalities? 14
Average Life Expectancy (years) Per Capita Spending in USD 3/31/2016 Higher Per Capita Spending in the U.S. does not Translate into Longer Life Expectancy The Cost of a Long Life 82 81 United States 5000 4500 4000 80 3500 79 3000 78 2500 77 2000 1500 76 1000 75 500 74 Japan San Marino Monaco Switzerland Australia Sweden Iceland Andorra Canada France Italy Austria Spain Norway Singapore Israel Luxembourg New Zealand Netherlands Germany Greece Malta Belgium Finland United Kingdom Denmark United States Cuba Cyprus Ireland Portugal 0 Life Expectancy Per Capita Spending 2006 CIA FACTBOOK Shelby County Chronic Disease 15
Overlay of Social Indicators Poverty; Crime Legend ACSPovertyPercentage / none < -1.5 Std. Dev. -1.5 - -0.50 Std. Dev. -0.50-0.50 Std. Dev. 0.50-1.5 Std. Dev. 1.5-2.5 Std. Dev. > 2.5 Std. Dev. Legend censusjuvenile.juvierate / none 0.00000000-20.0000000 20.0000001-41.0000000 41.0000001-62.0000000 62.0000001-86.0000000 86.0000001-121.000000 Commercial Appeal: 5-26-04 by Karen Pulfer Focht: Inmates (Roscoe Allen and Jerry Nelson) help Robert Savage (left) bury babies in Potter's Field, the counties public cemetery. Shelby County has the highest rate of infant mortality in the United States. More than 14,000 bodies, mostly babies, lay beneath the earth about one mile north of Wolfchase Mall. Many are buried with no ceremony or visitors at all. 16
Rate per 1,000 live births 3/31/2016 Infant Mortality Rates by Region, US, 2006-2011 16.0 14.0 12.0 % Change 2006 to 2010 US: -8.1%* SE Region: -13.0%* TN: - 8.8% Shelby: -25.2%* * significant p<0.05 10.0 8.0 US SE Region TN Shelby 6.0 4.0 2006 2007 2008 2009 2010 2011 Note: SE REgion includes AR, LA, MS, AL, GA, FL, SC, NC, TN Infant Mortality Rate by Race, Shelby County, TN, 2006-2011 20.0 18.0 16.0 14.0 12.0 10.0 8.0 6.0 4.0 2.0 0.0 2006 2007 2008 2009 2010 2011 Shelby County Total Shelby County White Shelby County Black TN Breastfeeding Rates Substantially Below Targets 81.9 34.1 46.2 60.6 25.5 CDC National Immunization Survey, 2013, 2010 births http://www.cdc.gov/breastfeeding/data/nis_data/index.htm 17
Shelby County Breastfeeding Initiation Tennessee Department of Health, Office of Vital Statistics, 2013 Editorial: Another rude awakening on obesity After all that's been done to promote a healthier lifestyle in Memphis, it's discouraging to hear the news that the city's stroke rate is 37 percent above the national average and that its obesity rate is the highest across the United States. Commercial Appeal, March 27, 2016 Pediatric Obesity Prevalence (2012) Nearly one-third (31.7%) of American children ages 2-19 (approx. 25 million) are overweight or obese (Ogden 2014) 18
Pediatric Obesity Prevalence Overweight or obese 34.6% boys 32.6% girls 26.5% Hispanic boys 24.8% African American girls (Ogden 2010) Memphis City Schools 2013 YRBS High school students (in past 7 days) 33%: no milk 68%: insufficient physical activity 7%: no fruit or juice 13%: no vegetables 19%: no breakfast Memphis City Schools 2013 YRBS (cont.) 37% obese (18%) or overwt (19%) 23% consume sugar-sweetened beverages two or more times a day 48% watch television 3 or more hrs on typical school day 43% play video games/use computer (not school work) 3 or more hrs/school day 19
WHO Recommendations: address main social determinants Stress Early life Social exclusion Working conditions Unemployment Social support Addiction Healthy food Transportation The built environment is social policy set in concrete. Dr. Richard Jackson 20
Compared rates of hypertension, diabetes, obesity, smoking, and use of health services among blacks and whites living in census tracks in SW Baltimore that had similar proportions of blacks and whites who had similar income and education. Concluded that place matters: The racial disparity we normally see in national samples was attenuated or completely erased when white and black Americans live under similar conditions. Research question: Do people experience improvements in health when moved from poor neighborhoods to richer neighborhoods? Design: A social experiment, using randomized controlled methodology NEJM, 2011, 365. 1509-1519 Ludwig et al., 2011 Methods HUD Moving to Opportunity (MTO) demonstration project Subjects: Families with children living in public housing in census tracts with poverty rates of 40% or more (Baltimore, Boston, Chicago, Los Angeles, NY) 1994-98, families invited to participate in randomized lottery to receive a rent-subsidy voucher ¼ of eligible families applied, 4498 were randomized to 1 of 3 groups: Voucher that had to be used in census tract with low poverty rate (<10%) Voucher that could be used anywhere No voucher Health outcomes assessed 2008-10 (12 years later) Obesity (BMI >30, >35, >40) Diabetes (HbA1c >6.5) 21
Ludwig et al., 2011 Results At follow-up, low-poverty voucher group were less likely to be living in poverty or living in high-poverty neighborhoods Compared to control group, women in the low-poverty voucher group were less likely to be obese (36% vs. 31%) or to have diabetes (36% vs. 31%) Link between Education and Health Work and economic conditions Well educated are less likely to be unemployed, are more likely to work full-time, to have fulfilling, subjectively rewarding jobs, high incomes, and low economic hardship Social-psychological resources Well educated report a greater sense of control over their lives and health; higher levels of social support Healthy lifestyle Well educated are less likely to smoke, are more likely to exercise, get health check-ups, drink moderately Ross and Wu, American Sociological Review, 60(5): 1995 Health-risk behaviors and school grades, United States, 2009 Source: www.cdc.gov/healthyyouth/health_and_academics/pdf/health_risk_behaviors.pdf. 22
Age-adjusted death rates among persons ages 25 64 years for several condition groupings, by sex and educational attainment. Selected US states, 1994 2005 Hahn and Truman, Int J Health Serv. 2015; 45(4): 657 678. Pathways from educational attainment to health outcomes Hahn and Truman, Int J Health Serv. 2015; 45(4): 657 678. Summary Despite spending more on health care, in both absolute and relative terms, than any other country, the U.S. does worse than more than 4 dozen other nations on length and quality of life. Inequalities particularly by race and social position -- are a major reason for this situation. Improving healthcare technology, training more providers, or increasing insurance coverage aren t going to solve the problem. 23
Summary Solutions hinge on the concept of Liberty, Equality, and Fraternity Place matters! Education promotes health equity! Knowledge is not morally neutral and often demands action. Public Health Leadership Society, 2002 If not us, who? If not now, when? 24
THANK YOU! 25