Post on 11-Dec-2015
Chicago, 11/3/10
Health Disparities: Health Disparities: Origins and Origins and
OpportunitiesOpportunities
Barry Zuckerman, MDBarry Zuckerman, MDThe Joel and Barbara Alpert Professor and The Joel and Barbara Alpert Professor and
Chairman of PediatricsChairman of PediatricsBoston Medical Center/Boston Medical Center/
Boston University School of MedicineBoston University School of Medicine
Race and HealthRace and Health
Racism
↓ Poverty
↓ Unequal Medical Care↑ Stress
Poor Adult Health
Educational opportunity
Employment opportunity
Stress/violence
Poor diet
Poor learning environment
Medication/other health expenditures
Cigarettes and alcohol
Copyright ©2006 American Public Health Association
Geronimus, A. T. et al. Am J Public Health 2006;96:826-833
FIGURE 1-- Probability of having an allostatic load of 4 or higher, as predicted by race (a) and race and gender (b)
FIGURE 1-- Probability of having an allostatic load of 4 or higher, as predicted by race (a) and race and gender (b)
Copyright ©2006 American Public Health Association
Geronimus, A. T. et al. Am J Public Health 2006;96:826-833
Sickle Cell Sickle Cell Anemia: A Special Anemia: A Special Case Study of Race Case Study of Race
and Healthand Health
Variable SCD Cystic Fibrosis
US prevalence 80,000 30,000
Federal support
NIH fiscal-year 2004 funding, in millions of dollars
NIH funding per person with disease, $
90
1125
128
4267
Private philanthropic support, $
Cystic Fibrosis Foundation 2003 annual review
Sickle Cell Disease Association of America 2003 annual revenue
Revenue per person affected with the disease
498,577
6
152,213,000
5074
Total NIH and private support, in millions, $ 90.4 280.2
Total support per person affected with disease, $ 1130 9340
NIH Research Funding and Private, NIH Research Funding and Private, Nonprofit Association Support of Nonprofit Association Support of
SCD and Cystic FibrosisSCD and Cystic Fibrosis
Number of Federal Government Number of Federal Government Requests for Applications Funded Requests for Applications Funded for Sickle Cell Disease and Cystic for Sickle Cell Disease and Cystic
Fibrosis: 1975-2004Fibrosis: 1975-2004
0
50
100
150
200
250
300
350
400
450
No
. o
f fu
nd
ed R
FA
's
1975 1980 1985 1990 1995 2000 2004
SCD research grants
CF research grants
Race and HealthRace and Health
Racism
↓ Income
↓ Access↑ Stress
Poor Health
Adult Health Disparity Adult Health Disparity by Incomeby Income
Adult Health Adult Health Disparities:Disparities:
Life Course TrajectoryLife Course Trajectory
Adult Health Disparities:Adult Health Disparities:
How Early Experiences Get How Early Experiences Get Embedded in Biology and Embedded in Biology and
Influence HealthInfluence HealthEnvironmentEnvironment →→ Gene- Gene- → → NeurochemicalNeurochemical SocialSocial EnvironmentEnvironment Adaptations &Adaptations & PhysicalPhysical InteractionInteraction DisruptionsDisruptions NutritionNutrition
Poor education & economic Poor education & economic productivityproductivity
↕↕→→ Brain → School failureBrain → School failure Poor health behavior Poor health behavior
↕↕ Poor physical & mental healthPoor physical & mental health
→→ OrgansOrgans
Early experiences are Early experiences are biologically embedded in biologically embedded in development of brain and development of brain and
other organsother organsEarly Early
ExperiencesExperiences
PositivePositive Nurturing and Nurturing and
stimulationstimulation
AdverseAdverse Stress/harmful Stress/harmful
interactionsinteractions Neurotoxic Neurotoxic
exposureexposure Inadequate Inadequate
nutritionnutrition
Child and Adult Child and Adult HealthHealth
Brain DevelopmentBrain Development
Brain DevelopmentBrain Development
Parental Language Addressed to Parental Language Addressed to Child by SESChild by SES
0
500
1000
1500
2000
2500
Wor
ds P
er H
our
PublicAssistance
Working Class Professional
Hart & Risley, (1995)Hart & Risley, (1995)Hart & Risley, (1995)Hart & Risley, (1995)
Early experiences are Early experiences are biologically embedded in biologically embedded in development of brain and development of brain and
other organsother organsEarly Early
ExperiencesExperiences
PositivePositive Nurturing and Nurturing and
stimulationstimulation
AdverseAdverse Stress/harmful Stress/harmful
interactionsinteractions Neurotoxic Neurotoxic
exposureexposure Inadequate Inadequate
nutritionnutrition
Child and Adult Child and Adult HealthHealth
Positive and Tolerable Positive and Tolerable StressStress
Positive and Tolerable Positive and Tolerable StressStress
Toxic StressToxic StressToxic StressToxic Stress
Gianaros, P.J., et al. Neuroimage, 2007.
Direct Effects of StressDirect Effects of StressDirect Effects of StressDirect Effects of Stress
Farah, M.J., et al. Brain Res, 2006
Effect Size Between Low and Middle Effect Size Between Low and Middle Income Children on Neurocognitive Income Children on Neurocognitive
Functioning (N=60)Functioning (N=60)
Stress: Adverse Childhood Stress: Adverse Childhood Events and Adult CV Events and Adult CV
DiseaseDisease
0
0.5
1
1.5
2
2.5
3
3.5
0
1
2
3
4
5,6
7,8
Dong et al, 2004 ACEs
Od
ds
Rat
io
Adverse Childhood Events Adverse Childhood Events and Adult Depressionand Adult Depression
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
0
1
2
3
4
5+
Od
ds
Rat
io
ACEs
Chapman et al, 2004
Caspi, A., et al. Science. 301:386-389 2003
Stress and Genetic Stress and Genetic Vulnerability for Vulnerability for
DepressionDepression
Stress and Genetic Stress and Genetic Vulnerability for Vulnerability for
DepressionDepression
Caspi, A., et al. Science. 297:851-854 2002
Stress and Genetic Stress and Genetic Vulnerability for Antisocial Vulnerability for Antisocial
BehaviorBehavior
Stress and Genetic Stress and Genetic Vulnerability for Antisocial Vulnerability for Antisocial
BehaviorBehavior
What to do: ExamplesWhat to do: Examples
1.1. Society: comprehensiveSociety: comprehensive
2.2. Health careHealth care RaceRace
Regulations tied to new constructionRegulations tied to new construction Target quality improvement of select hospitalsTarget quality improvement of select hospitals Cultural competencyCultural competency Increase racial diversity among physicians, nurses, Increase racial diversity among physicians, nurses,
etc.etc. Interpreters (technology)Interpreters (technology) Use of non-health care settingsUse of non-health care settings
BarbersBarbers ChurchesChurches salonssalons
Use Health Care to Disrupt Use Health Care to Disrupt Link Between Poverty and Link Between Poverty and
Poor HealthPoor Health
Reach Out and ReadReach Out and Read Medical-Legal PartnershipMedical-Legal Partnership Project HEALTHProject HEALTH
Reach Out and ReadReach Out and ReadReach Out and ReadReach Out and Read
Advice and books given at pediatric well child visits until age 5
Frequency of Reading Aloud
(High et. al., 2000)
0
2
4
6
Num
ber
of d
ays
and
nigh
ts
per
wee
k
Days/ week Nights/ week
InterventionControl
Children’s Expressive and Children’s Expressive and Receptive Language Receptive Language
CompetenciesCompetencies
74
76
78
80
82
84
86
88
90
92
94
Vo
cab
ula
ry s
core
s
Receptive language Expressive language
Intervention
Comparison
Mendolsohn, et al., Mendolsohn, et al., 19951995
Mendolsohn, et al., Mendolsohn, et al., 19951995
Reach Out and Read Reach Out and Read StatisticsStatistics
● Founded in 1989 at Boston City Founded in 1989 at Boston City HospitalHospital
● Over 4,500 sites Over 4,500 sites
● Over 3.5 million children from low-Over 3.5 million children from low-income families reached last yearincome families reached last year
● Over 5 million books distributed last Over 5 million books distributed last yearyear
Social Determinants of Social Determinants of Healthy Development: Healthy Development:
MechanismsMechanisms1.1. Direct:Direct:
DeprivationDeprivation FoodFood MoneyMoney HealthHealth medicationsmedications
ExposuresExposures caloric foodcaloric food LeadLead Asthma triggersAsthma triggers
2.2. Indirect: StressIndirect: Stress
Specialist saves the Specialist saves the dayday
A 11 yr old boy arrives for an urgent care visit. In the A 11 yr old boy arrives for an urgent care visit. In the past 2 months, he has needed several courses of oral past 2 months, he has needed several courses of oral steroids despite an appropriate medication regimen and steroids despite an appropriate medication regimen and an asthma action plan which his mother follows. an asthma action plan which his mother follows. However, the landlord has refused to do the needed pest However, the landlord has refused to do the needed pest control measures you suggested. control measures you suggested.
The patient has missed school repeatedly and is at risk of The patient has missed school repeatedly and is at risk of failing.failing.
A new specialist was consulted and within 6 weeks, the A new specialist was consulted and within 6 weeks, the teen was weaned off steroids and was back in school.teen was weaned off steroids and was back in school.
NICU Babies Have NICU Babies Have Legal NeedsLegal Needs
Baby Isabel, born 28 wks. Parents Baby Isabel, born 28 wks. Parents are legal immigrants from the are legal immigrants from the Dominican Republic. Dominican Republic.
As a NICU patient, Isabel is eligible As a NICU patient, Isabel is eligible for many benefits and services that for many benefits and services that will protect her health and prevent will protect her health and prevent re-hospitalization: SSI, early re-hospitalization: SSI, early intervention, etc.intervention, etc.
Parents don’t understand if and how Parents don’t understand if and how Isabel’s access to benefits impact their Isabel’s access to benefits impact their immigration status. Front-line and immigration status. Front-line and hospital staff – nurses, case managers, hospital staff – nurses, case managers, pediatricians – don’t know how to pediatricians – don’t know how to advise them.advise them.
Parents decide not to pursue benefits. Parents decide not to pursue benefits. Isabel is seen in the ED 3 months later Isabel is seen in the ED 3 months later with fever, secondary infection of with fever, secondary infection of diaper rash due to diarrhea and FTT.diaper rash due to diarrhea and FTT.
Medical-Legal Medical-Legal Partnership for Disparity Partnership for Disparity
ReductionReduction
Social
Doctors
Lawyers
Childhood Illness
Biological
The MLP Network – March The MLP Network – March 20092009
81 partnerships in over 180 hospital and health centers
Perry Preschool Project:Perry Preschool Project:
0
20
40
60
80
100
H.S. graduate (orequivalent)
Average or betterliteracy at age 19
90 or higher IQ atage 5
Ever in program foreducable mental
impairment
InterventionControl
Perry Preschool Project:Perry Preschool Project:
00.5
11.52
2.53
3.54
4.55
All arrests Arrests forviolence
Drug dealing
InterventionControl