Boston Public Health Commission Taking Action –The Boston Public Health Commission’s Efforts To...

Boston Public Health

Commission

Taking Action –The Taking Action –The Boston Public Health Boston Public Health

Commission’s Efforts To Commission’s Efforts To Undo Racism Undo Racism

Barbara Ferrer Ph.D., MPH

Deputy Director

Boston Public Health Commission


Commission

Racial Disparities in BostonRacial Disparities in BostonHealth Issue Black WhiteAsthma / Male 5-14 (Hosp) 6.4 1.7Birth Weight (Less than 3.3lbs) 3.4% 1.0%Body Weight 63% 46.%Breast Cancer (Morality) 24.2 per 100,000 20.7 Cervical Cancer (Mortality) 8.4 per 100,000 2.2Death Rate (Mortality) 1028.1 per 100,000 942.8 Diabetes (Mortality) 33 per 100,000 15.2Health Insurance 11.5% 6.1%Heart Disease (Mortality) 224.8 per 100,000 230.6High Blood Pressure 26.4% 16.6%HIV / AIDS (Mortality) 24.9 per 100,000 7.2Homicide 19.7 2.5Infant Mortality (Mortality) 13.6 per 1000 2.8Hospitalization 155.3 per 1000 108.4Lung Cancer (Mortality) 66.8 67.2Prostate Cancer (Mortality) 71.4 per 100,000 27.5Smoking during pregnancy 6.8% 9.4%Drug Related Mortality 11.7 13.0Suicide (Mortality) 3.5 8.1Teen Birth Rate 63.696 per 1000 10.242


Commission

Definition of RacismDefinition of Racism

• Any type of action or attitude, individual or institutional, which prescribes and legitimizes a minority group’s subordination by claiming that the minority group is biogenetically or culturally inferior.

O’Sullivan, J., See, K., Wilson, W.J. (1998). Race and ethnicity. In: Smelser, N.J. (Ed), Handbook of Sociology, Newbury Park, California: Sage Publications, pp 233-242.


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Racism DefinitionRacism Definition

Race Prejudice + Power = Racism

Prejudice defined as “a preconceived idea, usually one that is unfavorable”


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Levels of RacismLevels of Racism

• Institutional - differential access to the goods services and opportunities of society by race.

• Personally-mediated - prejudice (differential assumptions about the abilities, motives and intentions of others based upon their race)and discrimination (differential actions toward others based upon race)

• Internalized - acceptance by members of the stigmatized races of negative messages about their own abilities and intrinsic worth.

Camara Jones, MD, MPH, Ph.D. Levels of Racism: A Theoretical Framework and a Gardener’s Tale, American Journal of Public Health, Volume 90 (8) August 2000


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How Can Racism Affect How Can Racism Affect Health Status?Health Status?

• Differences in socio-economic status, exposures and stresses by “race”

• Differences in access to health care services

• Differences in diagnostic testing, treatment, and the quality of care received within the health care system


Commission

24%

5% 4% 4% 3%8%

39%

14%

84%

44%

2%

14%

53%

3%

48%

15%

6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

BOSTON

Allsto

n/Brig

hton

Back B

ay

Charle

stow

n

East B

osto

n

Fenway

Hyde

Park

Jamai

ca P

lain

Mat

tapa

n

North

Dor

ches

ter

North

End

Roslin

dale

Roxbu

ry

South

Bos

ton

South

Dor

ches

ter

South

End

Wes

t Rox

bury

Pe

rce

nta

ge o

f T

ota

l Po

pula

tion

Of

Ne

ighb

orh

oo

d

DATA SOURCE: US Department of Commerce, Bureau of the Census, American Fact Finder, Census 2000DATA ANALYSIS: Boston Public Health Commission, Research Office

Black Resident Population by NeighborhoodBoston, 2000


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Median Annual Earnings, Full-Time Workers, 1999Median Annual Earnings, Full-Time Workers, 1999

$27,000

$22,000

$18,000

$15,000

$13,000

$0 $5,000 $10,000 $15,000 $20,000 $25,000 $30,000

Whites

Blacks

All Hispanics

Hispanic Non-Citizens

Hispanic Non-Citizensin U.S. Since 1994

SOURCE: Project HOPE Center for Health Affairs, based on overlap of February and March Supplements to the 1999 Current Population Survey.GRAPHIC: Boston Public Health Commission, Research and Technology Services.


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IndicatorsBostonOverall

BlackResidents

Less than High School Graduation or GED 21% 27%

% of Population Below Poverty Level* 20% 23%

% of Children (Under 18) Below Poverty Level* 26% 28%

% of Adults 65 and Older Below Poverty Level* 18% 23%

Median Household Income in 1999** $39,629 $30,447

*Based on income in 1999**Estimated Median Household Income in 1999NOTE: These data from the US Census include Hispanics in the racial category for Blacks.

Selected Socioeconomic IndicatorsBoston Overall and Black Residents, 2000

DATA SOURCE: US Department of Commerce, Bureau of the Census, American Fact Finder, Census 2000, Summary File-3Sample DataDATA ANALYSIS: Boston Public Health Commission, Research Office


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Health Insurance Status, by Race and Ethnicity, 1997: Health Insurance Status, by Race and Ethnicity, 1997: TotalTotal Nonelderly Population Nonelderly Population

14%23%

36%22% 27%

22%

19%19%

79%

54%45%

69%55%

8%

9%

0%

50%

100%

White, non-Latino

AfricanAmerican

Latino Asian/PacificIslander

NativeAmerican

Uninsured Medicaid Private/Other

DATA: Urban Institute analysis of the March 1998 Current Population Survey.SOURCE: KMCU, Medicaid Today: Profile of a Program and the People it Covers, 1999.GRAPHIC: Boston Public Health Commission, Research and Technology Services.


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Access to Specialty Care by Adults, by Race and Hispanic Access to Specialty Care by Adults, by Race and Hispanic Origin, 1994Origin, 1994

118

16

2226

19

2427

41

812

0

10

20

30

40

50

Per

cent

rep

ortin

g a

"maj

or p

robl

em" Total

WhiteBlackTotal HispTotal Asian AmMexican AmPuerto RicanCuban AmChinese AmVietnamese AmKorean Am

SOURCE: Authors’ tabulations of The Commonwealth Fund 1994 National Comparative Survey of Minority Health Care.

GRAPHIC: Boston Public Health Commission, Research and Technology Services.


Commission

Percent with No Doctor Visit in Past Year:Percent with No Doctor Visit in Past Year:Adults 18-64 in Fair to Poor Health, 1995 and 1996Adults 18-64 in Fair to Poor Health, 1995 and 1996

13%

3%5%

29%

12%

19%

5%7%

26%

16%

24%

7% 8%

40%

19%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Uninsured Medicaid PrivateCoverage

Uninsured Medicaid PrivateCoverage

White, non-Latino African American Latino

*Sample too small to make accurate estimates.DATA: National Health Interview Surveys, 1995 and 1996.SOURCE: Brown et al 1999.

WOMEN MEN

* * *


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Pharmaceutical Use by Persons with HIVPharmaceutical Use by Persons with HIVReceiving Medical Care, 1996Receiving Medical Care, 1996

56%

11%

38%

44%

7%

36%32%

7%

23%

0%

10%

20%

30%

40%

50%

60%

Needed but did notreceive combination

therapy

Never receivedcombination therapy

Needed but did notreceive PCP prophylaxis

in last 6 months

percent

African American

Latino

White

*Significantly different from whites in multivariate analysis to adjusting for CD4 counts, sociodemographic characteristics, and insurance.

DATA: HIV Cost and Services Utilization Study (HCSUS).SOURCE: Shapiro et al, 1999.

*

*

*


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Health Care Access Indicators for Massachusetts Racial/Ethnic Groups 1999

Indicator Massachusetts % White % Black % Hispanic % Asian %No HealthInsurance

5.4 4.9 8.5 7.5 8.4

UncheckedBloodPressure

0.4 0.1 0.2 3.4 2.4

UncheckedCholesterol

19.8 18.5 23.8 28.6 31.6

Never Having aMammogram

9.5 9.1 7.7 18.5 *

Never Having aPap Test

6.7 5.5 7.3 14.7 25.3

Never Having aDigital

29.4 27.8 37.7 54.6 *

* Insufficient sample size

Source: Massachusetts Department of Public Health: BRFSS, 1999.


Commission

Do you think the average African Do you think the average African American is better off, worse off, or American is better off, worse off, or just about as well off as the average just about as well off as the average white person in terms of access to white person in terms of access to

health care?health care?

0

10

20

30

40

50

60

70

Whites African

Americans

Better Off

About the Same

Worse Off

No Opinion

Source: Morin, 2001


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SummarySummary"Disparities in the health care delivered to racial and ethnic minorities are real and are associated with worse outcomes in many cases, which is unacceptable. The real challenge lies not in debating whether disparities exist, because the evidence is overwhelming, but in developing and implementing strategies to reduce and eliminate them."

-- Alan Nelson, retired physician, former president of the American Medical Association and chair of the committee

that wrote the Institute of Medicine report, Unequal Treatment: Confronting Racial and Disparities in Health Care


Commission

Evidence of Racial and Ethnic Evidence of Racial and Ethnic Disparities in HealthcareDisparities in Healthcare

• Disparities consistently found across a wide range of disease areas and clinical services

• Disparities are found even when clinical factors, such as stage of disease presentation, co-morbidities, age, and severity of disease are taken into account

• Disparities are found across a range of clinical settings, including public and private hospitals, teaching and non-teaching hospitals, etc.

• Disparities in care are associated with higher mortality among minorities (e.g., Bach et al., 1999; Peterson et al., 1997; Bennett et al., 1995)


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Black and White Differences in Specialty Procedure Utilization Among Medicare Beneficiaries Age 65 and Older, 1993

Black White Black-to-

White Ratio

Angioplasty (procedures per 1,000 beneficiaries per year)

2.5 5.4 0.46

Coronary Artery Bypass Graft Surgery (procedures per 1,000 beneficiaries per year)

1.9 4.8 0.40

Mammography (procedures per 100 women per year)

17.1 26.0 0.66

Hip Fracture Repair (procedures per 100 women per year)

2.9 7.0 0.42

Amputation of All or Part of Limb (procedures per 1,000 beneficiaries per year)

6.7 1.9 3.64

Bilateral Orchiectomy (procedures per 1,000 beneficiaries per year)

2.0 0.8 2.45

Source: Gornick et al., 1996


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Potential Sources of Racial and Potential Sources of Racial and Ethnic Healthcare Disparities – Ethnic Healthcare Disparities –

Healthcare Systems-level FactorsHealthcare Systems-level Factors Cultural and linguistic barriers – many non-Cultural and linguistic barriers – many non-English speaking patients report having English speaking patients report having difficulty accessing appropriate translation difficulty accessing appropriate translation servicesservices

Lack of stable relationships with primary Lack of stable relationships with primary care providers – minority patients, even when care providers – minority patients, even when insured at the same level as whites, are more insured at the same level as whites, are more likely to receive care in emergency rooms and likely to receive care in emergency rooms and have less access to private physicianshave less access to private physicians

Financial incentives to limit services – may Financial incentives to limit services – may disproportionately and negatively affect disproportionately and negatively affect minoritiesminorities

“ “Fragmentation” of healthcare financing Fragmentation” of healthcare financing and deliveryand delivery


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SUMMARY OF FINDINGS

Racial and ethnic disparities in health care exist and, because they are associated with worse outcomes in many cases, are unacceptable. Racial and ethnic disparities in health care occur in the context of broader historic and contemporary social and economic inequality, and evidence of persistent racial and ethnic discrimination in many sectors of American life. Many sources – including health systems, health care providers, patients, and utilization managers – contribute to racial and ethnic disparities in health care.


Commission

“If racism was constructed, it can be undone.

It can be undone if people understand when it was constructed, why it was constructed, how it functions, and how it is maintained.”

---People’s Institute For Survival and Beyond


Commission

Principles of Anti-Principles of Anti-Racism WorkRacism Work

• Race is a political construct that establishes and maintains white privilege.

• There is a need to develop a common set of definitions and an analytical framework for understanding racism and its central role in perpetuating racial disparities in health.

• Undoing institutional racism within the health care system requires participatory structures/strategies that allow for leadership and decision-making to rest in the hands of those “being served.”


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Core FunctionsCore Functions

• “Assessment”…how is racism at play here?

• “Policy development”…what policies/standards/protocols can dismantle institutional racism?

• “Assurance”…which organizing strategies are effective in bringing about change?


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Addressing Differences Addressing Differences in Access to Carein Access to Care

• Support/fund neighborhood-based providers

• Identify and reduce barriers to health care utilization

• Work to protect/expand publicly-funded health insurance programs


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Addressing Differences Addressing Differences in Treatmentin Treatment

• Provide anti-racism training• Train medical interpreters• Review provider practice patterns• Review institutional policies and

procedures• Establish a community review board• Identify “best practices”/treatment

protocols


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Addressing Differences Addressing Differences in Socio-Economic in Socio-Economic

ConditionsConditions• Participate in “community mapping”

of assets and challenges

• Create forums for discussing racism and it’s impact on health

• Participate in community-led efforts to address and eliminate racism


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FrameworkFramework

Improvement in the health status of non-dominant populations can be addressed by focusing on both political issues of lack of equal opportunity, discrimination, and exposure to differential risks as well as by specific quality improvement initiatives within the health care system.


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StrategiesStrategies

• Build/support community partnerships

• Promote an anti-racist work environment

• Re-align external activities to address racism


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Build Community Build Community PartnershipsPartnerships

Structural1. Create mechanisms for involving

community residents in designing, implementing, and evaluating programs/services

2. Establish a community review board to provide oversight of research and evaluation activities


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Build Community Build Community PartnershipsPartnerships

Activities1. Sponsor “Undoing Racism” training

opportunities for community residents/clients

2. Develop and implement a community needs assessment process that examines and documents issues related to racism

3. Participate in community-based coalitions


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Promote an Anti-racist Promote an Anti-racist Work EnvironmentWork Environment

Structural1. Assemble an internal team to guide on-

going anti-racism work2. Increase opportunities for shared

decision-making that involve staff across disciplines and job titles

3. Create/adapt a grievance review process/mechanism to address complaints about racism in the workplace


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Assessment Activities1. Provide all employees with anti-racism training2. Develop multiple methods to assess how

racism is at play within the institution3. Assess workforce composition by

race/ethnicity and develop strategies for increasing diversity at all levels

4. Create/use a tool to assess “institutional racism” that can identify challenges, suggest quality improvement strategies and measure progress


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Policy Development 1. Establish shared vision/mission/goals that

articulate an institutional commitment to undoing racism as a central public health activity and create a corresponding set of performance measures to assess progress

2. Review sick leave/bereavement/family leave policies and amend as needed to reflect differences in cultural norms/health status


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3. Review performance evaluation criteria to assess its ability to respect diverse cultural values

4. Establish recruitment and retention policies that reflect the need for increased representation of people of color in all service and leadership positions

5. Establish standards on ‘community inclusion’ for all projects, programs, services, evaluations and compliance mechanisms


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Promote an Anti-Racist Promote an Anti-Racist Work EnvironmentWork Environment

6. Establish standards for creating culturally competent health education materials, program materials, and compliance mechanisms

7. Develop a uniform standard for collecting staff & client race/ethnicity data that adheres to the principle of self-identification and includes ethnic sub-groups.


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Refocus External Refocus External ActivitiesActivities

Structural1. Create an inter-departmental working group

within city government to develop a blueprint for “undoing racism” across city departments

2. Work with community residents, medical schools, teaching hospitals, and health centers to incorporate “cultural competency” curriculum and training opportunities and to support “pipeline” efforts to create a more diverse workforce


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Refocus External Activities Refocus External Activities to Incorporate Anti-Racist to Incorporate Anti-Racist

StrategiesStrategiesAssessment• Sponsor “undoing racism”

trainings for health care providers and their clients

• Prepare and distribute an annual health report describing racial/ethnic disparities in health outcomes


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Refocus External Refocus External ActivitiesActivitiesPolicy

1. Link funding for all health activities to efforts to reduce racial/ethnic disparities in health outcomes by including language in all contracts with vendors that requires:- collecting client race/ethnicity data- preparing annual reports that include information on health outcomes by ethnicity- developing projects to reduce documented disparities- assessing/improving institutional “cultural competency”


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Policy

2. Explore possibility of creating cultural competency licensure requirements and expanding cultural competency training for providers


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Assurance

1. Target funding to support initiatives addressing documented racial disparities in health


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What Does It Take…….What Does It Take…….

• Commitment to social justice• Ability to collect and use data to

demonstrate racial disparities in health

• Willingness to ask questions and listen to answers

• Tools for understanding and assessing how racism is manifested


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What does it take…..What does it take…..

• Ability to shift from a focus on individual personal health behaviors to a focus on institutions and systems (requires “training” and “skill building”)

• Community leadership/coalitions addressing racism

• Desire to work “across issues”• Willingness to shift existing resources to

support anti-racism work

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