Health Equity: The Evolution of Public Health Practice in the 21 st Century December 4, 2013 Rex...

Health Equity:The Evolution of Public Health

Practice in the 21st CenturyDecember 4, 2013

Rex Archer, MD MPH

Director of Health

Kansas City, Missouri

Saving Lives, Protecting People from Health Threats,

Saving Money through Prevention

“Public health is what we, as a society, do collectively through organized actions to assure the conditions in

which all people can be healthy.”

-Institute of Medicine (1988), Future of Public Health

“Show-Me” Health

Overall National Rank 2012: 422011 Rank: 40 1990 Rank 24

"The reason we have government is to solve

problems collectively that we can not solve

individually."Dr. Thomas Farley, NYC Health Commissioner (from

the HBO May, 2012 Documentary, "Weight of the Nation"



Zip Code*

Life expectancy(years)

Zip Code*

Life expectancy(Years)

64158 85 64108 7664112 83 64110 7664113 83 64111 7664156 83 64131 7664157 83 64133 7664151 82 64124 7564152 81 64134 7564153 81 64129 7464154 81 64123 7364114 79 64145 7364117 79 64106 7164118 79 64127 7164155 79 64109 7064116 78 64128 7064119 78 64132 7064137 78 64130 6964138 78

Life Expectancy by Zip Code, Kansas City, MO, 2008-2009

*Zip codes with population >5,000 people.

10-16 years difference

Life expectancy by zip code, Kansas City, MO 2008-2009

Life expectancy Nonwhite

Below poverty,

Median household

(year) % % income ($)81-85 years 14.1 7.3 76,92873-79 years 35.1 20.5 46,24169-71 years 83.5 39.0 23,363

Life expectancy

81-85 years

73-79 years

69-71 years

Too small pop.*

*Too small population to calculate life expectancy

64153 64154 64156

64163

64155

6411964151

64134

64129

64120

64157

64161

64132

64138

64149

64116

64130

64137

64117

64118

64160

64164

64139

64127

64165

64133

64108

64133

64128

64147

64118

6413164114

64146

64136

64145

64133

64110

64111

64113

6415864152

64109

64126

64079

64106

64166

64112

6412464123

64125

64012

64152

6410564101

64102

64167

64030

64079

64081

64079

64152

Longest and Shortest Life Expectancy Area by Zip Code, KCMOLongest and Shortest Life Expectancy Area by Zip Code, KCMO

Longest life expectancy

Shortest life expectancy

4zipcodes area has 55,846 residents5zipcodes area has 46,162 residentsKansas city, MO has 459,787 residents

64153

64163

64154 6415664155

64119

64134

64151

64129

64157

64120

64161

64132

64149

6413864131

64116

64130

64117 64160

64137

64136

64118

64164

64139

64127

64147

64165

64133

64108

64133

64128

64158

64118

64114

6414664145

64133

64110

64111

64113

64152

64109

64126

64106

64112

64166

6412364124 6412564105

64152

6410164102

64167

Leading Causes Crude Mortality Rates in Two Areas, CMO 2005-2009

4zipcodes include zip code 64109, 64128, 64130, 64132, which are the shortest life expectancy; 5zipcodes include zip code 64112, 64113, 64156, 64157, and 64158, which are the longest life expectancy.

1. INTERRUPT TRANSMISSION

How Are Epidemics Reversed?

3. CHANGE COMMUNITY NORMS

2. BEHAVIOR CHANGE

The Cure Violence / Aim4Peace The Cure Violence / Aim4Peace Model to Stop Shootings and Model to Stop Shootings and KillingsKillings

Identification and Detection

Change Behaviors and

Norms

Interruption, Intervention and Risk Reduction

Data and Monitoring

Image: Neil SladeImage: Neil Slade

Interrupt Transmission: Interrupt Transmission: AngerAnger

Prepared by: T.ColePrepared by: T.Cole

Exhibit AEPD Sector 330 – Yellow EPD Sectors 320 & 340 - Grey


Aim4Peace is not a silver bullet… We are focused on prevention of gun-related violence that is primarily related to arguments and retaliation in targeted areas of East Patrol, but we seek to expand to the entire Kansas and

Missouri Region.

A4P Current Target Zone: Kansas City Police Sector 330 (Beat 324 is of keen interest. We monitor, without proper staffing level.)

2010 (Jan-Dec)

2011 (Jan-Dec)

2012 (Jan-Dec)

diff % change 2013 (Jan-Dec 1, 2013)

diff % change

331 0 4 3 -1 -25% 2 -1 -33%332 6 3 7 4 133% 1 -6 -86%333 0 5 2 -3 -60% 0 -2 -100%334 8 3 4 1 33% 3 -1 -25%

14 15 16 1 7% 6 -10 -63%

324 4 7 4 -3 -100% 1 -3 -75%

January – October 2013 January – October 2013 ResultsResults


Conflict Mediations by KCPD Sector

Sector 110 1

Sector 140 1

Sector 210 1

Sector 320 7

Sector 330 31

Other 6

A4P Current Target Zone: Kansas City Police Sector 330

Provide Alternatives to violence:• 47 Conflicts mediated• 34 Dispute intakes (calls for service)

Annualized infant mortality rates by zip code median family income, KCMo, 2003-2007



Kansas City’s Geography of Health Inequity

16

Source: Map produced by and data derived from the Kansas City Health Department,

2010 Community Health Assessment

Fam

ily

&

C

ult

ure

Fam

ily

&

C

ult

ure

Health Inequities

Health Disparities

Fam

ily

&

C

ult

ure

PlacePolicyNarrative

POWER

Health System Dynamics

Safer,Healthier

Population

VulnerablePopulation

Becomingvulnerable

Becoming nolonger vulnerable

Afflictedwithout

ComplicationsBecomingafflicted

Afflicted withComplications

Developingcomplications

Dying fromComplications

Presented by: Jeanne F. Ayers, Minnesota Department of Health - Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Syndemics Prevention Network, Centers for Disease Control and Prevention; April 15, 2008. Available at: http://www.cdc.gov/syndemics/monograph/index.htm

http://www.cdc.gov/syndemics/monograph/index.htm

Safer,Healthier

Population BecomingVulnerable

Becoming nolonger vulnerable

VulnerablePopulation Becoming

Afflicted

Afflictedwithout

Complications DevelopingComplications

Afflicted withComplications

Targetedprotection

Primaryprevention

Secondaryprevention

Dying fromComplications

Tertiaryprevention

Society's HealthResponse

Generalprotection

Adverse LivingConditions

World of Providing…

• Education• Screening• Disease management • Pharmaceuticals• Clinical services• Physical and financial access• Etc…

Medical and Public Health Policy

DISEASE AND RISK MANAGEMENT

World of Transforming…

• Deprivation• Dependency• Violence• Disconnection• Environmental decay• Stress• Insecurity• Etc…

By Strengthening…

• Leaders and institutions• Foresight and precaution• The meaning of work• Mutual accountability• Plurality• Democracy• Freedom• Etc…

Healthy Public Policy & Public Work

DEMOCRATIC SELF-GOVERNANCE

Presented by: Jeanne F. Ayers, Minnesota Department of Health - Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Syndemics Prevention Network, Centers for Disease Control and Prevention; April 15, 2008. Available at: http://www.cdc.gov/syndemics/monograph/index.htm

Areas of Emphasis

http://www.cdc.gov/syndemics/monograph/index.htm

Refocusing Upstream

Seeing a Wider Set of Relationships

Health

LivingConditions

Capacity toAct

Centers for Disease Control and Prevention, Bobby Milstein

Power

• Ability to act or produce an effect

Arena’s of Power

• Directly impacting decision makers

• Developing deeper relationships and aligning interests

• Consciously shifting the narrative

Latinos/Hispanics in Kansas City, Missouri2001-2010

Hispanic Population, 2000 and 2010Distribution of Hispanic population, by age, Kansas City, Missouri, 2000 and 2010

2000 2010

Age (Years) HispanicPercent Hispanic

All Races HispanicPercent Hispanic

All Races

0-4 3,615 11.4% 31,755 6,009 17.4% 34,557

5-9 3,015 9.5% 31,829 5,969 19.3% 30,874

10-14 2,447 8.0% 30,770 4,700 16.5% 28,566

15-19 2,465 8.5% 29,053 3,948 13.6% 28,931

20-24 3,237 10.2% 31,590 3,556 10.4% 34,043

25-34 6,092 8.4% 72,393 8,975 11.9% 75,490

35-44 4,226 5.9% 71,309 6,731 11.0% 60,956

45-54 2,549 4.5% 56,492 5,386 8.3% 64,947

55-64 1,326 3.8% 34,662 2,330 4.6% 50,717

65-74 1,001 3.7% 27,163 1,364 5.1% 26,701

75+ 631 2.6% 24,529 832 3.5% 24,005

Total 30,604 6.9% 441,545 49,800 10.8% 459,787

Hispanic Males, 2000 and 2010Distribution of Hispanic men, by age, Kansas City, Missouri, 2000 and 2010

2000 2010



All Races

0-4 1,876 11.6% 16,105 3,333 19.0% 17,570

5-9 1,550 9.6% 16,219 3,109 19.8% 15,703

10-14 1,280 8.1% 15,807 2,454 16.9% 14,525

15-19 1,370 9.4% 14,578 2384 16.5% 14,420

20-24 1,859 12.2% 15,284 1,549 9.5% 16,277

25-34 3,435 9.5% 36,079 4,445 12.0% 37,191

35-44 2,358 6.6% 35,498 3,359 11.0% 30,564

45-54 1,368 5.0% 27,154 2,946 9.2% 32,073

55-64 652 4.0% 16,185 1,324 5.5% 23,997

65-74 449 3.8% 11,671 863 7.2% 11,943

75+ 257 3.0% 8,561 280 3.1% 8,920

Total 16,454 7.7% 213,141 26,046 11.7% 223,183

Hispanic Females, 2000 and 2010Distribution of Hispanic women, by age, Kansas City, Missouri, 2000 and 2010

2000 2010



All Races

0-4 1,739 11.1% 15,650 2,676 15.8% 16,987

5-9 1,465 9.4% 15,610 2,860 18.9% 15,171

10-14 1,167 7.8% 14,963 2,246 16.0% 14,041

15-19 1,095 7.6% 14,475 1564 10.8% 14,511

20-24 1,378 8.5% 16,306 2,007 11.3% 17,766

25-34 2,657 7.3% 36,314 4530 11.8% 38,299

35-44 1,868 5.2% 35,811 3,372 11.1% 30,392

45-54 1,181 4.0% 29,338 2,440 7.4% 32,874

55-64 674 3.6% 18,477 1,006 3.8% 26,720

65-74 552 3.6% 15,492 501 3.4% 14,758

75+ 374 2.3% 15,968 552 3.7% 15,085

Total 14,150 6.2% 228,404 23,754 10.0% 236,604

BirthsHispanic births, Kansas City, Missouri, 2001-2010

Year Hispanic Percent Hispanic All Ethnicities2001 997 13.6% 7,3452002 1,015 13.8% 7,3572003 1,152 15.7% 7,3452004 1,282 17.2% 7,4422005 1,271 16.8% 7,5822006 1,258 16.0% 7,8662007 1,324 16.5% 8,0232008 1,231 15.7% 7,8502009 1,092 14.1% 7,7582010 1,032 13.9% 7,429Total 11,654 15.3% 75,997

DeathsHispanic deaths, Kansas City, Missouri, 2001-2010

Year Hispanic Percent Hispanic All Ethnicities2001 100 2.6% 3,8962002 112 2.9% 3,8402003 117 3.1% 3,7422004 123 3.3% 3,7452005 113 3.0% 3,7842006 112 2.9% 3,8092007 128 3.4% 3,7212008 103 2.6% 3,9032009 82 2.3% 3,6092010 103 2.8% 3,643Total 1,093 2.9% 37,692

Poverty and incomePoverty and income, by race and ethnicity, 2007-2011, Kansas City, Missouri, American Community Survey

Families living in poverty (n (%))

Households receiving food stamps (n(%))

Mean per capita income (in

dollars)

White 5,664 7.64% 10,059 35.92% $30,033

Black or African American 8,547 35.43% 15,051 53.74% $21,258

American Indian and Alaska Native

79 189 0.67% $15,999

Asian 347 15.77% 496 1.77% $ 24,707

Native Hawaiian and Other Pacific Islander

66 98 0.35% $11,024

Hispanic or Latino origin (of any race)

2,357 31.21% 2,618 9.35% $20,151

White alone, not Hispanic or Latino

4,558 6.52% 8,745 31.22% $31,048

LanguageLanguages spoken at home, Kansas City, Missouri, 2007-2011, American Community Survey

Number Percent

Population 5 years and over

511,606 92.77

English only 456,566 89.24

Language other than English

55,041 10.76

Speak English less than "very well"

23,836 43.31

Spanish 32,479 6.35

Speak English less than "very well"

15,185 46.75

Expansion of Medicaid coverage reduces mortality among adults

Benjamin D. Sommers DB et al. Mortality and Access to Care among Adults after State Medicaid Expansions. N Engl J Med 2012; 367:1025-1034

176 insured to prevent one death per year

For every 10M more insured, ~57,000 lives saved per year

For every 300,000additional Missouriansinsured by Medicaid

~1,700 lives saved per year

~150 KCMO lives Saved per year

Questions?

Your Nationally Accredited

Kansas City, Mo., Health Department

Improving Service.Protecting People. Saving Lives.

POPULATION APPROACH VS. INDIVIDUAL APPROACH

Public Health As A Social Justice Enterprise

JUSTICE = TRUTH + POWER

Public Health Practice Research + Data

Community Organizing

=

Of all the forms of inequality, injustice in health is the

most shocking and inhumane.-- Martin Luther King, Jr.

Presentation at: The Second National Convention of the Medical Committee for Human Rights;

March 25, 1966; Chicago, IL.

In U.S., Latinos outlive In U.S., Latinos outlive whites by 2 1/2 years whites by 2 1/2 years

CDC's report on life CDC's report on life expectancy yields expectancy yields surprising resultssurprising results

--Associated Press 10-13-10Associated Press 10-13-10

January – October 2013 January – October 2013 ResultsResults


A4P Current Target Zone: Kansas City Police Sector 330

Indicator Quarterly Data

Quarterly Data

May June July Q1 (May-July)

August September October Q2 (Aug - Oct)

Aim4Peace (street conflict) mediations 5 2 6 13 2 1 4 7

Number of community changes in intermediary measures to assess how Aim4Peace Program is contributing to overall change in the zone

3 1 2 6 3 2 1 7

Number of participants and pre-participants who received case management services through the Aim4Peace Program

87 65 68 220 55 51 53 159

Number of contacts with participants and pre-participants (target is 4 contacts per participant) 117 301 332 750 294 172 214 680

Percent of participants who are high risk 100% 93% 87% 93.3% 84% (26/31) 84% (27/32) 84%

(27/32)84%

(26.7/31.7)

ExamplesCondoms, eat healthy, be physically active

Rx for high blood pressure, high cholesterol

Poverty, education, housing, inequality

Immunizations, brief intervention, cessation treatment, colonoscopy

Fluoridation, 0g trans fat, iodization, smoke-free laws, tobacco tax

Religious, moral teachings, beliefs

LargestImpact

SmallestImpact

Contributory (Social) Justice

Changing the Contextto make individuals’ default

decisions healthy

Long-lasting Protective Interventions

ClinicalInterventions

Counseling & Education

Socioeconomic Factors

Factors that Affect Health

Frieden, Archer

Population and EmploymentPopulation and employment by race/ethnicity, Kansas City, Missouri, 2007-2011, American Community Survey

Population (n (%)) Adults in labor force (n (%)) Unemployed (n (%))

Total population 551,464

One race 534,651 96.95%

White 357,905 64.90% 205,826 57.51% 18,399 10.94%

Black or African American

142,617 25.86% 69,840 48.98% 19,539 32.10%

American Indian and Alaska Native

2,265 0.41% 1,267 55.94% 183 18.90%

Asian 13,005 2.36% 7,247 55.73% 639 10.82%

Native Hawaiian and Other Pacific Islander

1,074 0.19% 435 40.50% 14 3.99%

Hispanic or Latino origin (of any race)

48,866 8.86% 23,480 48.05% 3,978 18.40%

White alone, not Hispanic or Latino

331,709 60.15% 192,997 58.18% 16,702 10.67%

Health Equity: The Evolution of Public Health Practice in the 21 st Century December 4, 2013 Rex...

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