Health and Social Policy: Time to Reshift the Paradigm

1
Health and Social Policy Time to Reshift the
Paradigm?

• Will Ross, M.D.
• Associate Dean for Diversity
• Associate Professor of Medicine
• Washington University School of Medicine

June 11, 2008
2
Objectives

• Identify the benefits and limitations of the WHO
  definition of health
• Debate the roles of genetics and social forces in
  perpetuating health disparities
• Promote a health model that embraces an
  ecological approach to reducing health disparities

3
Is it the right time for a paradigm shift?
4
Is Health Care Breaking Through as a Political
Issue?
Thinking about the campaign for the presidential
election in 2008, what two issues would you most
like to hear the presidential candidates talk
about? (open-ended, top 4 responses shown)
Note Adds up to more than 100 due to multiple
responses. Source Kaiser Health Tracking Poll
Election 2008
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Disparities in Healthcare Quality

• The evidence is overwhelming
• Disparities exist even when insurance status,
  income, age, and severity of conditions are
  comparable
• Minorities are less likely than whites to receive
  needed services
• Disparities contribute to worse outcomes in many
  cases
• Differences in treating heart disease, cancer,
  HIV infection partly contribute to ?er death
  rates for minorities

Unequal Treatment Confronting Racial and
Ethnic Disparities in Healthcare, 2002.
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Eight Americas Investigating Mortality
Disparities Across Races, Counties, and
Race-Counties in the United States
Christopher J.L. Murray, MD,
DPhil Institute Director, Institute for Health
Metrics and Evaluation Professor of Global
Health, University of Washington
Majid Ezzati, Ph.D. Associate
Professor Harvard School of Public Health
Institute for Health Metrics and
Evaluation September 12, 2006
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Definitions of the Eight Americas

• America 1 Asians living in countries where
  Pacific Islanders lt 40 of population
• America 2 White low-income rural Northland
• America 3 Middle America
• America 4 White poor Appalachia and Mississippi
  Valley
• America 5 Western Native Americans
• America 6 Black middle America
• America 7 Black poor rural south
• America 8 Black high-risk urban

Institute for Health Metrics and Evaluation
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(No Transcript)
9
Dorothy Langes Migrant Mother Collection.
FSA-OWI, 1936
10
President Roosevelt signs Social Security Act, at
approximately 330 pm EST on August 14, 1935
11
Civil rights demonstrator May 3, 1963,
Birmingham, Ala.
Medical Committee for Human Rights Archive, US
Health Activism History Collection Institute of
Social Medicine and Community Health,
Philadelphia, PA
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The time has come for an all-out world war
against poverty. The rich nations must use their
vast resources of wealth to develop the
underdeveloped, school the unschooled, and feed
the unfed. Ultimately a great nation is a
compassionate nation. No individual or nation can
be great if it does not have a concern for the
least of these".
Rev. Dr. Martin Luther King Jr, Excerpted from
his Nobel Prize Lecture, University of Oslo,
December 11, 1964
13
President Lyndon B. Johnson signs the 1965 Social
Security Amendments (Medicare and Medicaid)
14
Hurricane Katrina
Lee Celano for The New York Times, Tuesday
November 6th, 2007
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World Health OrganizationDefinition of Health1

• . . . a state of complete physical, mental, and
  social well-being and not merely the absence of
  disease and infirmity.

But it also includes . . .
. . . governments have a responsibility for the
health of their peoples which can be fulfilled
only by the provision of adequate health and
social measures.
1 The Constitution was adopted by the
International Health Conference held in New York
from 19 June to 22 July 1946, signed on 22 July
1946 by the representatives of 61 States (Off.
Rec. Wld Hlth Org., 2, 100), and entered into
force on 7 April 1948. Amendments adopted by the
Twenty-sixth, Twenty-ninth, Thirty-ninth and
Fifty-first World Health Assemblies (resolutions
WHA26.37, WHA29.38, WHA39.6 and WHA51.23) came
into force on 3 February 1977, 20 January 1984,
11 July 1994 and 15 September 2005 respectively
and are incorporated in the present text.
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Do we have the financial resources to capitalize
our paradigm shift?
17
The Marshall Plan
American should do whatever it is able to do to
assist in the return of normal economic health in
the world, without which there can be no
political stability and no assured peace."
Secretary of State George C. Marshall June 5,
1947 Harvard University
Children playing amid new housing construction in
Marseille, France. Courtesy of the George C.
Marshall Research Library, Lexington, Virginia.
GCMRL3118)
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"The Americans will always do the right thing -
after they've exhausted all the alternatives.
Winston Churchill
19
U.S. Health Expendituresas Share of GDP
Expected to RiseThrough Next Decade
Expenditures as percent of gross domestic product
(GDP)
Projected
Source Center for Medicare and Medicaid
Services, Office of the Actuary, 19982003 from
CMS Health Accounts data file nhegdp03.zip
available at http//www.cms.hhs.gov/statistics/nhe
/default.asp 20042014 published in Heffler et
al., "U.S. Health Spending Projections for
20042014," Health Affairs Web Exclusive
(February 23, 2005) W5-74W5-85.
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Higher Spending Does Not Necessarily Lead to
Higher Quality
Source Baicker and Chandra (Health Affairs 2004)
21
Benefits of Human Genome Project
22
Annualized Growth of the NIH Budget, 1971
to 2005 (The growth rates shown have
been adjusted for inflation)
Loscalzo J. NEJM, 20063541665-1667
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As the NIH budget flattens, competition for
grants escalates
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Will Isnt this so-called paradigm shift just
a back door attempt to market a socialized
medicine scheme?
25
(No Transcript)
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Income inequality and life expectancy at birth
among industrialised countries
Less inequality
More inequality
De Vogli, R. et al. J Epidemiol Community Health
200559158-162
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Pathways by which Socioeconomic Status Affects
Health Behaviors
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Impact of social factors on risk of hypertension
and diabetes
NHANES III 1988-1994
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www.macses.ucsf.edu Accessed June 5, 2008
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Two kinds of policies are required to
reducepremature death and eliminate health
disparities

• Policies that impact income and wealth
  distribution, educational attainment and
  occupational mobility.
• Educational policies
• Fiscal policies
• Skills training policies
• Policies that buffer individuals from the
  damaging conditions of living below the top rungs
  of the socioeconomic ladder.
• Policies affecting the environment
• Policies affecting the workplace
• Policies enabling healthier behaviors

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Recent study examined Medicare claims over the
past two decades for evidence of racial and
geographic disparities in several indicators of
health care quality

• Sixty-four percent of white women ages 65 to 69
  received recommended breast cancer screenings in
  2004 and 2005, compared with 57 of black women,
  while screening rates by state ranged from 74 in
  Maine to 56.9 in Mississippi (Wilde Mathews,
  Wall Street Journal, 6/5)
• In all but two states, blacks with diabetes were
  less likely than whites to receive annual
  hemoglobin testing, and in Colorado, 66 of
  blacks were screened, compared with 88 of blacks
  in Massachusetts (New York Times, 6/5)
  andBlacks nationwide had their legs amputated
  at about four times the rate of whites. Black
  residents of Louisiana, Mississippi and South
  Carolina had six amputations per 1,000 Medicare
  beneficiaries, while blacks in Colorado and
  Nevada had less than two per 1,000 beneficiaries
  (Appleby, USA Today, 6/5).

Dartmouth Atlas of Healthcare,
www.dartmouthatlas.com. Accessed June 6, 2008
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Robert Wood Johnson Foundation Announces
300-Million Commitment to Narrow Health
Disparities Across Lines of Race and Geography
Disparities in the quality of care spur nation's
largest health care philanthropy to attack the
problem in 14 communities across America
June 5, 2008
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Aligning Forces for Quality will concentrate its
resources in 14 communities across the
country Cincinnati, Ohio Cleveland, Ohio
Detroit, Mich. Humboldt County, Calif. Kansas
City, Mo. Maine Memphis, Tenn. Minnesota
Seattle, Wash. South Central Pennsylvania
Western Michigan Western New York Willamette
Valley, Ore. Wisconsin
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If you dont know where you are going, you might
wind up somewhere else.

• Yogi Berra

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Revised definition of health

• A condition of physical, mental, spiritual, and
  social well-being arrived at through a balance of
  prevention, health education and health
  protection, culminating in an enhanced socially
  and economically productive life.

World Health Organization, 1948 Downie, Fyfe, and
Tannahill, 1990 Saracci, 1997
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Are we ready for a paradigm shift?
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In order to resolve health care disparities, we
must pay attention to the broader social forces
that influence health. We must recognize that
our health is intimately related to the health of
our neighborhoods, and that health care should be
tied to health promotion, the formation of
healthy communities that provide a safe living
environment, living wage jobs, affordable
housing, and high quality schools.
Conclusion