Category Archives: Health disparities
“Hypertension affects nearly one in three adults and kills more people around the world than anything else. It is both too common and too often poorly controlled.”
So said Tom Frieden, MD, MPH, director of the U.S. Centers for Disease Control and Prevention (CDC), during a panel discussion at the annual meeting of the American Society of Hypertension (ASH) this past weekend. The panel was convened by ASH, the American Heart Association and the CDC to launch a project supporting improved control of hypertension worldwide. According to the panel an estimated 970 million people have hypertension worldwide, and the disease is responsible for more than nine million deaths, as hypertension can lead to heart disease and stroke.
Data from the groups finds that rates of hypertension have increased in both developed and developing nations, due in part to an aging population and lifestyles that include high salt diets and low physical activity.
For the developing world, the CDC; the Pan American Health Organization; and other regional and global stakeholders are identifying both cost effective medicines and inexpensive delivery strategies for the drugs to help patients afford and receive them.
In the United States, the Affordable Care Act is expected to increase the number of people on hypertension medications, but despite the availability of coverage for hypertension diagnosis and treatment there remains concern over disparities. A study of more than 16,000 members of the Hispanic community published in the American Journal of Hypertension earlier this year found that while the prevalence of hypertension among Hispanics is nearly equal to that of non-Hispanic whites, diagnosis of the disease is much lower, as is general awareness of its symptoms and treatment options.
"Given the relative ease of identifying hypertension and the availability of low-cost medications, enabling better access to diagnostic and treatment services should be prioritized to reduce the burden of cardiovascular disease on Hispanic populations,” said Paul Sorlie, MD, the lead author of the study and an epidemiologist with the National Heart, Lung and Blood Institute. “This study gives us the information needed to support the development of policies that can improve this access and, subsequently, the overall health of countless US citizens.”
- A new infographic from the Measure Up/Pressure Down initiative of the American Medical Group Association provides some key patient information about hypertension, including normal and dangerous ranges of blood pressure—numbers patients should be familiar with.
- A map from the Institute for Health Metrics and Evaluation at the University of Washington shows hypertension levels for 2001 to 2009 by race and gender.
Despite certain positive shifts in overall health outcomes for residents in Alameda County, Calif., significant inequities exist, particularly among African-Americans, Latinos and Native Hawaiian/Pacific Islanders, as well as low-income residents.
The Alameda County Place Matters team works throughout Alameda County, including the City of Oakland, the largest city in the county.
Team Objectives include:
- Affordable housing
- Quality education
- Access to economic opportunities
- Criminal justice reform including reducing the incidence of incarceration
- Improvements to land use
- Accessible, safe and affordable transportation
Alameda County Supervisor Keith Carson initiated the Alameda County Place Matters team. The team is currently housed within the Alameda County Public Health Department and supported by health department staff. The initiative has numerous community partners that include community-based organizations; city and county government agencies; and nonprofits.
Among the critical issues the Place Matters team is currently focused on are displacement, the built environment, and development and how those impact health, according to team communications lead Katherine Schaff.
The team is working with community partners and planners on a healthy development checklist that the city of Oakland can use to take health considerations into account during city permitting and decision making to try to ensure more transparency and accountability to residents in that process. She said the goal is to have city planners go through the checklist before projects are approved. The checklist, said Schaff, might have allowed for more time for community comment before plans were authorized for a new crematorium that is expected to add to pollution and exacerbate asthma cases.
The Cuyahoga County, Ohio Place Matters team's focus is on ensuring health implications and equity considerations are at the forefront as policy makers and others make decisions that substantially impact the county’s residents and the neighborhoods in which they live.
Key Team Objectives:
- A broader definition of health. Health is not simply the absence of disease—health begins where people live, work, learn, age and play. Health includes the social conditions one lives in, such as the jobs we do, the money we're paid, the schools we attend and the neighborhoods we live in, as well as our genes, our behaviors and our medical care.
- Inform, influence and engage policy makers and community members to develop policies—using an overarching health equity lens—that have long-term impacts, create conditions for optimal health and reduce inequities.
- Utilize "place-based" interventions to engage and empower residents in under-resourced communities to revitalize their communities.
East Cleveland is one of the most densely settled communities in Cuyahoga County. The city has a poverty rate of 32 percent, while its heart disease mortality rates (355/100,000) are higher than in the county (10 percent higher) and the nation (32 percent higher).
Team objectives include building effective partnerships; striving for equal opportunity for all; equity; recognition that neighborhood condition is the context in which health and wellbeing begins; health in all policies; mobilizing the community for action; and measuring indicators of social determinants of health.
The Prince George's County, Maryland Place Matters team is addressing food inequity by establishing a Food Policy Council and working with the county's recreation department to design and implement after-school healthy eating and active-living programs.
The project is beginning with the waterfront towns of Bladensburg, Colmar Manor, Cottage City and Edmonston, which have drafted a Community Action Plan with strategies on how to reduce chronic disease in Prince George's County. Partners on the Community Action Plan included Kaiser Permanente, the Consumer Health Foundation, United Way of the National Capital Area and the Meyer Foundation. Place Matters plans to replicate the initiative in other county municipalities.
Prince George's County is the most diverse in Maryland; 80 percent of the population is made up of minority groups. According to the 2010 Census, 8 percent of households live below the poverty line, but some of the towns have higher rates of poverty. Cottage City has a 21 percent poverty level, Bladensburg has a poverty level of 12 percent and Edmonston has a poverty rate of 9 percent.
Key Team Objectives:
- Improve healthy food access and wellness for all through food policy and action.
- Create reliable public transit, bike and pedestrian access to schools and recreational facilities.
- Enhance community capacity to lead and support the Community Action Plan.
“What we decided to do was instead of trying to address the full county is to build a model which the county could replicate,” said team co-leader David Harrington. Harrington said the project, which started seven years ago, has “had some good success in helping to address some policy issues and system change issues.”
Place Matters is building a team around stakeholders called the Community Implementation Team and a countywide team called the Policy Development Team, which consists of the county agencies that influence policy and can provide support for help in doing the community work. They were engaged early in the conversation “so that they would consider administrative and other policies that will help them buttress the community work, and then the community work would help then influence their work, so this becomes a supportive concentric circle of activity that helps systems change, as well as change at the community level,” said Harrington.
In 1979 a dam broke at a uranium processing mill in McKinley County, New Mexico, releasing more than 1,100 tons of uranium mining waste and 100 million gallons of radioactive water—the second largest radioactive materials accident in the United States. Since then, say public health experts, minimal attention has been given to the health risks associated with the environmental contamination from the accident, or of the risks posed by plans for new mining opportunities in the region.
The McKinley County Place Matters team and its partners want to ensure that people are aware of the health risks associated with working in the mines, as well as secondary exposure through such things as a relative’s clothes or pollutants from the mines. The team also wants to address the health and social needs that resulted from the accident decades ago. In addition, people living in the community have noticed increased rates of cancers and other health problems, and state health assessment reports show that between 2008 and 2010, cancer was the leading cause of death in McKinley County.
“To proceed with more mines without knowing the scope of impact to people’s health is dangerous,” said Jordon Johnson, the county’s Place Matters team leader.
The team’s vision statement is that “all people in McKinley County live in a safe, healthy, and prosperous environment that honors health-in-all policies and leaves a legacy of responsible leadership grounded in equity.” Its mission is to use a health equity lens to change systems that perpetuate environmental health disparities related to the impacts of multi-generational trauma and institutional racism by empowering participating communities within the county to impact equitable policy change.
Key Team Objectives:
- Heal individual and community health and restore the environment with Traditional and Western values and medicine.
- Use the Navajo Nation Fundamental Laws as the foundation to shift conversations around uranium mining and justice.
- Conduct a health impact assessment on mining in the county to look at determinants of health including environmental pollution and contamination; displacement and relocation; community efficacy; and cultural relevance of the land to holistic health.
- Support the community in building a multipurpose facility to serve as a space to heal, gather for meetings, and provide education.
- To educate decision makers and general public about the poor health outcomes related to uranium mining.
- To model a non-hierarchal structure, establishing shared leadership and creating a safe space for open and honest discussions to emerge about difficult subjects, particularly related to environmental justice and race relations. These conversations, along with a foundational understanding and commitment to moving the local community forward in a culturally relevant way, contribute to elevating the voices of community members participating in local decisions, said team leader Jordon Johnson.
King County is the largest county in Washington State. Although it ranks among the 100 most affluent counties by income in the United States, it also has some of the poorest people on the country according to Ngozi Oleru, director of the King County Health Department Environmental Health Services Division and Place Matters team leader for the county. The focus area for the Place Matters team in the region is racism, with a goal to institutionalize equity and social justice within government agencies, branches and departments in the county.
Key Team Objectives:
- Increase the capacity of King County departments to identify actions that will increase health and well-being and decrease inequities.
- Give communities a role in the decision making within the county by enhancing existing efforts.
- Work with local communities to partner with county staff and others to address their issues of concern
As work progressed, the initiative became law in 2010, as the Equity and Social Justice Ordinance. The law covers all of King County government and includes a set of determinants of equity that the team continues to work on to be sure they are improving the social determinants of health. Oleru said the ultimate goal is to eliminate any inequities. She noted that the Affordable Care Act provides a strong example of implementation.
“Through the work that we have been doing over the years, we had an idea of how many people did not have health coverage in King County and as it became time to begin enrolling people last year, we made a commitment as a county that we’re going to work on enrolling as many people as possible—if not everyone—who did not have health insurance coverage.”
“Five years after the Great Recession officially came to an end, the United States has yet to fully recover from the economic devastation sparked by the collapse of an $8 trillion housing bubble and the ensuing turmoil that saw global financial systems teetering on the brink of collapse. But while the economic costs of the downturn have drawn the lion’s share of attention, the damage to our bodies could end up far surpassing the damage to our bank accounts.”
Those are the opening lines of a new special report from the Harvard School of Public Health (HSPH), “Failing Economy, Failing Health: The Great Recession’s Toll on Body and Mind,” detailing how poverty and inequality resulting from the economic maelstrom pulled down so many—and what that will mean for public health in the long term.
“Health is a long-run thing, but the methods we use to analyze current data only estimate short-term effects,” says SV Subramanian, HSPH professor of population health and geography. “It may take awhile for the health impact of the Great Recession to kick in, but once it does, it could be dramatic.”
The data is strong on the links between employment and health—people who are unemployed, underemployed or laid off are less healthy and don’t live as long.
A 2009 study found that in the 12 months after men lost their jobs in mass layoffs, they saw their chances of dying nearly double. While over time the risk lessened it was still significant two decades later. Another study that same year found that losing a job when a business shuts its doors increases the odds of fair or poor health by 54 percent among workers with no preexisting health conditions while also increasing the risk of new health conditions by 83 percent. The stress of the situation, according to the researchers, heightens the odds of stress-related conditions such as stroke, hypertension, heart disease, arthritis, diabetes and psychiatric problems.
Yet another study, this one in 2010, found that about 4 in 10 Americans with heart disease or diabetes and 1 in 5 with cancer said the stress of the Great Recession made it more difficult to manage their illnesses.
What’s more complex is unearthing the pathways behind why this is the case. The HSPH article outlines some of the mechanisms by which unemployment affects health.
Place Matters is a national initiative of the Joint Center for Political and Economic Studies designed to build the capacity of local leaders around the country to identify and improve the social, economic and environmental conditions that shape health. “Addressing upstream causes of poor health, such as issues related to employment, education, poverty, and housing and environmental health risks through community action, policy development, and measuring the indicators associated with these determinants of health, are at the heart of our Place Matters work,” said the project’s program director, Autumn Saxton-Ross, PhD.
Nineteen Place Matters teams are currently working in 27 jurisdictions. This week NewPublicHealth will be highlighting six teams, chosen by Ross as representing both what needs to be fixed and what can be done.
Jefferson County, Alabama is the most populous county in the state. The Place Matters team, headquartered at the University of Alabama at Birmingham, found that the county leads the nation in chronic diseases and conditions linked to premature death, disability, decreased productivity and high health care costs. The leading causes of death in the county are heart disease, cancer and diabetes, and the county also exceeds state and national rates for obesity.
“At the heart of the Jefferson County Place Matters Team is a commitment to empowerment and civic engagement,” said team leader Monica Baskin, PhD, as associate professor of preventive medicine at the University of Alabama/Birmingham Nutrition and Obesity Research Center. The team works to improve the social determinants of health by:
- Informing and illuminating public policy debates via research, analysis and information dissemination
- Building capacity of community leaders
- Facilitating community action planning and implementation.
Baskin, who has led the team for two and half years, said it has so far focused on improving access to healthy, affordable foods; physical activity opportunities; and obesity-related issues. The team also released a health equity report about the county, timed to coincide with the 50th anniversary of the Birmingham campaign, a touchstone moment in the U.S. civil rights movement.
CDC: American Indians, Alaska Natives Have 50 Percent Higher Death Rates than Non-Hispanic Whites
American Indian and Alaska Native (AI/AN) death rates were approximately 50 percent higher than rates among non-Hispanic whites—for both men and women—from 1999 to 2009, according to a new study in the American Journal of Public Health. The study determined that patterns of mortality were strongly influenced by the high incidence of diabetes, smoking prevalence, problem drinking and health-harming social determinants. Among the findings:
- Among AI/AN people, cancer is the leading cause of death followed by heart disease. Among other races, it is the opposite.
- Death rates from lung cancer have shown little improvement in AI/AN populations and AI/AN people have the highest prevalence of tobacco use
- Suicide rates were nearly 50 percent higher for AI/AN people
- Death rates from motor vehicle crashes, poisoning and falls were two times higher among AI/AN people
- Death rates were higher among AI/AN infants
“The Indian Health Service is grateful for this important research and encouraged about its potential to help guide efforts to improve health and wellness among American Indians and Alaska Natives,” said Yvette Roubideaux, MD, MPH, acting IHS director, in a release from the U.S. Centers for Disease Control and Prevention. “Having more accurate data along with our understanding of the contributing social factors can lead to more aggressive public health interventions that we know can make a difference.” Read more on health disparities.
FDA Proposes New Program to Help Patients With Unmet Tech Needs
The U.S. Food and Drug Administration (FDA) has proposed a new program designed to help treat or diagnose people with serious conditions, but whose needs aren’t met by current technology. The proposed Expedited Access Premarket Approval Application for Unmet Medical Needs for Life Threatening or Irreversibly Debilitating Diseases or Conditions (“Expedited Access PMA” or “EAP”) program would include earlier and more interactive engagement with FDA staff, with the goal of providing patients with earlier access to safe and effective medical equipment. “The program allows manufacturers to engage early and often with the agency,” said Jeffrey Shuren, MD, director of the FDA’s Center for Devices and Radiological Health. “We expect most devices that enter this program will be in the pre-clinical trial phase.” Read more on technology.
Study Links Internet Use, Lower Depression Rates in Older Americans
Older Americans who spend more time online are also less likely to suffer from depression, according to a new study in The Journals of Gerontology: Series B. Using data on 3,075 retired men and women who didn’t live in nursing homes gathered by the U.S. Health and Retirement Survey, researchers determined that the 30 percent who were Internet users also had a 33 percent lower probability of depression. "The largest impacts on depression were actually for those people who lived alone, so it's really suggesting that it's about connecting with others, eliminating isolation and loneliness," lead study author Shelia Cotton, according to Reuters. Read more on aging.
“Of all the forms of inequality, injustice in health care is the most shocking and inhuman,” said the Rev. Dr. Martin Luther King Jr. in 1966 at the Convention of the Medical Committee for Human Rights, which was organized to support civil-rights activists during Mississippi's Freedom Summer. Those words are part of the Health is a Human Right: Race and Place in America exhibit on display at the David J. Sencer Centers for Disease Control and Prevention (CDC) Museum in Atlanta. The museum, located at the CDC’s Visitor Center, mounts several exhibits each year. The timing for the Health as a Human Right exhibit coincides with National Minority Health Month, observed each April to raise awareness of health disparities in the U.S. among ethnic and racial minorities.
The CDC exhibit, curated by museum director Louise Shaw, is organized by social determinants of health such as housing and transportation. Photographs, like those of teeming settlements in urban cities, are a key tool to show museum goers and online viewers the health disparities in U.S. history and present day.
Among the items in the exhibit:
- Mexican men sprayed with DDT on their arrival for a guest worker program in the 1950s.
- A corroded sanitation pipe and bottles of unsafe drinking water from the Community Water Center in the San Joaquin Valley, California.
- An inventive and cheap air sampler from New Orleans that people used to catalogue pollution levels and share with law makers.
- A Chinese version of the "Be Certain: Get Tested for Hepatitis B," campaign.
- A March of Dimes poster depicting an African American child with polio from the late 1950s. (For a long time after the polio epidemic began, many believed African Americans could not contract the virus. As a result, precaution campaigns were rare and late among that population.)
The exhibition is sponsored by CDC's Office of Minority Health and Health Equity, the CDC's Office of the Associate Director for Communication and the California Endowment.
NewPublicHealth spoke with Louise Shaw in Atlanta.
NewPublicHealth: What made you decide to mount and curate this exhibit?
Louise Shaw: Three years ago the CDC Museum was approached by CDC’s Office of Minority Health and Health Equity (OMHHE) to organize an exhibition to commemorate its 25th anniversary. As curator of the Museum, I was excited by the possibilities and conceived of a project that extended beyond just honoring OMHHE accomplishments. Dr. Leandris Liburd, OMHHE director, and her terrific staff, quickly jumped on board, and we all agreed to develop a historic exhibition framed by the social determinants of health.
NPH: What are some of the most striking issues you found in disparities between whites and minorities when it comes to social determinants of health?
Louise Shaw: Although we have made progress in many areas, we are still tackling similar issues in the 21st century that were debated 100 years ago. For instance, how we provide quality education to all children, regardless of race, ethnicity, or income status, was and is one of the greatest challenges facing our country. As the Robert Wood Johnson Foundation has documented, education and the optimum health outcomes are closely linked. Ultimately, education is the pathway to eliminating health disparities. Income equality/inequality is another complex issue that is being hotly debated today. One more specific example: although pre-term birth rates have greatly declined over the past century among all groups, the disparities of those rates between whites and minorities stubbornly remain, and are yet to be eliminated. We need to ask ourselves why that is so. Collectively, we have still not resolved what it means to live in a diverse, multicultural society.
NPH: Do you know of any outcomes that have come from the exhibit?
Louise Shaw: Internally at CDC, the exhibition has been an important touchstone for discussion and debate. I have received incredible feedback about the honesty of the exhibition, thanking me for connecting the dots visually among race, place, and health. By the time it closes on April 25th, over 30,000 people will have seen the show. I don’t think we have ever mounted an exhibition that has been visited by so many college and university students — some even virtually. A consortium of faculty members from the University of Connecticut, Emory University, and Georgia State University, have developed a formal evaluation tool. In addition, there is a local and national movement underfoot to figure out how the show can live on whether online or in another form.