eliminating inequalities

Eliminating Health Inequalities Intersections and Ethics : 

Eliminating Health Inequalities Intersections and Ethics John R. Stone, MD, PhD Creighton University School of Medicine Center for Health Policy and Ethics

Aims: 

Aims Summarize that: Health inequalities are significant Eliminating health inequalities should involve what justice demands in light of intersecting bases of well-being. Intersectional, multidimensional approaches are essential, including affected communities Have a discussion

Healthcare and HealthEmbeddedness and Perspective: 

Healthcare and Health Embeddedness and Perspective Humility Arrogance Ignorance

Inequalities (Disparities) in Health Status and Healthcare: 

Inequalities (Disparities) in Health Status and Healthcare Tragic Horrendous Ethically unacceptable Moral problems of the first order

Universal and Substantial Healthcare: 

Universal and Substantial Healthcare Respect and justice demand such healthcare. BUT To eliminate disparities in health status, much more must be done.

Influence on Excess Mortality: Poor & Minorities: 

Influence on Excess Mortality: Poor & Minorities H. Jack Geiger. Health Disparities: What do we know? What do we need to know? What should we do?. In Gender, Race, & Health: Intersectional Approaches. Edit by Amy J. Schulz & Leith Mullings. San Francisco. Jossey-Bass, 2006, p. 265.

Interactive Determinants: 

Interactive Determinants “The determinants that interact to create good or ill health derive from various sources and sectors. Among other factors, health is shaped by laws and policies, employment and income, and social norms and influences.” The Future of the Public's Health in the 21st Century (2002). Board on Health Promotion and Disease Prevention (HPDP) Institute of Medicine (IOM). The National Academies Press. P. 2 http://books.nap.edu/openbook.php?record_id=10548&page=R1 (Accessed 4/13/2007)

Missoula County*Gender, “Race,” Ethnicity: 

Missoula County* Gender, “Race,” Ethnicity * 2000 Census, http://www.dphhs.mt.gov/PHSD/health-profiles/pdf/missoula.pdf, accessed 4/13/2007 Health Status?

Missoula County: Income: 

Missoula County: Income * 1 2000 Census, 2 MT. Dept. Labor & Industry 2001 http://www.dphhs.mt.gov/PHSD/health-profiles/pdf/missoula.pdf, accessed 4/13/2007

Slide10: 

Health Insurance Coverage of Children 0-18 Living Near Poverty (100% - 199% FPL) States (2004-2005), U.S. (2005) http://www.statehealthfacts.org/cgi-bin/healthfacts.cgi?action=compare&category=Health+Coverage+%26+Uninsured&subcategory=Health+Insurance+Status&topic=Near+Poor+Children&link_category=&link_subcategory=&link_topic=&datatype=&printerfriendly=0&viewas=map&showregions=0&from=none&sortby=Uninsured (Accessed 4/13/2007)

Slide11: 

Health Insurance Coverage of Children 0-18 States (2004-2005), U.S. (2005) States with 15% uninsured: 2 States with > 15% uninsured: 4 Range of uninsured: 6%-20% http://www.statehealthfacts.org/cgi-bin/healthfacts.cgi?action=compare&category=Health+Coverage+%26+Uninsured&subcategory=Health+Insurance+Status&topic=Children+%280%2d18%29&link_category=&link_subcategory=&link_topic=&printerfriendly=0&from=none&viewas=table (Accessed 4/13/2007)

Health Insurance Coverage of Adults 19-64States (2004-2005), U.S. (2005): 

Health Insurance Coverage of Adults 19-64 States (2004-2005), U.S. (2005) http://www.statehealthfacts.org/cgi-bin/healthfacts.cgi?action=compare&category=Health+Coverage+%26+Uninsured&subcategory=Health+Insurance+Status&topic=Adults+%2819%2d64%29&link_category=&link_subcategory=&link_topic=&printerfriendly=0&from=none&viewas=table (Accessed 4/15/2007)

Healthcare’s Major Influences: 

Healthcare’s Major Influences Disability Pain Suffering Quality of life H. Jack Geiger. Health Disparities: What do we know? What do we need to know? What should we do?. In Gender, Race, & Health: Intersectional Approaches. Edit by Amy J. Schulz & Leith Mullings. San Francisco. Jossey-Bass, 2006, p. 272.

Health Status: Major Determinants: 

Health Status: Major Determinants Providers Institutions Systems Policies H. Jack Geiger. Health Disparities: What do we know? What do we need to know? What should we do?. In Gender, Race, & Health: Intersectional Approaches. Edit by Amy J. Schulz & Leith Mullings. San Francisco. Jossey-Bass, 2006.

Collaborative Effort: 

Collaborative Effort “There is a growing recognition that individuals, communities, and various social institutions can form powerful collaborative relationships to improve health that government alone cannot replicate.” The Future of the Public's Health in the 21st Century (2002). Board on Health Promotion and Disease Prevention (HPDP) Institute of Medicine (IOM). The National Academies Press. P. 2 http://books.nap.edu/openbook.php?record_id=10548&page=R1 (Accessed 4/13/2007)

Proposed “areas of action and change”: 

Proposed “areas of action and change” “Adopting a population health approach that considers the multiple determinants of health;” “Building a new generation of intersectoral partnerships that also draw on the perspectives and resources of diverse communities and actively engage them in health action;” [bold added] The Future of the Public's Health in the 21st Century (2002). Board on Health Promotion and Disease Prevention (HPDP) Institute of Medicine (IOM). The National Academies Press. P. 4 http://books.nap.edu/openbook.php?record_id=10548&page=R1 (Accessed 4/13/2007)

Public HealthPotential Agents : 

Public Health Potential Agents Governmental Public Health Healthcare Academia Communities Community organizations Businesses The Future of the Public's Health in the 21st Century (2002). Board on Health Promotion and Disease Prevention (HPDP) Institute of Medicine (IOM). The National Academies Press. P. 2 http://books.nap.edu/openbook.php?record_id=10548&page=R1 (Accessed 4/13/2007)

IntersectionsEliminating Health Inequalities: 

Intersections Eliminating Health Inequalities Community Agencies & Orgs Businesses Public Health Government Community

Intersectional WorkEthically/morally guided by what?: 

Intersectional Work Ethically/morally guided by what?

Ethics & Health of the PublicEthical Foundations: 

Ethics & Health of the Public Ethical Foundations John Rawls Amartya Sen Norman Daniels Martha Nussbaum Madison Powers Ruth Faden Social Justice: The Moral Foundations of Public Health and Health Policy. NY. Oxford, 2006. Public Health Consequentialism

Madison Powers & Ruth FadenSocial Justice: The Moral Foundations of Public Health and Health Policy: 

Madison Powers & Ruth Faden Social Justice: The Moral Foundations of Public Health and Health Policy Health: one of six major, interactive, components of well-being “Sufficiency” account Denial of separate spheres of justice Community involvement Reduced significance of healthcare

Well-being & JusticePowers & Faden: 

Well-being & Justice Powers & Faden “Sufficiency” of the “essential dimensions” Understanding of dimensions’ interactions Assume “inequalities beget inequalities”: e.g. oppression and subordination involved in racism and sexism (p. 8) Target systematic patterns that influence self-determination. Stress “children and their futures” (p. 8)

Justice: Powers and Faden: 

Justice: Powers and Faden “Justice in our view requires ensuring for everyone a sufficient amount of each of the essential dimensions of well-being, of which health is one.” (p. 9) “Insofar as possible.” (16) Essential dimensions are those “characteristically present within a decent life” (p. 15)

“The Job of Justice”Powers & Faden: 

“The Job of Justice” Powers & Faden “The achievement of a sufficiency of six essential dimensions of human well-being” (p. 5) A “nonideal theory” that addresses “which inequalities matter most” in “a concrete empirical context” (p. 5) Concerned not just with distrubutive principles, but also inter-personal relations (p. 6)

Madison Powers & Ruth FadenSocial Justice: The Moral Foundations of Public Health and Health Policy: 

Madison Powers & Ruth Faden Social Justice: The Moral Foundations of Public Health and Health Policy Cost-effectiveness analysis is not paramount Denial of public health’s primary focus on aggregative health, constrained by justice and liberty Job of justice: “to specify those background social and economic conditions that determine whether…inequalities…are unfair.”(xi)

Powers & Faden: 

Well-being Structures Policy Health History Social Context Social Determinants Power Multiculturalism Dominance Lens of Social Justice & Public Health Powers & Faden Healthcare Biomed Culture

Related Concerns: 

Related Concerns Cross-cultural health and healthcare Principles Respect Justice Care Community Insurgent multiculturalism

Conclusions: 

Conclusions Health inequalities are important and tragic Powers & Faden’s ethical framework is promising Research and interventions should be in light of interactive dimensions of well-being Intra-academic partnering is essential Multi-dimensional collaboration is crucial Healthcare institutions and professionals must be part of the solution Dominant hierarchies & power structures need changing, including whiteness & male dominance