A Discussion on Health Inequities with Dr. LaMar Hasbrouck

Caitlin Cotter, DVM, MPH

This blog post is part of a weekly series focusing on different aspects of public health leading up to Public Health Thank You Day on Monday, November 21, 2016. Join the conversation on social media with the hashtag #PHTYD and visit www.publichealththankyouday.org for more information. 

LaMar Hasbrouck, M.D., MPH, is the Executive Director of the National Association of County and City Health Officials (NACCHO). The National Association of County and City Health Officials (NACCHO) represents the nation's nearly 3,000 local governmental health departments. These city, county, metropolitan, district, and tribal departments work every day to protect and promote health and well-being for all people in their communities. For more information about NACCHO, visit www.naccho.org.

How would you describe the health inequities currently found in counties and cities of the US?

Health inequities parallel the level and scope of social and economic inequity. In those cities and counties with the greatest degree of inequity (and that includes social exclusion, marginalization, exploitation, domination—lacking control over work life and living conditions, including segregation), research shows higher levels of health inequity across all diseases, and often significant differences in life expectancy and well-being. Sharp differences in health outcomes are often found in neighborhoods that are only short distances apart.

In many cities, land use decisions and increasing levels of gentrification lead to dispossession and its resulting stresses. So too does the fear of police violence, adverse childhood experiences, and the effects of mass incarceration by creating severe stress for many families and children. Right now, overall, the continuous deterioration of the public sector also weakens the “social immune system” in cities: the infrastructure of schools, water systems, electrical grids, public transportation and so forth required for a thriving community. Inequities in the U.S. are higher than at any time since before the Great Depression. In fact, we have worse health outcomes than many other wealthy nations, primarily due to these inequities.

As public health leaders, it is our job to first explore these issues in order to better understand them, so that we can address them effectively. We can do this by being frank about the reality of disparities, and researching the underlying factors that cause them. This part of the mission must be anchored in collecting and analyzing quality data about the state of health in our communities, which is why we created tools like the Big Cities Health Inventory, which we will be releasing on November 29. The key is addressing inequities in a way that takes into account all of the root factors that affect and shape health in our communities, using a lens of social justice in our everyday public health practice. 

What do you believe to be some of the causes of these health inequities?

Well, in the simplest terms wealth determines health. A family with a good income has access to a whole range of social benefits those living in poverty do not. That means educational opportunities, employment, housing, childcare, access to nutritious food, medical care and safe neighborhoods. And when we look at poverty in America, we see the lasting legacy of racism. Tony Iton, M.D., JD, MPH, Senior Vice President of Health Communities at the California Endowment wrote in Tackling Health Inequities Through Public Health Practice, “African-American and Latino households have less than ten cents for every dollar in wealth owned by white households. These racialized patterns of wealth distribution are consistent from community to community across the United States.” Unfortunately, the past continues to have a negative effect on many minority families.

How do these health disparities affect public health?

Health inequities pose serious consequences and have great social costs. Health inequities limit people’s ability to gain access to the resources they need. People are less likely to achieve their full human capabilities, such as obtaining well-paid employment or participating in community social and civic life. Quality of life simply declines. Psychological stresses weaken the immune system. More generally, when people lack access to decision-making and the ability to participate in everyday life, their health suffers.

What can cities, counties, states, and society at large do to improve health inequities?

NACCHO supports the incorporation and adoption of principles of social justice into everyday public health practice, in order to take effective action on the root causes of health inequities. Based on those principles, NACCHO encourages local health departments to act more directly, with allies, on structures of inequity associated with class, race, gender and sexual orientation, as they are bound with, imbalances in political power. As part of that work, NACCHO specifically encourages the transformation of public health practice to include the following:

  1. Develop, track, and regularly present indicators that (a) measure social health and well-being, including inequities in population health status, similar to the national presentation of economic indicators; and (b) identify the institutional sources of decision-making cumulatively generating health inequities (e.g., investment in local infrastructure by neighborhood; distribution of city fiscal resources by neighborhood; bank loans, lending practices, and foreclosures by neighborhood; political influence).
  2. Recruit a racially/ethnically diverse workforce.
  3. Engage in anti-racism training for and dialogue with the public health workforce.
  4. Support local policies that begin to address root causes, such as paid sick leave and living wage.
  5. Support the use of Health Impact Assessments across all policy areas.
  6. Develop long-term relationships with communities based on mutual trust and a recognition of each other’s strengths, leadership capacities, and common interests in confronting the social inequities at the root of health inequities and social injustice.
  7. Support research that explores the generation of social and economic inequity and the power arrangements or mechanisms that increase social and economic inequity.
  8. Create alliances with constituents, community organizers, and relevant institutions as a means toward changing the structures and processes that generate health inequities.
  9. Develop a public narrative that articulates the relationship between health inequities and the underlying social inequities. 

Caitlin Cotter is the Science and Policy Fellow at Research!America.

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Luck shouldn't play a role in why I'm alive.
Laurie MacCaskill, a seven-year pancreatic cancer survivor