1. Envisioning Health Equity
Peter A. Gorski, M.D., M.P.A.
Children’s Board of Hillsborough County and
University of South Florida

2. Social Determinants of Health and Wealth
Your neighborhood
Physical, social, economic, educational qualities
Your skin color
Race, ethnicity
Who’s your daddy
Parents’ education, income, health, social capital

3. Poverty Sickens
Strong connections between child health and adult health
Between child wealth and adult wealth
Between child wealth and adult health
Regardless of child’s health condition
Regardless if social class changes from childhood to adulthood
Childhood poverty gets biologically embedded

4. Epigenetics Life Course Perspective
Balance of stresses and supports across life course exert cumulative influence on health
Especially during sensitive periods of development, powerful experience gets embedded into our biology
Reforming DNA structure, gene expression and brain chemistry
Consequences to BMI, blood pressure, immune function, memory, learning, attention and mental health

5. Racial and Ethnic Disparities in Birth Outcomes: A Life Course Perspective
This may be particularly important for MCH, where one developmental stage often gets disconnected from another. In perinatal health, we focus so much on events occurring in the 9 months of pregnancy we forget that there are a great deal of life course influences on perinatal outcomes, and a great deal of perinatal influences on life course outcomes.
For example, in explaining the Black-White gap in infant mortality, for decades we searched for maternal risk factors during pregnancy rather than looking at the mothers’ cumulative life course experiences. The danger of focusing solely on risk factors during pregnancy is not only that it doesn’t adequately explain the disparities, but more importantly it can misguide public health interventions and policies. For two decades we thought if we could get women universal access to good quality prenatal care, then we can do something about reducing infant mortality and racial disparities in this country.
Many of us recognize now that to expect prenatal care, in less than nine months, to reverse all the cumulative disadvantages and inequities over the life course of the woman, may be expecting too much of prenatal care. If we as are serious as a nation about improving birth outcomes and reducing disparities, we have to start taking care of women not only during pregnancy, but before pregnancy and between pregnancies and indeed, across the entire life course of women and families.
Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective. Maternal Child Health J. 2003;7:13-30.

6. School Readiness Trajectories
Strategies to Improve
School Readiness Trajectories
Poverty
Lack of health services
Toxic Stress
Age
6 mo mo mo mo yrs yrs
Ready to learn
Pre-school
“Healthy” Trajectory
Health Services
Appropriate Discipline
Reading to child
“At Risk” Trajectory
Parent education
Emotional Health
Literacy
“Delayed/Disordered ” Trajectory
Birth
Early Infancy
Late Infancy
Early Toddler
Late Toddler
Early Preschool
Late Preschool

7. Race is Not a Proxy for Poverty or Wealth

8. Beyond (or Underneath) SES
African American infant mortality higher in more segregated cities even when controlling for SES

9. SES? – Ask the Professionals
10.2
6.8
And that African American women with more than 16 years of schooling still have higher infant mortality than White women with less than nine years of schooling. Think about this. These are African American women who have graduated from college, and gone on to graduate schools, medical schools, law schools, business schools to get their MD’s and JD’s, and MBA’s. We are talking about African American doctors and lawyers and business executives. And they still have higher infant mortality than White women who never went to high school in the first place.
NCHS 2002

10. SES? – Ask the Africans
Birth weight distribution of African-born blacks is more closely related to US-born whites than to US-born blacks
David RJ, Collins JW. Differing birth weight among infants of U.S.-born blacks, African-born
blacks, and U.S.-born whites. N Engl J Med Oct 23;337(17):

11. Pathogenesis (and Salutogenesis): Complex Interaction between Biology and Environment
This explains why many, if not all, of the chief public health killers have common root causes.
Degradation of personal dignity, social justice and community
I can only be as healthy as my neighbors

12. Enhancing Public Health – A Provocative Perspective
Single disease prevention approach rarely works
Treating symptoms rather than root causes
Since inequities are at root of health disparities, we must work for the equitable distribution of conditions that promote health and healthy development –
Social, educational, economic and environmental capital
healthcare

13. Even More Provocative
Compensatory or Disparities Model (Affirmative Health Action) flawed
See next slide
Equity Framework
Health is a human right
Every human being has intrinsic worth.
Policies should be directed to what every person needs and deserves to thrive and contribute

14. Why Target Whole Communities?
Health and well-being of each person depends on condition of all (see next slide)
Cannot predict individual course based on group risk factors
Cost burden of case-finding and treatment too high
Moral weakness of accepting unequal outcomes

15. Post-neonatal Infant Mortality (per 100,000 live births,1986)
Wilkinson RG. Income distribution and life expectancy. BMJ. 1992;304:

16. My Vision-Dream for the Health Equity Coalition
Expand public understanding of health equity framework
Forge strategic partnerships across the county’s public and private sectors – every decision impacts health
Document and demonstrate the correlation and causal association between social, economic, educational, environmental and healthcare equity and population health outcomes
Advocate for policies and practices that promote and create advantage for all citizens