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Chicago, 11/3/10 Health Disparities: Origins and Opportunities Barry Zuckerman, MD The Joel and Barbara Alpert Professor and Chairman of Pediatrics Boston.

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Presentation on theme: "Chicago, 11/3/10 Health Disparities: Origins and Opportunities Barry Zuckerman, MD The Joel and Barbara Alpert Professor and Chairman of Pediatrics Boston."— Presentation transcript:

1 Chicago, 11/3/10 Health Disparities: Origins and Opportunities Barry Zuckerman, MD The Joel and Barbara Alpert Professor and Chairman of Pediatrics Boston Medical Center/ Boston University School of Medicine

2 Race and Health Racism ↓ Poverty ↓ Unequal Medical Care ↑ Stress Poor Adult Health Educational opportunity Employment opportunity Stress/violence Poor diet Poor learning environment Medication/other health expenditures Cigarettes and alcohol

3 Copyright ©2006 American Public Health Association Geronimus, A. T. et al. Am J Public Health 2006;96:826-833 FIGURE 1-- Probability of having an allostatic load of 4 or higher, as predicted by race (a) and race and gender (b)

4 Copyright ©2006 American Public Health Association Geronimus, A. T. et al. Am J Public Health 2006;96:826-833

5 Sickle Cell Anemia: A Special Case Study of Race and Health

6 VariableSCDCystic Fibrosis US prevalence80,00030,000 Federal support NIH fiscal-year 2004 funding, in millions of dollars NIH funding per person with disease, $ 90 1125 128 4267 Private philanthropic support, $ Cystic Fibrosis Foundation 2003 annual review Sickle Cell Disease Association of America 2003 annual revenue Revenue per person affected with the disease 498,577 6 152,213,000 5074 Total NIH and private support, in millions, $90.4280.2 Total support per person affected with disease, $11309340 NIH Research Funding and Private, Nonprofit Association Support of SCD and Cystic Fibrosis

7 Number of Federal Government Requests for Applications Funded for Sickle Cell Disease and Cystic Fibrosis: 1975-2004

8 Race and Health Racism ↓ Income ↓ Access ↑ Stress Poor Health

9 Adult Health Disparity by Income

10 Adult Health Disparities: Life Course Trajectory

11 Adult Health Disparities:

12 How Early Experiences Get Embedded in Biology and Influence Health Environment→Gene- → Neurochemical Social Environment Adaptations & Social Environment Adaptations & Physical Interaction Disruptions Physical Interaction Disruptions Nutrition Nutrition Poor education & economic productivity Poor education & economic productivity↕ →Brain → School failure Poor health behavior ↕ Poor physical & mental health Poor physical & mental health →Organs

13 Early experiences are biologically embedded in development of brain and other organs Early Experiences Positive Nurturing and stimulation Nurturing and stimulationAdverse Stress/harmful interactions Stress/harmful interactions Neurotoxic exposure Neurotoxic exposure Inadequate nutrition Inadequate nutrition Child and Adult Health

14 Brain Development

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16 Parental Language Addressed to Child by SES Hart & Risley, (1995)

17 Early experiences are biologically embedded in development of brain and other organs Early Experiences Positive Nurturing and stimulation Nurturing and stimulationAdverse Stress/harmful interactions Stress/harmful interactions Neurotoxic exposure Neurotoxic exposure Inadequate nutrition Inadequate nutrition Child and Adult Health

18 Positive and Tolerable Stress

19 Toxic Stress

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21 Gianaros, P.J., et al. Neuroimage, 2007. Direct Effects of Stress

22 Farah, M.J., et al. Brain Res, 2006 Effect Size Between Low and Middle Income Children on Neurocognitive Functioning (N=60)

23 Stress: Adverse Childhood Events and Adult CV Disease Dong et al, 2004 ACEs Odds Ratio

24 Adverse Childhood Events and Adult Depression Odds Ratio ACEs Chapman et al, 2004

25 Caspi, A., et al. Science. 301:386-389 2003 Stress and Genetic Vulnerability for Depression

26 Caspi, A., et al. Science. 297:851-854 2002 Stress and Genetic Vulnerability for Antisocial Behavior

27 What to do: Examples 1. Society: comprehensive 2. Health care Race Race Regulations tied to new construction Regulations tied to new construction Target quality improvement of select hospitals Target quality improvement of select hospitals Cultural competency Cultural competency Increase racial diversity among physicians, nurses, etc. Increase racial diversity among physicians, nurses, etc. Interpreters (technology) Interpreters (technology) Use of non-health care settings Use of non-health care settings Barbers Barbers Churches Churches salons salons

28 Use Health Care to Disrupt Link Between Poverty and Poor Health Reach Out and Read Reach Out and Read Medical-Legal Partnership Medical-Legal Partnership Project HEALTH Project HEALTH

29 Reach Out and Read Advice and books given at pediatric well child visits until age 5

30 Frequency of Reading Aloud (High et. al., 2000)

31 Children’s Expressive and Receptive Language Competencies Mendolsohn, et al., 1995

32 Reach Out and Read Statistics ● Founded in 1989 at Boston City Hospital ● Over 4,500 sites ● Over 3.5 million children from low-income families reached last year ● Over 5 million books distributed last year

33 Social Determinants of Healthy Development: Mechanisms 1. Direct: Deprivation Deprivation Food Food Money Money Health Health medications medications Exposures Exposures  caloric food  caloric food Lead Lead Asthma triggers Asthma triggers 2. Indirect: Stress

34 Specialist saves the day A 11 yr old boy arrives for an urgent care visit. In the past 2 months, he has needed several courses of oral steroids despite an appropriate medication regimen and an asthma action plan which his mother follows. However, the landlord has refused to do the needed pest control measures you suggested. A 11 yr old boy arrives for an urgent care visit. In the past 2 months, he has needed several courses of oral steroids despite an appropriate medication regimen and an asthma action plan which his mother follows. However, the landlord has refused to do the needed pest control measures you suggested. The patient has missed school repeatedly and is at risk of failing. The patient has missed school repeatedly and is at risk of failing. A new specialist was consulted and within 6 weeks, the teen was weaned off steroids and was back in school. A new specialist was consulted and within 6 weeks, the teen was weaned off steroids and was back in school.

35 NICU Babies Have Legal Needs Baby Isabel, born 28 wks. Parents are legal immigrants from the Dominican Republic. As a NICU patient, Isabel is eligible for many benefits and services that will protect her health and prevent re-hospitalization: SSI, early intervention, etc.

36 Parents don’t understand if and how Isabel’s access to benefits impact their immigration status. Front-line and hospital staff – nurses, case managers, pediatricians – don’t know how to advise them. Parents decide not to pursue benefits. Isabel is seen in the ED 3 months later with fever, secondary infection of diaper rash due to diarrhea and FTT.

37 Medical-Legal Partnership for Disparity Reduction Social Doctors Lawyers Childhood Illness Biological

38 The MLP Network – March 2009 81 partnerships in over 180 hospital and health centers

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40 Perry Preschool Project:

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