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

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

3. Healthcare and Health Embeddedness and Perspective Humility Arrogance Ignorance

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

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

6. Influence on Excess Mortality: Poor & Minorities Lifestyle30% Healthcare10% All others 60% 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.

7. 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 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)

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

9. 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 http://www.dphhs.mt.gov/PHSD/health-profiles/pdf/missoula.pdf

10. Bar Graph Bar Graph Tabl e Ma p Tabl e Bar Graph Tabl e Less than 10% Less than 10% 10% to 12% 10% to 12% 13% to 17% 13% to 17% More than 17 More than 17 Health Insurance Coverage of Children 0-18 Living Near Poverty (100% - 199% FPL) States (2004-2005), U.S. (2005) Less than 10% 10% to 12% 13% to 17% More than 17% http://www.statehealthfacts.org/cgi- bin/healthfacts.cgi?action=compare&category=Health+Coverage+%26+Uninsured&subcategory=Health+Insurance+St atus&topic=Near+Poor+Children&link_category=&link_subcategory=&link_topic=&datatype=&printerfriendly=0&viewas =map&showregions=0&from=none&sortby=Uninsuredhttp://www.statehealthfacts.org/cgi- bin/healthfacts.cgi?action=compare&category=Health+Coverage+%26+Uninsured&subcategory=Health+Insurance+St atus&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)

11. Health Insurance Coverage of Children 0-18 States (2004-2005), U.S. (2005) UninsuredEmployerIndividualMedicaid Other Public United States 12%56%4%26%1% Montana15%52%6%25%2% 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+Stat us&topic=Children+%280%2d18%29&link_category=&link_subcategory=&link_topic=&printerfriendly=0&from=none&vie was=tablehttp://www.statehealthfacts.org/cgi- bin/healthfacts.cgi?action=compare&category=Health+Coverage+%26+Uninsured&subcategory=Health+Insurance+Stat us&topic=Children+%280%2d18%29&link_category=&link_subcategory=&link_topic=&printerfriendly=0&from=none&vie was=table (Accessed 4/13/2007)

12. Health Insurance Coverage of Adults 19-64 States (2004-2005), U.S. (2005) Uninsured Uninsured Employer Employer Medicaid Medicaid Individual Individual Other Public Other Public United States United States 21% 63% 63% 6% 8% 8% 3% 3% Montana Montana 24% 54% 54% 10% 10% 7% 7% 5% 5% http://www.statehealthfacts.org/cgi- bin/healthfacts.cgi?action=compare&category=Health+Coverage+%26+Unin sured&subcategory=Health+Insurance+Status&topic=Adults+%2819%2d64 %29&link_category=&link_subcategory=&link_topic=&printerfriendly=0&fro m=none&viewas=table (Accessed 4/15/2007)

13. Healthcare’s Major Influences Disability Disability Pain Pain Suffering Suffering Quality of life 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.

14. Health Inequalities “Race” – Ethnicity - Socioeconomic Status - Gender - Sexual Orientation - Other Social Determinants Healthcare

15. Health Status: Major Determinants Blame victims Colorblind Focus Ideology of superiority Toxins Safety Neighborhood Racism Discrimination Occupation 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.

16. 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.” “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)

17. Proposed “areas of action and change” 1. “Adopting a population health approach that considers the multiple determinants of health;” 3. “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)

18. Public Health Potential Agents Public Health Potential Agents Governmental Public Health Governmental Public Health Healthcare Healthcare Academia Academia Communities Communities Community organizations Community organizations Businesses 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)

19. Intersections Eliminating Health Inequalities University Disciplines Centers Community Agencies & Orgs Businesses Healthcare Institutions Professionals Public Health Government Community

20. Intersectional Work Ethically/morally guided by what?

21. 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

22. Madison Powers & Ruth Faden Social 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 Health: one of six major, interactive, components of well-being “Sufficiency” account “Sufficiency” account Denial of separate spheres of justice Denial of separate spheres of justice Community involvement Community involvement Reduced significance of healthcare Reduced significance of healthcare

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

24. 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) “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) Essential dimensions are those “characteristically present within a decent life” (p. 15)

25. “The Job of Justice” Powers & Faden “The achievement of a sufficiency of six essential dimensions of human well-being” (p. 5) “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) 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) Concerned not just with distrubutive principles, but also inter-personal relations (p. 6)

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

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

28. Related Concerns Cross-cultural health and healthcare Cross-cultural health and healthcare Principles Principles RespectRespect JusticeJustice CareCare CommunityCommunity Insurgent multiculturalism Insurgent multiculturalism

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