This slide shows a composite satellite photograph of the world taken at night, illustrating who has electricity and who does not. This is a visual demonstration of the “North/South” divide.

Disparities, Inequality, and Inequity DISPARITY = INEQUALITY and implies differences between individuals or population groups (UN-equal) INEQUITY refers to differences which are unnecessary and avoidable but, in addition, are also considered unfair and unjust Give example: size 9 shoes equally distributed Birth weight – male/female Birth weight: Black/White 3

Tips for Staying Health: A Lifestyle Approach Don’t smoke. If you do, stop. Eat a balanced diet, include fruits/vegetables. Keep physically active. If you drink, do so in moderation. Cover up in the sun and protect your children. Practice safe sex. Participate in appropriate health screenings. Drive defensively; don’t drink and drive. Manage your stress. Maintain social ties. What is the problem of only focusing on this list? Think about people engaging in these in Boston

Health Outcomes by Race I have a ton of data slides that will show you that on almost every chronic disease measure, Blacks and Latinos are fairing worse than white: heart disease, cancer mortality, diabetes, rates of hospitalization, stroke, overall mortality…. I want to use asthma as an example to move our conversation beyond just rates of disease to talk about place and race This graph shows that asthma hospitalization rates for Black and Latino kids under 5 are 4xs higher than rates for Whites kids in the city. The Asian population, while below the city average, also experienced higher rates than Whites. However, currently “In 2009, the rates of asthma hospitalization for Black and Latino children were more than twice the rate for White children and three to four times the rate for Asian children.” Do you see similar patterns in data you use in your program/office? So what do we call these differences in health outcomes by race? 5 5

Boston Neighborhoods So what do the social and physical environments look like in Boston? Here’s a map of our fair city… Think about the neighborhood you live in, work in, shop in, eat in, visit friends and family in. As you move through the city you have no doubt observed differences among the resources and opportunities available in each neighborhood. 6 6

Place Matters Asthma Hospitalizations for Children under Age 5, by Neighborhood 2006, 2007, 2008 Combined When we do that, we see that rates aren’t distributed evenly across the city – some neighborhoods have higher rates of asthma hospitalization for children under 5 than others. This map shows us that Roxbury, the South End, and North Dorchester have higher rates of asthma hospitalizations for children under 5 than other neighborhoods, with Allston/Brighton, Back Bay, and West Roxbury as the least affected. 7 7

This story isn’t unique to asthma; many other poor health outcomes look similar when you place it on a map of Boston. Here are maps of Heart Disease, Diabetes, and Infant Mortality Rates. It’s the same central neighborhoods- the ones that have worse environmental conditions, higher concentrations of poverty, and are largely communities of color- that are disproportionately experiencing these health burdens. Keeping these maps and patterns in mind, we see that the social conditions in which people live, work and play are very different depending on one’s race. 8 8

A social determinant of health that correlates to asthma is the presence of parks and green space. We know that exposure to air pollutants such as smoke, vehicle exhaust, and chemicals increase the risk for asthma. We also know that children who spend more time indoors are exposed to more indoor allergens such as dust and mold. Therefore, parks and green space are important health promoting resources in communities – to reduce air pollutants and provide opportunities for kids to get outside. What we see when we look at this map of green space, is that neighborhoods that have higher rates of asthma, also have less green space than other neighborhoods. 9 9

Junkyards are a major source of pollution in cities Junkyards are a major source of pollution in cities. This map shows junkyard sites before 2000. You can see that junkyard locations correspond to the areas where asthma hospitalizations are higher. In fact, in Roxbury, the neighborhood that has the highest prevalence of asthma in the city, there 123 pollution generating sites per square mile – which includes trash transfer stations, bus depots, and superfund sites. (Miller, 2005) 10 10

This map shows elevated blood lead levels in children under age 5 This map shows elevated blood lead levels in children under age 5. Elevated blood lead levels in children have been linked to nervous system damage, behavior and learning difficulties, stunted growth and hearing disorders. High blood lead levels can be an indicator of poor housing stock, because older, poorer housing is more likely to have indoor toxins. Poor housing stock is also more likely to have indoor allergens that trigger asthma, such as dust, mold, and pests. So when we look at the geographic distribution of elevated blood lead levels, we see a relationship with the neighborhoods that have the highest rates of asthma. 11 11

These environmental conditions not only relate to asthma outcomes, they also relate to concentrations of poverty. Here we see the percent of the population living below 150% of the FPL, by census tract. The highest concentrations of poverty are in the same neighborhoods that had less open space, more junkyards, and higher rates of asthma. 12 12

The last map we’ll look at is of racial demographics across the city – the red dots are the Black population, yellow dots are Latinos, blue dots are Whites, and green dots are Asians. We can see that the neighborhoods that have higher asthma rates and higher concentrations of environmental pollutants are also predominantly Black and Latino. Neighborhoods that have lower rates of asthma hospitalization and have more open space and fewer environmental pollutants, are neighborhoods that are predominantly White. "In communities of color there are an average of 192,000 pounds of chemical pollution per square mile versus 19,000 in white communities,“ [Daniel Faber, associate professor of sociology at Northeastern] – Miller, 2005 In 2009, the diabetes hospitalization rate for Black and Latino residents was approximately four to five times the rate for Asians and the rate for Whites. [Health of Boston 2011] 13 13

Infant Mortality in Boston by Race

Infant Mortality and Cigarette Smoking Per 1,000 Live Births African American Non-Smokers White American Smokers NCHS 2002

Infant Mortality and Prenatal Care Per 1,000 Live Births African Americans 1st Trimester Prenatal Care White Americans Prenatal Care After 1st Trimester or None NCHS 2002

Racial & Ethnic Disparities Infant Mortality & Education 10.2 6.8 NCHS 2002

Racial & Ethnic Disparities Infant Mortality & Household Income 16.6 11.2

Tips for Staying Healthy: A Social Determinants Approach Don’t be poor. If you can, stop. If you can’t, try not too be poor for too long. Don’t have poor parents. Don’t live in a poor neighborhood. Own a car – but use only for weekends and walk to work. Practice not losing your job and don’t become unemployed. Don’t be illiterate. Avoid social isolation. Try not to be part of a socially marginalized group.

Social Determinants of Health Inequities Education Job Opportunity Socioeconomic Status Health Outcomes Racism Environmental Exposure Health Behaviors Access to Health Services Safe and Affordable Housing Reducing Violence

States using the “Reactions to Race” module 2002 to 2009 BRFSS Arkansas, California, Colorado, Delaware, District of Columbia, Florida, Indiana, Massachusetts, Michigan, Mississippi, Nebraska, New Hampshire, New Mexico, North Carolina, Ohio, Rhode Island, South Carolina, Tennessee, Vermont, Virginia, Washington, Wisconsin 21

General health status and “race” Being perceived as White is associated with better health Even within non-White self-identified “race”/ethnic groups Even within the same educational level Being perceived as White is associated with higher education Also, the most fundamental question that rarely gets raised because we rarely look at the underlying distributions of SES by "race", even when we look at SES and health, is why is socially assigned "race" associated with income distributions? I strongly suggest that this is because of institutionalized racism, the structures, policies, practices, and norms that perpetuate initial historical injustices. Camara Phyllis Jones, MD, MPH, PhD 22 22

Racial & Ethnic Disparities Low Birth Weight & Racism 20% P < 0.01 12%

What is racism? A system of advantage based on race. David Wellman, Portraits of White Racism

Adopted from the Applied Research Center Levels of Racism INTERNALIZED Interpersonal MICRO LEVEL INSTITUTIONAL STRUCTURAL MACRO LEVEL Adopted from the Applied Research Center

Our tasks Put racial justice/racial equity on the agenda Name racism as a force determining the distribution of other social determinants of health Routinely monitor for differential exposures, opportunities, and outcomes by “race” Camara Phyllis Jones, MD, MPH, PhD 26 26

4-year Graduation Rate: Grades 9-12 Boston, 2006 Percentage of High School Students Massachusetts Department of Education

“Pilot Program Aims to Reduce Infant Deaths” In an effort to drive down the disproportionately large number of deaths among black and Latino infants in Boston, city leaders yesterday unveiled a campaign to provide housing, counseling, and other critical support for pregnant women who are homeless or living on the edge.

Jamaica Plain Equity Collaborative Brookside, Martha Eliot and Southern Jamaica Plain Health Centers Bromley Health TMC JPNDC ESAC Hyde Square Task Force Teen Empowerment Spontaneous Celebrations Tree of Life/Arbol De Vida

March and Rally February 2010, 2011

Youth Racial Healing & Reconciliation Project

Documenting the Work Coleman This was an activity we did and we were divided into small groups: the government, corporation, middle income american workers, and very low income workers in mexico. I was in the mexican worker group. Eventually the other mexican worker got an opportunity to go to america and I was left all alone. I tried to hold out and lobby for my rights but I ended up caving and giving in to a deal from a major corporation so that I could provide for my family. It felt bad because I felt powerless to change my position and move up in the economy. Dfdsfmadf.,mf.,dasmf.sd,amf.,asdmf.sd,mf.sda,mf.asd,fm.sd,fmd.s,fmsd,.fmsd,.fmsd.,fmsd,.fmsd,.afmsd.a,fmds,.fmsd.a,fmsda,.fmsd.,fmd.as,fmd.as,mf.asd,mf.ad,smf.,asdmf.asd,mfasd.,mas.,fmasd.,fmas.,mf.asd,mf.,asdmf.asd,mfa.s,.a,smfd.s,afmasd,.fmsd.a,fma.sd,fmasd.,fmas.d,fm

Taking it to the JP Community

Loretta Ross Educating Us About a Frame… http://www.youtube.com/watch?v=82vl34mi4Iw

Thank You! Questions/Feedback???

Southern Jamaica Plain Health Center 640 Centre Street Abigail Ortiz , MSW, MPH Southern Jamaica Plain Health Center 640 Centre Street Jamaica Plain, Ma 02130 (617) 983-4104 land (857) 203-1202 cell aortiz3@partners.org Camara Phyllis Jones, MD, MPH, PhD 36 36