Transcript ROR talk-2003 - University of Chicago

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
Chicago, 11/3/10
Race and Health
↓ Poverty
Stress/violence
Poor diet
Poor learning environment
Educational opportunity
Employment opportunity
Medication/other health expenditures
Cigarettes and alcohol
Poor Adult Health
Racism
↓ Unequal Medical Care
↑ Stress
FIGURE 1-- Probability of having an allostatic load of 4 or higher, as predicted by race (a) and race and
gender (b)
Geronimus, A. T. et al. Am J Public Health 2006;96:826-833
Copyright ©2006 American Public Health Association
FIGURE 1-- Probability of having an allostatic load of 4 or higher, as predicted by race (a) and race and
gender (b)
Geronimus, A. T. et al. Am J Public Health 2006;96:826-833
Copyright ©2006 American Public Health Association
Sickle Cell Anemia: A
Special Case Study of
Race and Health
NIH Research Funding and Private, Nonprofit
Association Support of SCD and Cystic Fibrosis
Variable
US prevalence
SCD
Cystic Fibrosis
80,000
30,000
90
128
1125
4267
Federal support
NIH fiscal-year 2004 funding, in millions of dollars
NIH funding per person with disease, $
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
152,213,000
498,577
5074
6
Total NIH and private support, in millions, $
90.4
280.2
Total support per person affected with disease, $
1130
9340
Number of Federal Government Requests for
Applications Funded for Sickle Cell Disease
and Cystic Fibrosis: 1975-2004
450
No. of funded RFA's
400
350
300
SCD research grants
250
CF research grants
200
150
100
50
0
1975
1980
1985
1990
1995
2000
2004
Race and Health
↓ Income
Poor Health
Racism
↓ Access
↑ Stress
Adult Health Disparity by
Income
Adult Health Disparities:
Life Course Trajectory
Adult Health Disparities:
How Early Experiences Get Embedded
in Biology and Influence Health
Environment



→
Social
Physical
Nutrition
GeneEnvironment
Interaction
→
Neurochemical
Adaptations &
Disruptions
Poor education & economic productivity
→ Brain → School failure
→ Organs
↕
Poor health behavior
↕
Poor physical & mental health
Early experiences are biologically
embedded in development of brain
and other organs
Early Experiences
Positive
 Nurturing and
stimulation
Adverse
 Stress/harmful
interactions
 Neurotoxic
exposure
 Inadequate
nutrition
Child and Adult Health
Brain Development
Brain Development
Parental Language Addressed to Child by
SES
Words Per Hour
2500
2000
1500
1000
500
0
Public
Working Class Professional
Assistance
Hart & Risley, (1995)
Early experiences are biologically
embedded in development of brain
and other organs
Early Experiences
Positive
 Nurturing and
stimulation
Adverse
 Stress/harmful
interactions
 Neurotoxic
exposure
 Inadequate
nutrition
Child and Adult Health
Positive and Tolerable Stress
Toxic Stress
Direct Effects of Stress
Gianaros, P.J., et al. Neuroimage, 2007.
Effect Size Between Low and Middle Income
Children on Neurocognitive Functioning (N=60)
Farah, M.J., et al. Brain Res, 2006
Stress: Adverse Childhood Events
and Adult CV Disease
3.5
Odds Ratio
3
0
1
2
3
4
5,6
7,8
2.5
2
1.5
1
0.5
0
ACEs
Dong et al, 2004
Adverse Childhood Events and
Adult Depression
5
Odds Ratio
4.5
4
3.5
0
1
2
3
4
5+
3
2.5
2
1.5
1
0.5
0
ACEs
Chapman et al, 2004
Stress and Genetic Vulnerability for
Depression
Caspi, A., et al. Science. 301:386-389
2003
Stress and Genetic Vulnerability for
Antisocial Behavior
Caspi, A., et al. Science. 297:851-854
2002
What to do: Examples
1.
2.
Society: comprehensive
Health care

Race






Regulations tied to new construction
Target quality improvement of select hospitals
Cultural competency
Increase racial diversity among physicians, nurses, etc.
Interpreters (technology)
Use of non-health care settings



Barbers
Churches
salons
Use Health Care to Disrupt Link
Between Poverty and Poor Health



Reach Out and Read
Medical-Legal Partnership
Project HEALTH
Reach Out and Read
Advice and books given at pediatric well child visits until age 5
Frequency of Reading Aloud
Number of days and nights
per week
(High et. al., 2000)
6
4
Intervention
Control
2
0
Days/week
Nights/week
Children’s Expressive and Receptive
Language Competencies
94
Vocabulary scores
92
90
88
Intervention
Comparison
86
84
82
80
78
76
74
Receptive language
Expressive language
Mendolsohn, et al., 1995
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
Social Determinants of Healthy
Development: Mechanisms
1.
Direct:

Deprivation





Exposures



2.
Food
Money
Health
medications
caloric food
Lead
Asthma triggers
Indirect: Stress
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.
 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.
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.
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.
Medical-Legal Partnership for
Disparity Reduction
Biological
Doctors
Childhood Illness
Social
Lawyers
The MLP Network – March 2009
81 partnerships in over 180
hospital and health centers
Perry Preschool Project:
100
80
60
Intervention
Control
40
20
0
H.S. graduate (or
equivalent)
Average or better
literacy at age 19
90 or higher IQ at
age 5
Ever in program for
educable mental
impairment
Perry Preschool Project:
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Intervention
Control
All arrests
Arrests for
violence
Drug dealing