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This is a final research paper, it should be 7 pages long with a citations page, 12 pt font, double spaced. Please integrate all the provided papers whether it’s a direct quote or paraphrase (Please no more than one or two direct quotes, paraphrasing is okay)The paper is about how African American individuals suffer from class and racial inequality in the United States. It should include the following aspects:1. Power: How African American individuals lack power in the United States in comparison to the upper white class who control the corporates, economy, and the government in a way to help their business growth (An example would be how some large corporates avoid paying federal taxes)2. Wealth: The unequal distribution of wealth when comparing the upper white class with lower class African Americans. 3. Inequality: How this racial and social stratification affects black individuals in the health and education systems.
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BETTER HEALTH THROUGH EQUITY
Case Studies in Reframing Public Health Work
MARCH 2015
Healthy People 2020, the nation’s health objectives for the current decade, defines health
equity as the “attainment of the highest level of health for all people. Achieving health
equity requires valuing everyone equally with focused and ongoing societal efforts to address
avoidable inequalities, historical and contemporary injustices, and the elimination of health
and health care disparities.” Such goals aren’t unfamiliar to public health practitioners—the
field has a long and storied tradition of serving the most vulnerable and bringing life-saving
care to communities that would have otherwise gone without. And while the nation has come
a long way in identifying, acknowledging and addressing disparities1 in health and health
care access, it is clear that eliminating disparities cannot be accomplished without seriously
addressing the underlying social determinants of health2, many of which are shaped and
perpetuated by bias, injustice and inequality. Across the country, state and local public health
agencies are taking up this call to action in earnest, integrating a health equity framework
at an organizational level and using equity values to drive community health work. The
following are five case studies exploring the experience of public health departments as they
make a concentrated shift toward achieving health equity.
1. What’s the difference between health disparities and health inequities? According to Paula Braveman in an article published in Public Health Reports, “Health equity
means social justice in health (i.e., no one is denied the possibility to be healthy for belonging to a group that has historically been economically/socially disadvantaged). Health disparities are the metrics we use to measure progress toward achieving health equity. A reduction in health disparities (in absolute and relative
terms) is evidence that we are moving toward greater health equity.” (Source: www.publichealthreports.org/issueopen.cfm?articleID=3074)
2. The social determinants of health are the conditions in which people are born, grow, live, work, and age. These circumstances are shaped by the distribution of
money, power, and resources at the global, national, and local levels. Examples of resources include employment, housing, education, health care, public safety, and
food access. (Source: www.who.int/social_determinants/sdh_definition/en/index.html)
THE VALUE OF INVESTING IN HEALTH EQUITY
The efforts chronicled in this series of case studies are not only designed to improve health outcomes, they are also
poised to save the country billions in health care spending. According to one study published in 2009, more than 30
percent of direct medical costs faced by African Americans, Hispanics and Asian Americans can be tied to health inequities. Because of inequitable access to care, these populations are sicker when they do find a source of care and incur
higher medical costs. That 30 percent translates to more than $230 billion over a four-year period. If health disparities
among minorities had not existed between 2003 and 2006, direct medical care spending would have been reduced by
a whopping $229.4 billion.
Source: https://www.ndhealth.gov/heo/publications/The%20Economic%20Burden%20of%20Health%20Inequalities%20in%20the%20United%20States.pdf
ACKNOWLEDGEMENTS
With support through CDC Cooperative
Agreement#5U38HM000459-05, the American
Public Health Association (APHA) contracted
with Kim Krisberg to conduct a series of 5 case
studies of state, local and tribal health agency
efforts to create health equity. We would like to
acknowledge the staff at the health agencies
that provided the information essential to this
report. We are grateful for their participation
and willingness to share their stories. The contents of this report are solely the responsibility
of the authors and do not represent any official
views or endorsement by CDC. CDC funds
were not used to fund the work described
in the report. This report is not designed to
support or defeat enactment of any legislation, pending before Congress or any state or
local legislature. Federal, state, tribal and local
jurisdictions apply differing rules regarding
engagement with legislative bodies and other
policy-related activities. Jurisdictions considering legal or other policy initiatives should seek
the assistance of state or local legal counsel.
Additional guidance for CDC funded recipients
may be found at www.cdc.gov/od/pgo/funding/grants/foamain.shtm.
TABLE OF CONTENTS
ACHIEVING HEALTH EQUITY: LESSONS LEARNED……………………………. Page IV
SHIFTING THE DISCUSSION, APPLYING A NEW LENS
(MULTNOMAH COUNTY, OREGON)…………………………………………………Page 1
EQUITY IN ACTION: Multnomah County…………………………………………..Page 5
HARNESSING THE POWER OF CROSS-SECTOR COLLABORATION
(MENOMINEE INDIAN TRIBE, WISCONSIN)………………………………………Page 9
EQUITY IN ACTION: Menominee Indian Tribe…………………………………..Page 13
MAKING HEALTH EQUITY A COMMUNITY AFFAIR (VIRGINIA)…….Page 16
EQUITY IN ACTION: Virginia Department of Health…………………………..Page 21
INTEGRATE AND OPERATIONALIZE: RECOGNIZING EQUITY
EVERY DAY (COLORADO) ……………………………………………………………Page 24
EQUITY IN ACTION: Colorado Department of Public Health
and Environment ……………………………………………………………………….Page 30
TRANSFORMING THE WORK OF COMMUNITY HEALTH (TEXAS) …..Page 32
EQUITY IN ACTION: Texas Department of State Health Services …………Page 36
About APHA
APHA champions the health of all people and all communities. We strengthen the public health profession. We speak out for public health issues and policies backed by science. We are the only organization that influences federal policy, has a 140-plus year perspective and brings together members from all
fields of public health.
BETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK | Page III
ACHIEVING HEALTH EQUITY: LESSONS LEARNED
A number of lessons learned identified as essential to successfully implementing a health equity framework were gathered during APHA’s
Better Health Through Equity project. The following are the most salient.
WITHIN YOUR ORGANIZATION: Achieving health
equity first begins with building knowledge,
understanding and capacity within your organization
or agency.
listen and learn about the lives of the people you serve. This may
throw a wrench into all of your preconceived plans and force you to
go back to the drawing board. But that’s okay—achieving health
equity may mean taking as many steps backward as we do forward.
1
ACKNOWLEGE THAT EQUITY IS MORE THAN ANY ONE,
SINGLE INTERVENTION: Health equity truly is a state of mind. It’s
a framework within which public health practitioners from all disciplines can work. Making a purposeful shift toward achieving health
equity forces us to consistently view health status within the larger
context of society and history and will ultimately bring public health
farther upstream than it’s ever been before.
2
6
BUILD TRUST: Trust is the foundation of all health equity work. In
fact, it may be the only starting point that will lead to sustainable
progress. Building trust requires having an open mind, being flexible,
listening to people’s stories, respecting and integrating traditional
ways, engaging community leaders and empowering people with the
means to seek change for themselves and their communities.
WITHIN YOUR PRACTICE: Achieving health equity
means allowing community values and priorities
to shape and inform interventions. Science-based
evidence is always important to measuring needs and
progress, but gaining community buy-in is critical to
sustainability.
HAVE AN OPEN AND HONEST DIALOGUE: Start a conversation in your health agency—and ideally across fellow public agencies—about racism, bias and inequality and how they contribute to
disparate health outcomes. Use an icebreaker such as the documentary “Unnatural Causes: Is Inequality Making Us Sick?” and make
sure you tailor the event to fit your audience and create a respectful
environment. Talking about inequity is not always a comfortable
exercise—in fact, it can put some people on the defensive—but it is
vital to gaining buy-in and shifting the focus from traditional disease
prevention to tackling the social determinants of health.
7
PARTNER, PARTNER, PARTNER: Moving toward health equity
means zeroing in on the social determinants of health, which also
means that the public health sector can’t achieve health equity on its
own. Transportation, housing, health care, employment, environmental quality, working conditions, education, child care, law enforcement—all of these sectors and many more have a role in creating
the conditions that enable all people and communities to attain and
sustain good health. Public health workers are uniquely skilled at
convening players across sectors, and this skill will be invaluable in
achieving health equity.
8
3
WITHIN YOUR COMMUNITY: Achieving health equity
requires an empathetic approach that acknowledges a
community’s history, respects its traditions, listens to
its stories and actively engages its members as leaders
in any health equity intervention.
4
COMMUNITY OWNERSHIP IS PARAMOUNT: Community
participation is intrinsic to health equity work. This is probably a nobrainer for most practitioners, as community engagement is a fundamental component of public health work. However, ensuring that the
community is involved in every aspect of health equity work—from
data gathering to implementation to evaluation—is key.
9
10
BE MINDFUL OF HISTORY: Government and public policy played
enormous roles in perpetuating the very biases, injustices and
inequalities that created the health disparities and inequities we seek
to address today. Be mindful that many communities are still very
much experiencing and facing the effects of historical trauma. As a
public official, coming into such a community with a predetermined
plan and top-down approach only perpetuates that trauma.
5
FOLLOW THE DATA, BUT…: Data are essential to the work of
public health. We need data to pinpoint problems, deploy resources,
track progress, evaluate effectiveness and justify continued support.
But in the work toward health equity, data can’t be the only driver.
For example, worrisome data on prenatal care may lead you to initiate contact with a community. However, residents might have more
pressing concerns, such as few employment opportunities, difficulties
affording enough food and unsafe housing conditions. These are the
issues you have to tackle first if you want to positively impact infant
health in the long term.
LET GO OF YOUR AGENDA: Avoid going into a community that
has a long history of experiencing health and social inequities with a
predetermined agenda. Instead, go in with an open mind and simply
PAY ATTENTION TO PROCESS: The process of developing strategies to create health equity is as important as—and sometimes even
more important than—the actual initiatives. If you can create a process for developing interventions that is truly community-driven and
founded on trust, you have a better chance of sustaining momentum
on the long journey toward health equity.
KNOW WHEN TO STEP ASIDE: Despite your skills, experience,
education and competencies as a public health practitioner, you
might not be the best person to implement a strategy to create
health equity on the ground. Many successful health equity efforts
recruit and train workers from the community who have the same
lived experience as the residents you are hoping to reach. Keeping
this in mind will help build trust, community ownership and sustainability.
Page IV | BETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK
SHIFTING THE DISCUSSION, APPLYING A NEW LENS
Multnomah County Health Department, Oregon
“When we talked about disparities it was simply reflecting the data. We weren’t
telling the whole story, we weren’t talking about the structural pieces. …Until we
started looking through a lens of race, power and poverty, we really weren’t moving
upstream. Now we’re focusing on the conditions that lead to the outcomes we see.”
— BEN DUNCAN
FORMER PROGRAM MANAGER OF THE MULTNOMAH COUNTY HEALTH DEPARTMENT HEALTH EQUITY INITIATIVE
AND CURRENT DIRECTOR OF THE COUNTYWIDE OFFICE OF DIVERSITY AND EQUITY
I
n 2008 and in the wake of a report on racial and ethnic health disparities in
Multnomah County, Ore., local officials launched the Health Equity Initiative,
a countywide effort to raise community awareness of the root causes of
health inequities and put forth real solutions. The effort—led by the Multnomah
County Health Department with strong support and participation from county
leadership—began with the seemingly simple but critical step of encouraging
honest, reflective and often challenging conversations about the connections
between racism, injustice and health disparities. Those community conversations
eventually led to the creation of the Equity and Empowerment Lens: Racial
Justice Focus, a health equity tool that is slowly transforming the everyday work
of public health in Multnomah County.
BETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK | Page 1
VISUALIZING INEQUITY
Tackling health equity in a meaningful way means
confronting the social determinants at the root of
poor health and engaging the officials and community stakeholders who are well positioned to
drive change. But first, organizers in Multnomah
County needed a way to jumpstart cross-sector
collaborations, community conversations, and
the slow, sustained drive toward systemic change.
Taking on the social determinants of health would
mean talking openly about oppression, racism
and personal bias—topics that can make people
uncomfortable or even defensive—and organizers
needed an inclusive conversation starter.
Health Inequity
by the Numbers
Out of 33 counties in Oregon,
Multnomah ranks 15 in health outcomes.
Some examples of health inequities in Oregon
and Multnomah County include:
In 2011, 26 percent of
Multnomah County children
younger than 18 were living
in poverty, as compared
with a statewide rate of
23 percent and a national
rate of 14 percent.
26%
Multnomah County
23%
14%
USA
Oregon
An estimated 108,000 of Oregon’s children ages 0–6 are at risk of not being
ready for kindergarten as a result of poverty, adverse childhood experiences,
and other risk factors that are highly associated with or most often predicted
by race and ethnicity.
108,000
In 2010–2011, only 63 percent of
Multnomah County ninth-graders
graduated from high school within
four years, as compared with
68 percent statewide.
Multnomah
County
Oregon
63%
68%
Source: www.countyhealthrankings.org
3 http://www.unnaturalcauses.org/
To do that, staff from the Health Equity Initiative turned to film, specifically the four-hour PBS
documentary Unnatural Causes: Is Inequality
Making Us Sick?  3 In 2008, they began hosting local screenings of the documentary, using the film
to develop a shared understanding of the social
determinants that contribute to poor and disparate
health outcomes. In all, the initiative hosted 57
screenings open to both county officials and community members, eventually reaching more than
500 people. The screenings had three main goals:
raising community awareness, building the capacity to address inequity, and advancing relevant
policy solutions. During the screening events,
trained volunteers from county agencies and the
community facilitated open and honest discussions on the topic.
According to Ben Duncan, former program manager of the Multnomah County Health Department
Health Equity Initiative and current director of the
countywide Office of Diversity and Equity, Unnatural Causes “gave us new ways to talk about
equity…the concepts and values weren’t new, but
all of a sudden we had a language to talk about it.”
“Unnatural Causes created a platform to shift the
conversation from disparities to inequities—it was
Page 2 | BETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK
a very intentional shift,” Duncan says. “We used the screenings as catalysts to
start having conversations about what people were experiencing, but also to
start thinking about the types of needed policies to address [health inequities]
and the root causes that actually lead to lifelong negative health impacts. We
went from a typical public health approach…and we created a vision for building partnerships, addressing issues like education, and getting engaged in activities that were traditionally out of the purview of public health.”
“FINDING OUR TRUE NORTH”: APPLYING A HEALTH
EQUITY LENS
In the fall of 2012, the Multnomah County Office of Diversity and Equity
launched the Equity and Empowerment Lens (E&E Lens, link on page 8) to address inequities in services, policies, practices, and procedures across the county. Based on the health department’s pilot equity framework, the E&E Lens was
developed to help county agencies integrate key questions rooted in justice and
inclusion into their decision making. The new movement was a priority—the
county’s Office of Diversity and Equity had even created a new position dedicated to institutionalizing the lens countywide. In an introductory letter outlining
the new equity lens, then health department Director Lillian Shirley wrote:
“This work takes stepping into an unknown space, a space that makes us vulnerable.
Answering the Lens questions and institutionalizing clear, systemically-based recommendations based on equity and empowerment requires us to be brave, courageous,
and persistent in our efforts. Focusing specifically on racial justice is essential for the
health of all of our communities, because racial and ethnic inequities are the most
prevalent and pronounced according to our data.”
The E&E Lens also benefits organizations by driving quality improvements,
providing a more accurate assessment of client needs, and offering an enhanced
ability to explain how the work and role of an agency contribute to the community. The E&E Lens leads agencies through nine questions that “seek to
uncover patterns of inequities, separate symptoms from [the] actual causes of
such inequities, and maintain the visibility of impacts on communities of color,
immigrants, and refugees.”
For example, questions urge agency officials and staff to consider which particular group will be affected by a policy or decision or to think about how certain
processes contribute to the exclusion of populations that disproportionately
experience inequities. At the county health department, according to Duncan,
an administrative policy dictates that all programs use the E&E Lens. “You’ll see
the language of equity within almost every program within the agency,” he says.
T
he lens can help
workers realize that
regardless of their
competencies and professional
education, they might not be
best positioned to effectively
deliver public health services
within every cultural context.
BETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK | Page 3
“There is no doubt that if you asked what a core value of the health department
was, all staff would talk about equity.”
H OUSIN
CRIMIN
A
JUS T IC L
E
G
TRANSP ORATIO N
PU
HE BL IC
AL
TH
N
ow, because of the
deeper understanding of social deter-
minants brought about by the
equity initiative, public health
is regularly at the table with
officials from transportation,
criminal justice, education, and
housing. All agencies better …
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