UNNATURAL CAUSES is inequality making us sick? HEALTH EQUITY research topics and resources to learn more
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Policy & Change

Background: To paraphrase the Institute of Medicine’s (IOM) 2002 report on public health: what can we as a society do to fulfill our ongoing interest in assuring the conditions for people to be healthy?

Decisions that governments and corporations make every day benefit some and burden others. Unfortunately, they often reinforce class, racial and gender inequities that contribute to unequal patterns of illness and premature death. Building a social movement that can advocate effectively for more equitable social and economic policies is critical to changing our economic, physical and social environments so that they promote rather than threaten our health.

In other words, tackling health inequities is unavoidably a matter of politics; of engaging in struggles over how we want our government to allocate resources, regulate corporate power, and implement the principles of democracy.

Tony Iton, MD, director of the Alameda County Public Health Department in California, points out that social policies that produce and reproduce class and racial inequality have, over time, “taken many forms, including racially restrictive covenants on property, economic redlining in banking practices, school segregation, [unfair] housing and urban renewal policies, disinvestment in public transportation, discriminatory zoning practices, law enforcement racial profiling, [discriminatory] incarceration policies, and other deliberate governmental policies and practices.”

But we’ve also made many changes during the last century that have improved health equity by improving peoples’ lives: the eight-hour work day, universal public high school, the right to collective bargaining, social security, civil rights, environmental standards... There’s no reason why we can’t do so again.

Opportunities for change abound. Iton and others suggest a wide range of tangible policy options, including quality universal preschool, improved public school funding, living wage laws, affordable housing, land use and zoning reform, improved public transit, fair immigration policies, criminal justice reform, and, of course, full employment, fair trade and even progressive tax policy.

Some of these policy changes will be driven locally, some on the state level, others on the federal level. In general, they fall within three categories:

• Tackling inequality and improving living standards. These policies aim to close the gap between the rich and the rest of us, and between white people and people of color, such as living wage jobs, more equitable tax policy, affirmative action and family supports.

• Protecting those at the bottom of the pyramid. These policies protect under-resourced households and communities from health threats posed by the chaos and uncertainty of free markets. They promote not only additional programs and services, but more equitable allocation of public resources through needed social investments (such as quality schools, affordable housing, and public transit) so that the means for achievement are more available to those with fewer individual resources.

• Reforming decision-making. These policies aim to open and democratize decision-making processes that too often are dominated by concentrated economic and political power. Successful policy change depends more than anything else on those most affected by injustice working together to set priorities, generate solutions, make their voices heard, and to organize effectively to hold government accountable.

How does one advance “health in all policies”? How can local, state and national public policy action in support of health equity be brought about? What is the legislative agenda? What are the policy and program levers? What does this imply for organizations’ own strategies and structures? How do engaged groups communicate with each other and so avoid having to climb the same learning curve over and over again? How can a comprehensive and sustained health equity focus and movement best be built? Can these initiatives be brought together under one health equity national strategy, umbrella or coalition? Should they?

The articles and media in this “policy and change” section address some of the policies and strategies tackling patterns of advantage and deprivation, of hope and despair, and of health and illness.

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Image Thumbnail Community Health Centers Leveraging the Social Determinants of Health (pdf) E-mail to a friend
REPORT by Institute for Alternative Futures, 2011

A report providing leaders in community health centers, public health and policy an understanding of how health care providers can move beyond health care services alone to improve the health of the population by leveraging social determinants of health.

Image Thumbnail Course: Ethics, Global Health and the Fundamental Causes of Disease E-mail to a friend
SYLLABUS by Daniel Goldberg, J.D.. Ph.D, East Carolina University

Daniel Goldberg teaches a course at the Brody School of Medicine that aims to answer such questions as: What causes disease across the globe? What causes people in some parts of the world to have much higher rates of certain diseases than others? And what are the implications for global health policy and ethics?

Image Thumbnail Crossing Sectors: Experiences In Intersectoral Action, Public Policy And Health E-mail to a friend
Public Health Agency of Canada

This paper represents the first phase of a Canadian initiative on intersectoral action for health and provides an overview of approaches to intersectoral action at the global, sub-regional, national, sub-national, and community levels. It is intended to contribute to the World Health Organisation’s Commission on Social Determinants of Health (SDH)

Image Thumbnail Debating Policy to Improve Population Health: A Case Study and Simulation of the Marshall Islands (pdf) E-mail to a friend
LESSON PLANS by Jamie D. Brooks and Larry Adelman for California Newsreel, 2009

How should limited public resources be deployed to tackle inequities in health? This lesson plan uses a real health crisis in the Marshall Islands and a parliamentary simulation to help students assess the strengths and weaknesses of different health promotion policies and examine the roles of government, business, medical and public health systems, individuals, and community-based groups in governance. By the end of this activity, students will be able to argue and defend different approaches to tackling the root causes of health inequities and will better understand how the making of social policy is often influenced by political and economic factors that may have little to do with the merits of the proposals themselves.

Image Thumbnail Designing and Building Healthy Places E-mail to a friend
WEB SITE by the Centers for Disease Control

As the leading public health agency in the United States, the Centers for Disease Control and Prevention (CDC) scientifically considers all factors that affect the health of the nation. As we embark into the 21st century, the interaction between people and their environments, natural as well as human-made, continues to emerge as a major issue concerning public health.

CDC recognizes several significant health issues that are related to land use, including: Accessibility; Children's Health & the Built Environment; Elders' Health & the Built Environment; Gentrification; Health Impact Assessment; Injury, Mental Health; Physical Activity; Respiratory Health & Air Pollution; Social Capital; Water Quality.

Image Thumbnail Economic Mobility Project E-mail to a friend

Pew's Economic Mobility Project (EMP) focuses public attention on economic mobility - the ability to move up or down the income ladder within a lifetime, or from one generation to the next. By forging a broad and nonpartisan agreement on the facts, figures and trends in mobility, the project is generating an active policy debate about how best to improve economic opportunity in the United States and to ensure that the American Dream is kept alive for generations that follow.

Image Thumbnail Economic Policy Institute E-mail to a friend

EPI is a nonprofit, nonpartisan think tank that seeks to broaden the public debate about strategies to achieve a prosperous and fair economy. It conducts original research on economic issues, makes policy recommendations based on its findings, and disseminates its work to the appropriate audiences. EPI's research focuses on four main economic areas: Living standards/labor markets; Government and the economy; Globalization and trade; and Education.

Image Thumbnail European Portal for Action on Health Equity E-mail to a friend
EU Consortium for Action on the Socio-economic Determinants of Health

This Portal is a tool to promote health equity amongst different socio-economic groups in the European Union. Here, you can find information on policies and interventions to promote health equity within and between the countries of Europe, via the socio-economic determinants of health.

The information presented is the result of the collaboration of a wide range of health and social actors in the EU, that have come together in the context of a pan-European initiative that aims to stimulate action for greater health equity.

Image Thumbnail Evaluating the evidence base: Policies and interventions to address socioeconomic status gradients in health E-mail to a friend
William H. Dow, Robert F. Schoeni, Nancy E. Adler, and Judith Stewart

This piece discusses the current evidence base for policies that could address socioeconomic status (SES) health gradients in the United States.  Given the difficulty in developing randomized evidence for many types of interventions related to social determinants of health, the authors argue for conducting policy analysis by combining information on best available theory and evidence regarding probable health benefits and costs of an intervention, providing a framework that also incorporates the probable costs of inaction. The second half of the piece adopts a ladder metaphor to classify policies and interventions that could reduce SES gradients in population health.

Image Thumbnail Fair Growth 2020: A Tale of Four Futures E-mail to a friend
ARTICLE by Lance Freeman, House Facts & Findings, 2000

What will America look like in 2020, given the steady decline of our central cities and our unchecked suburban expansion? In this 2000 article, author Lance Freeman looks at four possible scenarios for the future, and their implications for urban sprawl and social equity.

Image Thumbnail Falling Behind: Life Expectancy in US Counties from 2000 to 2007 in an International Context E-mail to a friend
SCHOLARLY ARTICLE , Population Health Metrics 2011 9:16

This study uses mortality data from 2000 to 2007 to assess disparities in life expectancy across US counties. Life expectancy rates for counties are compared to the life expectancies across nations in 2000 and 2007.

Image Thumbnail FRONTLINE: Sick Around the World E-mail to a friend

In Sick Around the World, FRONTLINE teams up with veteran Washington Post foreign correspondent T.R. Reid to find out how five other capitalist democracies -- the United Kingdom, Japan, Germany, Taiwan and Switzerland -- deliver health care, and what the United States might learn from their successes and their failures. You can watch the entire program online, and the site contains more information on the pros and cons of the different systems, interviews, transcripts, a teaching guide, and links to other resources and readings.

Image Thumbnail Getting serious about the social determinants of health: new directions for public health workers E-mail to a friend
SCHOLARLY ARTICLE, Dennis Raphael, Promotion & Education, 2008

Though evidence indicated that compared to other developed nations Canada's health profile is mediocre and its public policy environment increasing unsupportive of health, the public health sector continues to focus on lifestyle issues. Much of this has to do with Canada being identified as being driven by a liberal political economy. Raphael explores reasons for Canada's neglect of structural and public policy issues and outlines ways by which public health workers in Canada and elsewhere can help to shift policymakers and the general public's understandings of the determinants of health.

Image Thumbnail Global Learning Device on Social Determinants of Health and Public Policy Formulation E-mail to a friend
ONLINE COURSE developed by the WHO / Pan-American Health Organization

Primarily intended for WHO/PAHO staff and health ministry officials, this course (available in English, Spanish, and Portuguese) aims to raise awareness of and provide insight into the Social Determinants of Health (SDH) in order to reduce health inequities, encourage changes in the political agenda and contribute to a better administration of social justice and enforcement of human rights. The authors wish to inspire a critical vision of SDH by facilitating both the dissemination of the approach and the understanding of the intervention criteria, drawing on validated scientific papers on SDH, public policies based on the SDH approach, and documents produced by the Commission on the Social Determinants of Health.

Image Thumbnail Guide to Health Impact Assessment: A Policy Tool for New Zealand E-mail to a friend
REPORT from the Public Health Advisory Committee, 2005

Health impact assessment (HIA) is a formal approach used to predict the potential health effects of a policy, with particular attention paid to impacts on health inequalities. It is applied during the policy development process in order to facilitate better policy-making that is based on evidence, focused on outcomes and includes input from a range of sectors. This Guide is for use – largely but not exclusively – by policy-makers in sectors other than health. Those likely to be affected by policy may also use it. We recommend that people who are using this Guide, or HIA for the first time, should attend an HIA training course and/or work alongside an experienced HIA practitioner.

Image Thumbnail Health Impact Assessment E-mail to a friend

The Health Impact Assessment (HIA) project is a joint endeavor of the Washington, D.C. based Partnership for Prevention and researchers at the UCLA School of Public Health. The HIA project aims to assess the feasibility of HIA and to develop prototype HIAs that demonstrate methodologies, eventually enabling HIA to contribute to more informed decision-making about public policies impacting health in the U.S.

Image Thumbnail Health in All Policies: Adelaide 2010 International Meeting E-mail to a friend
Public Health Bulletin South Australia

Our health is mostly determined by factors outside the operational sphere of the health sector, so the health sector must move beyond managing the health care system and seriously address those determinants of health in other spheres— education, housing, transport, employment, income, welfare etc.—where they impact on health. This is the Health in All Policies (HiAP) approach.
HiAP was the focus of much discussion in Adelaide, South Australia (SA), in April this year when the South Australian Government and the World Health Organization hosted the Adelaide 2010 Health in All Policies International Meeting. This issue of the Public Health Bulletin presents papers from a number of the participants at the meeting and reflects on the meeting’s themes and outcomes.

Image Thumbnail Health in Times of Global Economic Crisis E-mail to a friend
CONFERENCE VIDEOS, Oslo, Norway, 1-2 April 2009

Held by the World Health Organization in the European Region, this conference aimed to
- review the situation in the WHO European Region by identifying the main risks for health and health systems and the main opportunities for action;
- discuss policy options for responding to the negative impacts of the economic crisis on health systems and health outcomes in low-, middle- and high-income Member States in the Region;
- identify health- and health systems-related measures that could be used in the short and medium terms to counter the economic downturn and, in the longer term, to help address (some) structural issues confronting our societies.

Image Thumbnail Health Inequities in the Bay Area E-mail to a friend
REPORT from the Bay Area Regional Health Inequities Initiative (BARHII)

This report is an attempt to show how the various forces discussed in UNNATURAL CAUSES influence health in the nine-county California Bay Area, and to suggest the kinds of policy initiatives and activities that will be crucial for both reducing the disparities among populations and improving our health overall.

Image Thumbnail Health Leadership: Action Steps DVD E-mail to a friend
PRESENTATION available from Blue Cross and Blue Shield of Minnesota Foundation

The 2007 Blue Cross Foundation Leadership Award Program and Luncheon featured a keynote by Dr. Anthony Iton, director of the Alameda County (California) public health department, on how race, class, wealth, education, geography and employment affect health status.

Also includes presentations from Atum Azzahir, co-founder, president and executive director of the Powderhorn Phillips Cultural Wellness Center in Minneapolis, and remarks by Marsha Shotley, foundation president; the new Minnesota Health Commissioner, Dr. Sanne Magnan; and Blue Cross and Blue Shield of Minnesota President Colleen Reitan.

Image Thumbnail Health Policy Institute of the Joint Center for Political and Economic Studies E-mail to a friend

With the mission to ignite a Fair Health movement that gives people of color the inalienable right to equal opportunity for healthy lives, this pioneering program of the Joint Center for Political and Economic Studies undertakes research, publications, activities, and projects designed to accelerate progress beyond listing and analyzing a litany of health disparities. Rather, they are directed toward collective strategies that will produce real change—and real opportunities for health.

See also: HPI Place Matters

Image Thumbnail Healthy Development Measuring Tool E-mail to a friend

Developed by the San Francisco Department of Public Health, this tool is a comprehensive evaluation metric to consider health needs in urban development plans and projects. The Tool encompasses a community-based vision for planning and uses public health to explicitly connect physical and environmental planning to a wider set of social interests.

Image Thumbnail Healthy Homes and Early Learning: Addressing Social Determinants of Health in Seattle and King County (pdf) E-mail to a friend
PRESENTATION SLIDES from Jim Krieger, Public Health - Seattle & King County / University of Washington

The slides from a presentation by Jim Krieger, one of the experts featured in Place Matters, Episode 3 of UNNATURAL CAUSES. Krieger discusses how the High Point project sought to address various social determinants of health by building healthier homes and neighborhoods. The second half of the presentation discusses early childhood development and the need to provide early education.

Image Thumbnail HIA Gateway E-mail to a friend
WEBSITE by the Association of Public Health Observatories

A source of information on Health Impact Assessments.

Image Thumbnail High Point, Seattle E-mail to a friend

Information on the High Point Community in Seattle, featured in Place Matters, Episode 5 of UNNATURAL CAUSES

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