Focusing on Children's Health: Community Approaches to Addressing Health Disparities: Workshop Summary (2009)

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2 Disparities in Children’s Health: Major Challenges and Opportunities D r. David Satcher, in his keynote address, described how investments in children’s health can affect their later lives. In discussing the Healthy People 2010 initiative, he noted the four major determi- nants of health: Access to care, environment, genetics, and behavior. Despite annual progress reports, it is still difficult to definitively say how far we have come toward the goal of eliminating disparities in health, said David Satcher, 16th U.S. surgeon general and director of the Satcher Health Leadership Institute at Morehouse School of Medicine in Atlanta, Georgia. He cited the IOM report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (IOM, 2003) as a landmark in terms of increasing awareness about disparities in health and health care in the United States, and he noted that many efforts to address disparities have been undertaken by government, the private sector, and foundations across the country. Within the federal government, the Agency for Healthcare Research and Quality (AHRQ) issues a biennial report, the Health Services Research Administration (HRSA) has programs dealing with access to and quality of care, and the Centers for Disease Control and Prevention (CDC) supports the Racial and Ethnic Approaches to Community Health (REACH) program. Many good community programs have also been established. Major health plans such as Aetna, Kaiser, and United have instituted programs dealing with disparities in health. Although these programs focus primarily on the quality of health care, insurers are also beginning to invest in com- munities to foster health. So while it may not yet be possible to measure the effects, the ongoing efforts are encouraging. The bad news, Satcher said, is  

 FOCUSING ON CHILDREN’S HEALTH that the programs have not been adequately supported. This is especially true for government initiatives such as those at the National Institutes of Health (NIH) and the CDC. As long as those programs are not adequately supported, he said, we cannot be fully confident that we are collecting all of the quality data that we need. The World Health Organization (WHO) believes that health inequities in the world can be eliminated in the next generation. The country in the best position to lead, Satcher said, is the United States. We have the resources and the constitutional backing, and we can lead the world by starting with our own country, but we need sup- port and commitment. Two of the overarching goals of Healthy People 2010 are to increase years and quality of life and to eliminate racial and ethnic health disparities, although Satcher noted that it will take a few more decades beyond 2010 to fully realize these goals. Satcher concurred with Maupin that children’s health is the most important investment we can make. Infant mortality is one of the most dramatic examples of disparities in health. African Ameri- can babies are nearly two and half times as likely to die in their first year of life, and American Indian babies almost twice as likely to die, as the majority population. Interestingly, the United States trails other countries such as Cuba and Costa Rica in this regard, who although they have fewer resources than the United States, have lower overall infant mortality rates. Because we have failed to seriously make a commitment to eliminate dis- parities in health, we have pulled our whole health system down, and will continue to do so, Satcher said. Worldwide, mortality of children under 5 years of age is about 80 per 1,000 live births. In the United States the rate is about 8 per 1,000 live births. Sweden has the lowest rate on record of about 3 babies per thousand who die before their 5th birthday. Sub-Saharan Africa, however, has an under-5 mortality rate of 172 per 1,000. The world cannot be stable and exist in peace, Satcher said, as long as such health inequities exist. A study done at the Graham Center in Washington, DC, modeled what could have happened in the United States if disparities in health had been eliminated in the last century, assessing mortality ratios for African Americans and whites back to 1960 (Satcher et al., 2005). In 1900, the life expectancy in the United States was 47 years (49 for whites and 44 for blacks). Analysis of the data suggests that if disparities in health had been eliminated in the United States by the year 2000, there would have been 83,500 fewer deaths among African Americans. If infant mortality had been equal between both populations, 4,700 African American infants who died in the year 2000 would not have died. In terms of insurance coverage, there would have been 2.5 million fewer blacks uninsured, including over 600,000 children. In reality, in the year 2000 there were around 39 million 

DISPARITIES IN CHILDEN’S HEALTH  people uninsured in this country, and in 2008 the number had increased to around 47 million. Healthy People 2010 defined four major determinants of health: access to care, environment, genetics, and behavior. Figure 2-1 illustrates the interactions that take place among these various determinants of health. Environment and behavior have a tremendous effect on health. Our chal- lenge, said Satcher, is to address the disparities associated with each of the determinants of health and to do it in an interactive fashion. Environmental quality is a concern for African American and Hispanic children, who are much more likely to be exposed to toxic waste sites than other children. Twenty-five percent of preventable illnesses worldwide are caused by poor environmental quality. Mental health is also very important. The Office of the Surgeon General released a report in 2001 on disparities in the burden of mental illness as it relates to culture, race, and ethnicity (HHS, 2001a). The report concluded that there are tremendous disparities in the burden of mental illness owing to the lack of access to mental health services and the stigma associated with mental illness. For example, 1 in FIGURE 2-1 Determinants of health. SOURCE: HHS, 2000. Figure 2-1.eps (replaced with vector from original source) 

10 Nutrition training requirements for Parent training professional certification re: feeding (childcare Community-wide practices/healthy diets healthcare) Agriculture policy State/Federal Food subsidies food and menu education and expanded funding/ label campaigns BMI screening eligibility for NSLP/NSBP regulations Restaurant/Grocery and treatment store/School point of purchase prompts School soda bans/ Federal /State Zoning/Business Competitive food restrictions lobbying/Discharge incentive for regulation grocery stores, farmers markets (upstream) (midstream) (downstream) FIGURE 2-2 Population model of health promotion. SOURCE: McKinlay, 1995. Figure 2-2.eps landscape 

DISPARITIES IN CHILDEN’S HEALTH 11 10 American children and adolescents suffers from mental illness severe enough to cause some level of impairment, and fewer than 1 in 5 receives treatment. Family violence also affects children, often resulting in injuries and death. Another report from the surgeon general concluded that youth vio- lence is pervasive, and while certain racial and ethnic groups may be more likely to be arrested and sent to prison, youth violence is not limited to minorities (HHS, 2001b). The report concluded that intervention strategies exist that can be tailored to the needs of youth at every stage of develop- ment, and that there are programs that are effective in preventing serious youth violence. Another example of an issue where intervention strategies are needed is childhood obesity, and obesity in general in the United States. The surgeon general’s report on overweight and obesity details the dramatic increase in childhood obesity and the effect it has upon children (HHS, 2001c). One intervention, the Action for Healthy Kids program, engages schools in deal- ing with the obesity epidemic by helping them model good nutrition and increase students’ physical activity. Schools now realize that there is a con- nection between learning and wellness. To be successful, Satcher said, we must attack the issues downstream, dealing with individuals and families, midstream in terms of community, and upstream, with policy initiatives. Figure 2-2 illustrates this concept of a population model for health promo- tion as it relates to healthy diets for children. Satcher concluded by emphasizing that if we are to be successful in eliminating disparities in health we must first and foremost care enough. We also must know enough; research is critical and must continue at every level including the community-based research. Finally, we must be willing to do enough, and we must persist in our efforts. References HHS (U.S. Department of Health and Human Services). 2000. Healthy people 2010: Un- derstanding and improving health, 2nd ed. Washington, DC: U.S. Government Printing Office. HHS. 2001a. Mental health: Culture, race, and ethnicity—A supplement to mental health: A report of the surgeon general. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Mental Health Services. HHS. 2001b. Youth violence: A report of the surgeon general. Washington, DC: Department of Health and Human Services. HHS. 2001c. The surgeon general’s call to action to prevent and decrease overweight and obesity. Washington, DC: Department of Health and Human Services. IOM (Institute of Medicine). 2003. Unequal treatment: Confronting racial and ethnic dispari- ties in health care. Washington, DC: The National Academies Press. 

12 FOCUSING ON CHILDREN’S HEALTH McKinlay, J. B. 1995. The new public health approach to improving physical activity and autonomy in older populations. In Preparation for aging, edited by E. Heikkinen. New York: Plenum Press. Pp. 87-103. Satcher, D., G. E. Fryer, Jr., J. McCann, A. Troutman, S. H. Woolf, and G. Rust. 2005. What if we were equal?: A comparison of the black-white mortality gap in 1960 and 2000. Health Affairs 24:459-464.