Presentation by Camara Jones, MD, MPH, PhD at the 2009 Virginia Health Equity Conference. Dr. Jones presents the “Cliff Analogy” for understanding four levels of health intervention: medical care, secondary prevention, primary prevention, and addressing the social determinants of health. She described how health disparities arise on three levels (differences in quality of care, differences in access to care, and differences in underlying exposures and opportunities) and expand the “Cliff Analogy” to illustrate the relationship between addressing the social determinants of health and addressing the social determinants of equity, which is a fifth level of health intervention. She identifies racism as one of the social determinants of equity and a fundamental cause of “racial”/ethnic health disparities in the United States, with racism defined as a system of structuring opportunity and assigning value based on the social interpretation of how one looks, which is what we call “race.” She described how racism impacts health on three levels (institutionalized, personally-mediated, and internalized) and animate understanding of these levels of racism with her “Gardener’s Tale” allegory. Finally, using data from the “Reactions to Race” module on the 2004 Behavioral Risk Factor Surveillance System, she examined the relationship between responses to “How do other people usually classify you in this country?” and self-rated general health status to provide evidence of the impacts of racism on health. Dr. Jones challenges us to broaden the scope of our public health interventions by asking the question “How is racism operating here?” and then working to create a system in which ALL people are highly valued and ALL people are able to develop to their full potential.

1. Social Determinants of Health and Equity The Impacts of Racism on Health

2. Levels of health intervention

15. Medical care and tertiary prevention Safety net programs and secondary prevention Primary prevention Addressing the social determinants of health

24. Differences in access to care Differences in exposures and opportunities Differences in quality of care (ambulance slow or goes the wrong way)

25. Addressing the social determinants of equity: Why are there differences in resources along the cliff face? Why are there differences in who is found at different parts of the cliff?

26. Levels of health intervention Health services along a one-dimensional line

27. Levels of health intervention Health services along a one-dimensional line Addressing social determinants of health on a two-dimensional plane

28. Levels of health intervention Health services along a one-dimensional line Addressing social determinants of health on a two-dimensional plane Addressing social determinants of equity in three-dimensional space

29. Determinants of health Individual behaviors

30. Determinants of health Social determinants of health (contexts) Individual behaviors

31. Determinants of health and illness that are outside of the individual Beyond genetic predispositions Beyond individual behaviors Determinants of health Social determinants of health (contexts) Individual behaviors

32. Determinants of health and illness that are outside of the individual Beyond genetic predispositions Beyond individual behaviors The contexts in which individual behaviors arise Determinants of health Social determinants of health (contexts) Individual behaviors

33. Individual resources Education, occupation, income, wealth Determinants of health Social determinants of health (contexts) Individual behaviors

34. Individual resources Education, occupation, income, wealth Neighborhood resources Housing, food choices, public safety, transportation, parks and recreation, political clout Determinants of health Social determinants of health (contexts) Individual behaviors

35. Individual resources Education, occupation, income, wealth Neighborhood resources Housing, food choices, public safety, transportation, parks and recreation, political clout Hazards and toxic exposures Pesticides, lead, reservoirs of infection Determinants of health Social determinants of health (contexts) Individual behaviors

36. Individual resources Education, occupation, income, wealth Neighborhood resources Housing, food choices, public safety, transportation, parks and recreation, political clout Hazards and toxic exposures Pesticides, lead, reservoirs of infection Opportunity structures Schools, jobs, justice Determinants of health Social determinants of health (contexts) Individual behaviors

37. Determinants of health Societal determinants of context Social determinants of health (contexts) Individual behaviors

38. Societal determinants of context Social determinants of health (contexts) Determine the range of observed contexts Determinants of health Individual behaviors

39. Societal determinants of context Social determinants of health (contexts) Determine the distribution of different populations into those contexts Determine the range of observed contexts Determinants of health Individual behaviors

40. Societal determinants of context Social determinants of health (contexts) Determine the distribution of different populations into those contexts Determine the range of observed contexts Include capitalism, racism, and other systems of power Determinants of health Individual behaviors

41. Societal determinants of context Social determinants of health (contexts) Determine the distribution of different populations into those contexts Determine the range of observed contexts Include capitalism, racism, and other systems of power Determinants of health The social determinants of equity Individual behaviors

45. Naming and Addressing the Impacts of Racism on Health

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

65. How self-identify Two measures of “race” How usually classified by others White Black Hispanic AIAN . . . White 26,373 98.4 0.1 0.3 0.1 1.1 Black 5,246 0.4 96.3 0.8 0.3 2.2

66. How self-identify Two measures of “race” How usually classified by others White Black Hispanic AIAN . . . White 26,373 98.4 0.1 0.3 0.1 1.1 Black 5,246 0.4 96.3 0.8 0.3 2.2 Hispanic 1,528 26.8 3.5 63.0 1.2 5.5

67. How self-identify Two measures of “race” How usually classified by others White Black Hispanic AIAN . . . White 26,373 98.4 0.1 0.3 0.1 1.1 Black 5,246 0.4 96.3 0.8 0.3 2.2 Hispanic 1,528 26.8 3.5 63.0 1.2 5.5

68. 0 20 40 60 80 100 39.8 53.7 58.6 percent of respondents Report excellent or very good health Hispanic-Hispanic Hispanic-White White-White General health status, by self-identified and socially-assigned "race", 2004

69. 0 20 40 60 80 100 39.8 58.6 percent of respondents Report excellent or very good health Hispanic-Hispanic White-White General health status, by self-identified and socially-assigned &quot;race&quot;, 2004 Test of H 0 : That there is no difference in proportions reporting excellent or very good health Hispanic-Hispanic versus White-White p < 0.0001

70. 0 20 40 60 80 100 39.8 53.7 percent of respondents Report excellent or very good health Hispanic-Hispanic Hispanic-White General health status, by self-identified and socially-assigned &quot;race&quot;, 2004 Test of H 0 : That there is no difference in proportions reporting excellent or very good health Hispanic-Hispanic versus Hispanic-White p = 0.0019

71. 0 20 40 60 80 100 53.7 58.6 percent of respondents Report excellent or very good health Hispanic-White White-White General health status, by self-identified and socially-assigned &quot;race&quot;, 2004 Test of H 0 : That there is no difference in proportions reporting excellent or very good health Hispanic-White versus White-White p = 0.1895

72. How self-identify Two measures of “race” How usually classified by others White Black Hispanic AIAN . . . White 26,373 98.4 0.1 0.3 0.1 1.1 Black 5,246 0.4 96.3 0.8 0.3 2.2 Hispanic 1,528 26.8 3.5 63.0 1.2 5.5 AIAN 321 47.6 3.4 7.3 35.9 5.8

73. How self-identify Two measures of “race” How usually classified by others White Black Hispanic AIAN . . . White 26,373 98.4 0.1 0.3 0.1 1.1 Black 5,246 0.4 96.3 0.8 0.3 2.2 Hispanic 1,528 26.8 3.5 63.0 1.2 5.5 AIAN 321 47.6 3.4 7.3 35.9 5.8

74. 0 20 40 60 80 100 32 52.6 58.6 percent of respondents Report excellent or very good health AIAN-AIAN AIAN-White White-White General health status, by self-identified and socially-assigned &quot;race&quot;, 2004

75. 0 20 40 60 80 100 32 58.6 percent of respondents Report excellent or very good health AIAN-AIAN White-White General health status, by self-identified and socially-assigned &quot;race&quot;, 2004 Test of H 0 : That there is no difference in proportions reporting excellent or very good health AIAN-AIAN versus White-White p < 0.0001

76. 0 20 40 60 80 100 32 52.6 percent of respondents Report excellent or very good health AIAN-AIAN AIAN-White General health status, by self-identified and socially-assigned &quot;race&quot;, 2004 Test of H 0 : That there is no difference in proportions reporting excellent or very good health AIAN-AIAN versus AIAN-White p = 0.0122

77. 0 20 40 60 80 100 52.6 58.6 percent of respondents Report excellent or very good health AIAN-White White-White General health status, by self-identified and socially-assigned &quot;race&quot;, 2004 Test of H 0 : That there is no difference in proportions reporting excellent or very good health AIAN-White versus White-White p = 0.3070

90. Levels of Racism: A Gardener’s Tale Source: Jones CP, Am J Public Health 2000

94. Policies allowing segregation of resources and risks Redlining, municipal zoning, toxic dump siting Use of local property taxes to fund public education

95. Policies creating inherited group disadvantage Lack of social security for children Estate inheritance Lack of reparations for historical injustices

96. Policies favoring the differential valuation of human life by “race” Curriculum Media invisibility/hypervisibility Myth of meritocracy and denial of racism

97. Policies limiting self-determination De jure and de facto limitations to voting rights “ Majority rules” when there is a fixed minority

106. Health services Our goal: To expand the conversation

107. Health services Social determinants of health Our goal: To expand the conversation

108. Health services Social determinants of health Social determinants of equity Our goal: To expand the conversation Jones CP et al. Expanding the “Fence or Ambulance” Debate: Addressing the Social Determinants of Health and Equity. Under review, 2009.

112. Camara Phyllis Jones, MD, MPH, PhD 4770 Buford Highway NE Mailstop K-67 Atlanta, Georgia 30341 (770) 488-5268 phone (770) 488-5965 fax [email_address]

123. Camara Phyllis Jones, MD, MPH, PhD 4770 Buford Highway NE Mailstop K-67 Atlanta, Georgia 30341 (770) 488-5268 phone (770) 488-5965 fax [email_address]

124. Dual Reality: A Restaurant Saga

125. Walking Against the Tide Our Challenge