Interdisciplinary Medicine III Lecture – Community Engagement and Service Unit
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Commissioner Choucair presenting the Healthy Chicago public health agenda and how the Chicago Department of Public Health think about health disparities and the recent work addressing health disparities.
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Interdisciplinary Medicine III Lecture – Community Engagement and Service Unit
- 1. City of Chicago Mayor Rahm Emanuel Chicago Department of Public Health Commissioner Bechara Choucair, M.D.
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- 20. Percent of high school students who smoked cigarettes on at least 1 day (during the 30 days before the survey), Chicago, 2011 (YRBSS) • *Data not available
- 21. Percent of high school students who smoked cigarettes on at least 1 day (during the 30 days before the survey), Chicago, 2011 (YRBSS) • *Data not available
- 22. Percent of high school students who smoked cigarettes on at least 1 day (during the 30 days before the survey), Chicago, 2011 (YRBSS) • *Data not available
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- 31. * Data not available *Data not available
- 35. January 22, 2014 Chicago Board of Education Unanimously Adopts New Physical Education Policy • • •
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- 41. 80 70 60.2 60 59.1 56.9 54.8 55.4 49.4 50 48.3 46.8 44.2 43.4 40.3 40 30 20 10 0 1999 2000 2001 2002 All race-ethnicities 2003 NH White 2004 NH Black 2005 2006 Hispanic 2007 United States 2008 2009
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- 45. 120 100 80 85.2 80.5 76 69.3 65.6 60 64.8 61.9 65.1 66.1 61.4 57 40 20 0 1999 2000 2001 All race-ethnicities 2002 Hispanic 2003 2004 NH Asian 2005 NH Black 2006 NH White 2007 2008 United States 2009
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- 51. Chicago • • United State Female Male Hispanic NH White NH Black 0 10 20 30 40 50 60 70
- 52. Female Male Hispanic NH Black NH White MSM IDU MSM & IDU Heterosexual • • • • < 20 20-29 30-39 40-49 50-59 > 60 0 10 20 30 40 50 60 70 80 90
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- 62. 20 18 16 14 12 11.5 10.5 9.6 10 9 8.6 8.4 8.5 2004 2005 7.9 7.9 8 8 2006 2007 2008 2009 8 6 4 2 0 1999 2000 2001 All race-ethnicities 2002 Hispanic 2003 NH Asian NH Black NH White United States
- 63. 16 14 12 10.1 10 9.7 10.1 10 2002 2003 10 10.2 2004 2005 10.1 10.2 9.9 9.6 9.7 2008 2009 8 6 4 2 0 1999 2000 2001 All race-ethnicities Hispanic NH Asian NH Black 2006 NH White 2007 United States
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Notas do Editor
- First I’ll discuss the Healthy Chicago public health agenda and how we think about health disparities. Then I will discuss our recent work addressing health disparities. Then I want to briefly discuss our next steps.
- First I’ll provide a little background on the Healthy Chicago public health agenda. Then I will discuss our recent accomplishments and will provide disparities data where relevant. Then I want to briefly discuss next steps.
- For each Healthy Chicago priority area, we focus the most attention on closing the gap between those populations that are healthy and those that do not fare so well. Healthy environments are a very important focus of our strategies.We know that persons of lower SES are generally exposed to fewer factors that promote health and more factors that damage health. We strive to make healthy choices easier and more desirable for people who are most vulnerable.
- Let’s step back for a moment and take a closer look at health disparities.What are they and why do they exist?This definition is from U.S. Department of Health and Human Services' Office of Minority Health-Reducing disparities is both a health and social justice issue– our history of colonization, slavery, segregation, and discrimination has affected access to health care and health status-Social justice is one of public health’s core values
- -Efforts to remedy social injustices have led to some of the biggest changes in health disparities-for example, food stamps, civil rights act, voting rights, and desegregation of medical facilities -- Food stamps improved nutrition of the low income population; birth outcomes were improved through food stamps for both blacks and whites -- The Civil Rights Act and Voting Rights have had some of the largest impacts on health disparities. Led to declines in income disparities, increases in life expectancy, and decreases in mortality between black and white women --The desegregation of medical facilities was also very important in addressing health disparities. When desegregation was connected to Medicaid/Medicare funding, facilities complied. From 1965 to 1971, declines in the black infant mortality rate were dramatic, especially in the rural South. In Mississippi, for example,black postneonatal mortality fell 50 percent.--We hope that the Affordable Care Act will have an impact on health disparities, as well.
- Data helps us decide which areas of the City our efforts should focus on in order to address health disparities.Segregation determines the resources that community members have access to, having a big impact on health. A 2012 paper from the Manhattan Institute for Policy Research calculated isolation and dissimilarity indexes, which are measures of segregation in communities. They found that Chicago has the highest dissimilarity and isolation levels among large metropolitan cities in the US like NYC, Los Angeles, Houston, etc. Despite being the most segregated large metropolis in the country, there has been a 20% improvement since 1970 as measured by the dissimilarity index.
- The American Community Survey replaced the long form of the dicennial census. The data used to develop this index is from 2006-2010 surveys compiled together in order to generate population data at geographic levels smaller than the city, in this case, the 77 community areas.The Economic Hardship Index is based on the methodology used by Richard P. Nathan and Charles F. Adams, Jr. in “Understanding UrbanHardship,” It calculates an overall measure of hardship based on the average of six variables: unemployment, dependency, education, income level, crowded housing, and poverty. Scores on the index can range from 1 to 100, with a higher index number representing a greater level of hardship. The scores are standardized according to the data for the 77 community areas, and therefore cannot be compared to scores generated for other jurisdictions.
- First, tobacco.
- We see disparities in smoking behavior for both adults and children.In adults, males, and less educated adults have a higher prevalence of smoking in Chicago in 2012. http://app.idph.state.il.us/brfss/
- Non-Hispanic Whites and Blacks have a higher prevalence of smoking than Hispanics. http://app.idph.state.il.us/brfss/
- Persons ages 25-45 and 45-64 have a higher prevalence of smoking.http://app.idph.state.il.us/brfss/
- Lower income persons have a higher prevalence of smoking.http://app.idph.state.il.us/brfss/
- Similar to what we see in adults, male HS students report higher smoking rates than females.
- Unlike adults, Hispanic HS students have higher levels of smoking than NH Blacks. (There were too few NH White students to produce reliable prevalence rates. )
- 11th and 12th graders had an increased prevalance of smoking compared to 9th and 10th graders.
- So what are we doing to address tobacco disparities? One thing we are doing is focusing on smoking behavior where people live and go to school.
- Our most recent tobacco prevention victory is shown here-- City Council voted 45 to 4 to ban e-cig use wherever traditional tobacco products are currently prohibited.
- We are working to address menthol cigarette use, as well….
- The 50th anniversary of the Surgeon General’s Report on Smoking and Health was just last month. A new report– The Health Consequences of Smoking- 50 Years of Progress– emphasizes that smoking is still a huge public health issue. Chicago was specifically recognized, however, by Secretary Kathleen Sebelius for our work on smoking. We are consistently recognized as the nation’s leader in public health efforts on tobacco use.
- As you are all aware, overweight and obesity is a major public health problem affecting adults and children in the United States. Although the prevalence is high among all U.S. population groups, substantial disparities exist .
- Here we see that Black adults in Chicago have higher rates of overweight or obesity.Differences among persons by gender are not significant.
- There are not substantial differences based on age.
- There are not substantial differences by income.
- Here is some data on overweight or obesity in our CPS students. CPS estimates that its student population is made up of 87% low-income households, with a race-ethnicity composition of approximately 45% Hispanic and 42% non-Hispanic black students. CDPH assessed over 88,000 de-identified student physical exam records of students enrolled in kindergarten, sixth grade, and ninth grade in the 2010-11 school year.The overall prevalence of overweight or obesity for these 3 grade levels was 43%. Among demographic subgroups, overweight or obesity prevalence estimates varied substantially across each grade, sex, and race-ethnicity category. Consistent with national trends, at all three grade-levels the prevalence of obesity and overweight in Hispanic and non-Hispanic black students was higher than in non-Hispanic whites and non-Hispanic Asian/Pacific Islanders.Also consistent with childhood growth patterns and trends seen in national data, overweight or obesity prevalence was higher among sixth graders (48.6%) and ninth graders (44.7%) than in kindergartners (36.5%).
- More recent CPS data shows that obesity rates among CPS’s youngest students are decreasing. Over the past 10 years, obesity rates in kindergarten-aged students have dropped from 24% to 19.1%.In 2003, nearly one in four students was obese by the time they entered school. By 2012, that number had fallen to less than one in five. This means that over 1,000 children started the school year in 2012 at a healthier weight than they would have in 2003.And it is essential to note that this decline is being felt by all racial and ethnic groups, including African American and Hispanic children, who have historically had disproportionately high rates of obesity.
- We want to continue this downward trend. One policy we are particularly excited about is the new physical education policy adopted by the Board of Education…
- Our efforts on obesity are also making it easier to eat healthy foods and be physically active….
- We are promoting physical activity across the city…Chicago Streets for Cycling Plan 20202012 citywide network plan of 600 miles of bike facilities Safe and comfortable for all ChicagoansFocus on protected bike lanes and neighborhood greenways
- Centers for Disease Control and Prevention. [CDC Health Disparities and Inequalities Report– United States, 2013]. MMWR 2013;62(Suppl 3):[inclusive page numbers]
- Here is some heart disease data. Heart disease is the leading cause of death in Chicago and the US.Though heart disease mortality is higher in Chicago than the US, both Chicago and the US had similar rates of decline between 1999 and 2009, about 32-33%.In Chicago, NH Blacks have the highest rates of heart disease mortality compared to Hispanics and NH Whites.
- Stroke is the 3rd leading cause of death in Chicago and 4th in the US.Stroke mortality rates are similar in Chicago and the US, both experiencing similar levels of decline with heart disease mortality between 1999 and 2009, about 33-37%.In Chicago, NH Blacks have the highest rates of heart disease mortality compared to Hispanics and NH Whites. NH Blacks and Whites experiences very similar rates of decline in stroke over time, while Hispanics only decreased by 14%.Also, of note, although Hispanics comprise approximately 29% of Chicago’s population,this racial-ethnic group accounted for just 10% of 2009 deaths. This “Hispanic mortality advantage” is not unique to Chicago, having been observed on a national level with several theories put forth to explain it. These include factors related to social support, acculturation, the “healthy migrant effect,” return migration (i.e., the “salmon hypothesis”) and misclassification of ethnicity on death certificates.
- Pregnancy and childbirth among females aged <20 years have been the subject of long-standing concern among the public, the public health community, and policy makers (1–3). Teenagers who give birth are much more likely than older women to deliver a low birth weight or preterm infant, and their babies are at higher risk for dying in infancy (4–6). The annual public costs associated with births among teenage girls are an estimated $10.9 billion (7). According to the 2006–2010 National Survey of Family Growth (NSFG), an estimated 77% of births to teenagers aged 15–19 years were unintended (8).The 2010 U.S. birth rate among females aged 15–19 was 34.2 births per 1,000.
- One aspect of adolescent health we are interested in is the teen birth rate. The teen birth rate decreased 33% from 1999 to 2009, but Chicago’s rate is still one-and-a-half times that of the United States. As you see here, teen birth rates for Hispanics and NH blacks are higher than those in NH Asians and NH whites.
- At the end of 2009, approximately 1.1 million persons in the United States were living with human immunodeficiency virus (HIV) infection (1), with approximately 50,000 new infections annually (2). The prevalence of HIV continues to be greatest among gay, bisexual, and other men who have sex with men (MSM), who comprised approximately half of all persons with new infections in 2009 (2). Disparities also exist among racial/ethnic minority populations, with blacks/African Americans and Hispanics/Latinos accounting for approximately half of all new infections and deaths among persons who received an HIV diagnosis in 2009 (2,3). Improving survival of persons with HIV and reducing transmission involve a continuum of services that includes diagnosis, linkage to and retention in HIV medical care, and ongoing HIV prevention interventions (4).
- Chicago, like most other large urban areas in the United States, continues to have significantly higher rates of HIV diagnoses than the country overall. Racial/ethnic disparities in Chicago are significant and stark.Rates of new HIV diagnoses in 2011 in Chicago were highest among NH Blacks: more than double that of Hispanics, and over three times higher than that of NH Whites. New HIV infection rates are also higher in men.
- The burden of new HIV infection is among men having sex with men, NH Black, and under 30.In 2011, male-to-male sexual contact was the leading mode of transmission (69%), followed distantly by heterosexual contact (21%).While males account for 81% of all 2011 HIV infection diagnoses, this percentage varies by race/ethnicity. Among NH Black diagnoses, 75% are males, compared to 93% for Whites, and 86% for Hispanic men.Among females, heterosexual contact accounts for 86% of all HIV infection diagnoses in 2011 for all race/ethnicity groups. In 2011, 74% of new female HIV infections were among NH Blacks.
- Access to care is of course affected by health insurance. Populations more likely to be low-income such as Hispanic and NH Black have higher rates of uninsured, because most health insurance is through employers, so these groups primarily work without insurance benefits, or insurance was too costly for them.We think the Affordable Care Act will make a significant difference in the proportion of people, overall, without insurance.(506,371 total)
- Access to care is of course affected by health insurance. Populations more likely to be low-income such as Hispanic and NH Black have higher rates of uninsured, because most health insurance is through employers, so these groups primarily work without insurance benefits, or insurance was too costly for them.We think the Affordable Care Act will make a significant difference in the proportion of people, overall, without insurance.(506,371 total)
- We are helping people enroll in health insurance through our Enroll Chicago! Program….As of November, 125,000 applications submitted to state for approval. Officials say the expansion will generate $468 million next year for the county’s health programs, reducing the burden on taxpayers.
- Included educational presentations, health information tables, health care enrollment navigation.125 appointments with health care navigators.More than 150 participants in health education sessions.47 flu shots.
- Mother, infant and child health are especially important factors in lifelong health…The U.S. lags behind in the infant mortality rate. In a 2012 worldwide ranking by the CIA World Factbook -- a public of the U.S. Central Intelligence Agency -- the U.S. infant mortality rate ranked 49th, ahead of Croatia at No. 50, while Monaco ranked No. 1, with an infant mortality rate of 1.80 per 1,000 live births.https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html
- In Chicago, the infant mortality rate has remained relatively stable since 2006 at about 8 deaths per 1000 live births.Although this infant mortality rate is higher than the U.S. rate (6.4 per 1,000 in 2009), Chicago’s rate has decreased by more than 30% since 1999, while the national decrease has only been by 10%. Despite this decline, disparities in infant mortality rates persist in Chicago and nationally.The infant mortality rate for non-Hispanic blacks was 3 times higher than for non-Hispanic whites, and more than twice as high as for Hispanics in Chicago during 2007-2009. And while infant mortality rates decreased by 29% or more for Hispanics, NH Whites and NH Asians, the decrease seen in NH Blacks between 1999 and 2009 was only 21%.
- Low birthweight (< 2500 grams or 5 lbs, 8 oz) and preterm birth (<37 weeks) are associated with infant mortality. Low birthweight births have remained relatively unchanged between 1999 and 2009, hovering around 10%.Chicago has a higher rate of low birthweight than the US. NH blacks had the highest rate of low birthweight births (14.7%), about double that of Hispanics and NH whites. Similar trends are seen at the national level.
- We are addressing disparities through our baby-friendly hospital initiative, seen here at the upper right…We are also conducting home visits through our Maternal and Child health program. This year we expanded mammography services, an important need in Chicago.