Challenges and Successes in Reducing Health Disparities: Workshop Summary (2008)

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1 Introduction 1 I n early 2007, the Institute of Medicine (IOM) of the National Acad- emies convened the Roundtable on Health Disparities to increase the visibility of racial and ethnic health disparities as a national problem, further the development of programs and strategies to reduce dispari- ties, foster the emergence of leadership on this issue, and track promising activities and developments in minority care that could lead to dramati- cally reducing or eliminating disparities. The Roundtable on Health Dis- parities includes representatives from the health professions, state and local government, foundations, philanthropy, academia, advocacy groups, and community-based organizations. Its mission is to facilitate communication across sectors and—above all—to generate action. Through national and local activities, the Roundtable strives to advance the goal of eliminating health disparities. The Roundtable focuses on the disparities experienced by African A ­ mericans, Hispanics, Native Americans, Alaska Natives, Asians, and Pacific Islanders. These disparities are reflected in the frequency with which these groups experience such diseases as cancer, AIDS and HIV infection, cardio- vascular disease, infant mortality, asthma, stroke, and diabetes. They are also reflected in difficulties experienced in accessing health care services, as well as in differences in health outcomes. Altogether, these disparities result in shorter life expectancy and reduced quality of life. If not tackled effec- 1  The planning committee’s role was limited to planning the workshop, and the workshop summary has been prepared by the workshop rapporteur as a factual summary of what oc- curred at the workshop.  

 CHALLENGES AND SUCCESSES IN REDUCING HEALTH DISPARITIES tively now, health disparities could result in even more preventable deaths and disability as the racial and ethnic diversity of the country grows. Through its convening capacity and by holding public workshops at different locations across the nation, the Roundtable on Health Disparities aspires to advance understanding of health disparities and explore solutions for ending them. In doing so, it endeavors to make a lasting contribution to the quality of life for some of this country’s most vulnerable groups. ABOUT THE WORKSHOP On July 31, 2007, the first workshop of the Roundtable on Health Disparities was held at the Bank of America Theater at Emerson Perfor- mance Center on the campus of Harris-Stowe State University in St. Louis, Missouri. To help stimulate new thinking about solutions and to inform its future meetings and discussions, the Roundtable brought together a diverse group of participants from a variety of fields to discuss racial and ethnic differences in life expectancy in the United States. Measured in terms of life expectancy, tens of millions of Americans experience levels of health that are more typical of middle- and low-income developing countries. These mortality differences are caused primarily by chronic diseases and injuries with well-established risk factors and are potentially amenable to interven- tion. The goals of the workshop were to increase the Roundtable’s under- standing of (1) the importance of differences in life expectancy within the United States, (2) the reasons for the differences, and (3) the implications of this information for programs and policy makers. To specifically address the issues pertaining to U.S. life-expectancy rates, the Roundtable invited Dr. Christopher Murray, director of the Insti- tute for Health Metrics and Evaluation at the University of Washington, to discuss his recent paper, “Eight Americas: Investigating Mortality Dis- parities Across Races, Counties, and Race-Counties in the United States” (see Appendix C). In his presentation, Dr. Murray discussed the gap in life expectancies found in different parts of the country, global comparisons in life expectancy rates between the United States and other countries, and behavioral risk ­ factors—tobacco, alcohol, obesity, high blood pressure, and blood sugar—that can have a direct impact on life expectancy. Dr. Murray also offered several strategies for future research endeavors and for increasing life expectancies in the United States. Among his suggestions were increasing the availability of county-level data to improve capabilities for monitoring and tracking disparities, developing strategies for framing health disparities concerns that include a greater acceptance of international models, and adopting policies that would foster a broader spectrum of innovation toward reducing health disparities. 

INTRODUCTION  Dr. Dolores Acevedo-Garcia offered another perspective in her pre- sentation on the impact of an individual’s place of residence on health, discussing how living in disadvantaged metropolitan neighborhoods can have profound developmental, emotional, and physical effects on chil- dren and how these effects can have long-term implications throughout an individual’s life course. Among other suggestions, she proposed that, rather than working to salvage poverty neighborhoods, children would be better off moving to neighborhoods or areas that are rich with opportunity (such as those with access to healthy foods and safe environments) so they would not have to experience the consequences of living with poverty, crime, and other societal influences. During the discussion period following the presentations, Roundtable members and sponsors, workshop participants, and attendees discussed concerns and offered strategies for addressing several different factors related to health disparities. Among the topics discussed were the current state of the politics in the United States, the language and framing of dis- parities, institutional racism, data collection problems, collaborations and community innovations, and efforts toward reducing health disparities in St. Louis. The issues of framing and racism were the subjects that sparked the most lively discussion, with several workshop attendees stressing the importance of creating an open dialogue about these issues and the need for developing strategies to bring all relevant stakeholders together to discuss solutions. During the afternoon session, Drs. Edward F. Lawlor and Carol H ­ orowitz presented their paper, “Community Approaches to Addressing Health Disparities” (see Appendix D). The paper assesses the implications for developing actionable strategies and describes the benefits of—and approaches to—integrating clinical and community-based approaches to affect communities and reduce health disparities. Dr. Horowitz stressed that hybrid models, which blend clinical and community-based approaches, should integrate community participation and involvement and commu- nity owner­ship into disparities initiatives. Dr. Lawlor suggested that, for any community initiative to succeed, power and sophistication must be developed at the community level for communities to have the knowledge and skills necessary to gather their own social and economic data rather than relying on standard epidemiological data or health indicators alone. In this way, the health status of communities can be evaluated, monitored, and tracked over time. Dr. Lawlor also proposed that communities adopt strategies for leveraging existing public and community partnerships, align- ing goals with other stakeholders, and enacting policy changes that redirect their efforts to include a health focus. He believes that strategies such as 

 CHALLENGES AND SUCCESSES IN REDUCING HEALTH DISPARITIES these would have a dramatic impact on health disparities in the United States. Following the presentation, workshop participants and attendees shared views concerning leadership, funding, and community capacity, among other issues. While there was some disagreement about whether the infrastructure currently exists to cultivate a new generation of leaders, there was consensus about the importance of committing time and resources to identifying, train- ing, and mentoring individuals in communities who could become future leaders. Although strategies and methodologies varied, workshop presenters and attendees fundamentally agreed that additional, consistent funding was a necessity for community initiatives to succeed, and efforts to partner with relevant stakeholders and existing community-development ventures should be encouraged and actively pursued. Several workshop participants stressed that community initiatives should include community members as active participants in the planning and implementation of a program. In addition, initiatives must include plans for ongoing evaluations to measure and track a program’s progress and to strive to be sustainable. Workshop attendees also had the opportunity to hear from several presenters about their efforts to implement and manage local community interventions, as well as from representatives from the business commu- nity who discussed their organizations’ efforts to reduce health disparities. R ­ epresentatives from the Centers for Disease Control and Prevention’s (CDC’s) Racial and Ethnic Approaches to Community Health (REACH) and Steps to a HealthierUS programs gave individual presentations in which they shared how their community programs were initiated and developed, what some of their challenges have been, and why and how they are expe- riencing positive results in their communities. Business leaders shared orga- nizational strategies for reducing health disparities and discussed existing challenges and ongoing efforts for reaching future disparities goals. ORGANIZATION OF THE REPORT This workshop summary was prepared for the Roundtable membership and includes a collection of presentations and commentary. Sections of the workshop summary not specifically attributed to an individual reflect the views of the rapporteur and not those of the Roundtable on Health Dispari- ties, its sponsors, or the IOM. The contents of the unattributed sections are based on the presentations and discussions at the workshop. The report is organized into chapters as a topic-by-topic description of the presentations and discussions that took place at the workshop. Its pur- pose is to present lessons from relevant experience, to delineate a range of 

INTRODUCTION  pivotal issues and their respective problems, and to offer potential responses as described by workshop participants. Although this workshop summary provides an account of the indi- vidual presentations, it also reflects an important aspect of the Roundtable philosophy. The public workshop functions as a dialogue among represen- tatives from different sectors and presents their beliefs about which areas may merit further attention. The reader should be aware, however, that the material presented here expresses the views and opinions of the individuals participating in the workshop and not the deliberations and conclusions of a formally constituted IOM study committee. These proceedings sum- marize only what participants stated in the workshop and are not intended to be an exhaustive exploration of the subject matter or a representation of consensus evaluation. Chapter 2 includes Dr. Murray’s presentation of his recent paper, “Eight Americas: Investigating Mortality Disparities Across Races, ­Counties, and Race-Counties in the United States” (see Appendix C), examining the gap in life expectancies found in different parts of the United States, and Dr. Acevedo­-Garcia’s presentation discussing the connection between a person’s place of residence and subsequent health disparities. Further dis- cussion of these and other related topics raised by workshop attendees following these presentations are summarized in the chapter. Chapter 3 summarizes presentations by Drs. Carol Horowitz and Edward Lawlor, discussing their paper “Community Approaches to Address- ing Health Disparities” (see Appendix D), which assesses the implications for developing actionable strategies and describes the benefits of—and approaches to—integrating clinical and community-based approaches to affecting communities and reducing health disparities. Additional discus- sion pertaining to this presentation and to other related issues that were raised in reaction to their remarks are also included in the chapter. Chapter 4 summarizes presentations by individuals who implement interventions in their own communities as part of the CDC’s REACH 2010 and Steps to a HealthierUS programs. These representatives shared infor- mation about how the community programs were initiated, how programs have developed, what some of the challenges have been, and why and how they are experiencing positive results. Chapter 5 summarizes presentations by representatives from the busi- ness community that discuss successful strategies and programs aimed at reducing health disparities. Chapter 6 summarizes the salient points from the workshop and provides an overview for strategies to consider while moving forward. P ­ articipants’ comments pertaining to issues, such as data concerns, the 

 CHALLENGES AND SUCCESSES IN REDUCING HEALTH DISPARITIES importance of place, framing, racism, education, policy changes, fostering a broader spectrum of innovation, and funding, are summarized here. This report provides an account of presentations and discussions that took place during the workshop. It bears emphasizing again that the mate- rial presented in this and the following chapters represents the views and opinions of individual workshop participants only and is not to be con- strued as reflective of the deliberations of a formally constituted study committee. It is not intended to be an exhaustive exploration of the subject matter, but rather a contribution to the larger information-gathering efforts of the Roundtable.