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Using a Social Determinants of Health
Paradigm to Improve Chronic Disease
Management in Latino Communities
Sea Mar Community Health Centers
14th Annual Latino Health Forum
October 30, 2019
Julian Perez, MD
Sea Mar Community Health Centers
Today’s agenda
1. Review concept of Social Determinants of Health
2. Review evidence for Income Inequality being greatest
determinant of poor health outcomes in a population
3. Latest CDC chronic disease rate differences between Latin@s
and White population in USA
4. Birth weight and Mortality differences through economic
boom and busts and the political fallout
5. Closer look at US and WA chronic disease using GIS maps
6. Review a series of studies trying to uncover the mystery of the
Latin@ paradox
7. End with the sum evidence for theories for Latin@ resilience
and what we can and should be focused on in our clinics
8. Discussion
What makes Latin@ families healthy?
• Employment
• Community/Support system
• English fluency
• Immigration status
• Education/Literacy
• Environments “Place matters”
• Public health policies
• Diet
• Physical Activity
• Habits
• Genetics
• Preventative medicine
• Curative medicine
Healthy Sick Outcome
Symptoms Access
x x
Treatment
genetics 30% health care 10%
Societal determinants:
60% of health
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“The gap”
What’s the evidence?
Is income important for health?
Is income inequality bad for our health?
Is income equality good for our health?
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How rich is the USA?
(2017 World Bank data)
•#2 GDP = $17.7 trillion
•325 million population
•GNI per capita: $55,351
•Life expectancy at birth: 78.5 yrs
•Income inequality ranking: #1 (the highest)
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Mexico
World Income Inequality: USA
20.2% in 2004 (peak 21.4% in 1928)
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Take home #1
Sharing is good for
your health
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Infant mortality #/1000 live births
CDC 2013-2015
•US Total 5.9
•US Non-Hispanic Whites 5
•US Hispanic/Latinas 5
•WA State Total 4.6
•WA State Non-Hispanic Whites 4.2
•WA State Hispanic/Latinas 4.6
US Low birth weights (under 2.5kg)
Non-Hispanic Whites
•1980: 5.69%
•1990: 5.61%
•------.Com boom----------
•2000: 6.60%
•2005: 7.29% (Recession)
•2010: 7.14%
•----------ACA-------------
•2014: 6.96%
•2015: 6.93%
•2016: 6.99%
Hispanic/Latin@s
•1980: 6.12%
•1990: 6.06%
•------.Com boom---------
•2000: 6.41%
•2005: 6.88% (Recession)
•2010: 6.97%
•----------ACA----------
•2014: 7.05%
•2015: 7.21%
•2016: 7.31%
WA State Low birth weights
Under 2.5kg. CDC
Non-Hispanic Whites
•2000-2002: 5.43%
•2011-2013: 5.66%
•2014-2016: 5.87%
Hispanic/Latin@s
•2000-2002: 5.31%
•2011-2013: 6.24%
•2014-2016: 6.20%
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WA
Summary
•Income does correlate with longer life
•Inequality is a good predictor of poor
population health
•Higher income equity is associated with lower
mortality (longer life)
What makes Latin@s healthy?
•My Dad, “I married your mother”
•My Dad, “Low incomes make us eat at home
more”
•Me, “Mexican pride”
•My wife, “Telenovelas”
•Viejito, “Chile piquin”
•Aunt Rita, “Faith in God”
•Aunt Margie, “Close family”
What makes Immigrant families healthy?
• Immigration status
• Employment
• Community/Support system
• English fluency
• Education/Literacy
• Environments “Place matters”
• Public health policies
• Diet
• Physical Activity
• Habits
• Genetics
• Preventative medicine
• Curative medicine
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U.S. Chronic Disease Rates
CDC 2013-2016
Non-Hispanic Whites
• HTN 46% (48%M, 43%F)
• DM 9.6% (2% undiagnosed)
• DM A1c >9 = 16.6%
• Obesity 38% (M 37%,F 39%)
• Kids Ob 14.7%
• Asthma under 18 y/o: 7.1%
• Uninsured 7.3%
• Health “Fair/Poor” 7.6%
• Depression 3.7% (2.9% ‘90)
Hispanic/Latin@s
• HTN 54% (60%M, 50%F)
• DM 17% (4.7% undiagnosed)
• DM A1c >9 = 30%
• Obesity 45% (M 41%,F 48%)
• Kids Ob 23.6%
• Asthma under 18 y/o: 6.7%
• Uninsured 19.6%
• Health “Fair/Poor” 12.4%
• Depression 3.7% (5% ’90)
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Hispanic/Latin@ Population%
CDC 2013-2017
WA Less than HS 25+ y/o
CDC. 2013-2017
WA Poverty all ages. CDC 2016
WA Uninsured% Under 65 y/o
CDC 2016
Unemployment 16+y/o. CDC 2017
Hispanic/Latin@ Population%
CDC 2013-2017
Inactivity% WA 20+ y/o. CDC 2015
Obesity% WA 20+ y/o. CDC 2015
Diabetes% WA 20+ y/o. CDC 2015
HTN Medicare hospitalizations.
Latin@s. CDC 2014-2016
HTN Medicare hospitalizations Non-
Hispanic Whites. CDC 2014-2016
BP higher in undocumented Latin@s
J Urban Health. 2017 Dec;94(6):764-775. doi: 10.1007/s11524-017-0197-3
Legal Status, Time in the USA,
and the Well-Being of Latinos
in Los Angeles.
Young MT1, Pebley AR2.
Author information
1
University of California, Los Angeles, Los Angeles, CA, USA.
mariaelena@ucla.edu.
2
University of California, Los Angeles, Los Angeles, CA, USA.
Diabetes disparities. CDC 2017
Diabetes disparities. CDC 2017
SOURCE: NCHS, Health, United States, 2017, Figure 8. Data from the National Health Interview Survey (NHIS).
Current asthma among children. CDC 2006-
2016
Depression equal, but antidepressant
use is lower in Undocumented Latin@s
Ann Epidemiol. 2019 Sep;37:17-23.e3. doi:
10.1016/j.annepidem.2019.07.007. Epub 2019 Jul 12.
Association between immigration
status and anxiety, depression, and use
of anxiolytic and antidepressant
medications in the Hispanic
Community Health Study/Study of
Latinos.
Ross J1, Hua S2, Perreira KM3, Hanna DB2, Castañeda SF4, Gallo
LC5, Penedo FJ6, Tarraf W7, Hernandez R8, Vega Potler N2, Talavera
GA4, Daviglus ML6, Gonzalez F 2nd3, Kaplan RC2, Smoller-Wassertheil S2.
U.S. Causes of Death. CDC 2017
Non-Hispanic Whites
1. Heart disease 23.3%
2. Cancer 21.4%
3. Chronic Lung disease 6.4%
4. Unintentional injuries 5.8%
5. Stroke 5%
6. Alzheimers 4.7%
7. Diabetes 2.5%
8. Influenza/PNA 2%
9. Suicide 1.7%
14. HTN/ESRD 1.1%
Homicide #20 at 0.3%
Hispanic/Latinos
1. Cancer 20.6%
2. Heart disease 20%
3. Unintentional injuries 8.5%
4. Stroke 5.5%
5. Diabetes 4.7%
6. Alzheimers 3.7%
7. Cirrhosis 3.2%
8. Chronic Lung disease 2.8%
9. Suicide 2%
14. HTN/ESRD 1.4%
Homicide #12 at 1.6%
Life expectancy at birth, by sex and race
and Hispanic origin
NOTES: Life expectancy data by Hispanic origin were available starting in 2006 and were corrected to address racial
and ethnic misclassification. Life expectancy estimates for 2016 are based on preliminary Medicare data.
SOURCE: NCHS, Health, United States, 2017, Figure 1. Data from the National Vital Statistics System (NVSS),
Mortality.
Mortality Ages 45-54
Case, A. and A. Deaton (2017)
2016
Election
swing
• Best predictor
was combined
measure of low
exercise, heavy
EtOH, diabetes,
obesity, low life
expectancy =
worse health
made worse by
income inequality
“Hispanic Paradox”
Resiliency
Potential Life Years Lost
CDC 2016
Non-Hispanic Whites
• Total 6715
• Heart Disease 888
• Cancer 1251
• Accidents 1430
– Overdose 756
• Suicide 492
Hispanic/Latin@s
• Total 4926
• Heart Disease 574
• Cancer 900
• Accidents 914
– Overdose 402
• Suicide 239
Are Latin@s healthier because we
use more healthcare services?
Non-Hispanic Whites
• Medicaid beneficiaries 36%
• Medicaid payments/
beneficiary: $6691
• Medicare beneficiaries 75.6%
• Medicare payments/
beneficiary: $17,367
Is the healthcare system…
Hispanic/Latin@s
• Medicaid beneficiaries 17.4%
• Medicaid payments/
beneficiary: $2958
• Medicare beneficiaries 9.1%
• Medicare payments/
beneficiary: $18,651
bad for your health?
Do healthy behaviors decline with
greater acculturation?
Implications for the Latino
mortality paradox.
Soc Sci Med. 2005 Sep;61(6):1243-55. Epub 2005 Mar 3.
Abraído-Lanza AF1, Chao MT, Flórez KR.
Department of Sociomedical Sciences, Mailman School of Public
Health, Columbia University, 722 West 168 Street, 5th floor, New
York, NY 10032, USA. aabraido@columbia.edu
Do Healthy behaviors in Latino
populations decline w/
acculturation
Behaviors studied
• Smoking lower
• Alcohol use lower
• Leisure exercise lower
• BMI higher
Controlling for SES, age,
acculturation associated with
• Smoking up
• Alcohol use up
• BMI up
• Leisure exercise up
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Race/Ethnic Differences in Adult
Mortality: The Role of Perceived
Stress and Health Behaviors
Patrick M. Krueger,
1
Jarron M. Saint
Onge,
2
and Virginia W. Chang
3,4,5
Soc Sci Med. 2011 Nov; 73(9):
10.1016/j.socscimed.2011.08.007.
Published online 2011 Aug 26. doi: 10.1016/j.socscimed.2011.08.007
PMCID: PMC3816937
NIHMSID: NIHMS322231
PMID: 21920655
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Tobacco cigarette smoking
CDC 2014-2016, age & SES
Non-Hispanic Whites
• Total: 17.2%
• 18-24 y/o: 16.5%
• 25-34 y/o: 19.6%
• 35-44 y/o: 20.7%
• 45-64 y/o: 19%
• 65+ y/o: 7.8%
• Below 100% Pov: 37%
• 100-199%: 28%
• 200-399%: 18.6%
• 400+%: 8.8%
Hispanic/Latin@s
• Total: 7.3%
• 18-24 y/o: 5%
• 25-34 y/o: 6%
• 35-44 y/o: 8.3%
• 45-64 y/o: 9.5%
• 65+ y/o: 5%
• Below 100% Pov: 10%
• 100-199%: 7%
• 200-399%: 6%
• 400+%: 5.6%
Current smoking, stress, and
mortality by race/ethnicity
Alcohol consumption and mortality
by race/ethnicity
Alcohol use. CDC 2002-2016
Non-Hispanic Whites
• 2002 55%
• 2015 57%
• 2016 56%
• Binging 2016 25.4%
• Heavy 2016 7.2%
Hispanic/Latin@s
• 2002 42.8%
• 2015 42.4%
• 2016 42.5%
• Binging 2016 24.9%
• Heavy 2016 4.5%
Sleep hours and mortality by
race/ethnicity
Physical inactivity and Mortality by
Race/Ethnicity
Racial, Ethnic, and Gender
Differences in Physical Activity
J Hum Cap. 2013 Winter; 7(4): 378–410.
Henry Saffer, Dhaval Dave, Michael Grossman,
and Leigh Ann Leung
The Association Between Family
Social Network Size and Healthy
Lifestyle Factors: Results from the
Hispanic Community Health
Study/Study of Latinos (HCHS/SOL)
Rosenda Murillo et al. Journal of Behavioral
Medicine. pp1-11. 2019, July
Resiliency in the face of disadvantage:
do Hispanic cultural characteristics
protect health outcomes?
Gallo LC1, Penedo FJ, Espinosa de los
Monteros K, Arguelles W.
J Pers. 2009 Dec;77(6):1707-46. doi:
10.1111/j.1467-6494.2009.00598.x.
Epub 2009 Sep 30.
Hispanic cultural characteristics
Gallo
Allocentrism – needs of the many over the
individual – may lead to higher level of social
cohesiveness and community support
Simpatia – drive toward pleasant, non-
confrontational social interactions, perhaps
fostering socially desirable patterns and responses
– leading to better social relationships
Hispanic cultural characteristics
Gallo
Familialism –strong attachments to the nuclear and
extended family emphasized
Power distance/Personal space – amount of
physical space deemed appropriate for
interpersonal interactions. Hispanics are more
comfortable with close distances
Gender roles – machismo (male dominance) vs.
marianismo (female submissiveness) defined in
1973 as being characterized by female passivity,
dependence, self-sacrifice, and placing family
needs first
Hispanic cultural characteristics
Gallo
Religiousness – 94% of Hispanics had a religious
affiliation in 2003 and is associated w/ lower
smoking rates and lower mental health illnesses
and also predicts higher life satisfaction, lower
substance abuse rates and higher health seeking
behaviors for those that do have substance use
problems. Down to 83% in 2012 vs. 80% in general
population
Fatalism – believing that ones fate or destiny is
beyond one’s control
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Ask different questions
Ask better questions
Levels of Intervention: Clinic
STATE/NATIONAL
SYSTEMS
COMMUNITY
CLINIC
INDIVIDUAL
UPSTREAM
DOWNSTREAM
Patient case: Azucar
• 45 y/o F, 10+ yrs poorly controlled IDDM
• Transferred to me for “non-compliance”
• SDOH screen
Assets Deficits
Employed Unstable housing
Had food Mexican Immigrant woman
Had emergency contact Uninsured, Undocumented
Good health-seeking behavior Non-English speaker
Trust in doctors Can’t read/write
Azucar’s Treatment Plan
• Can’t read – was not refrigerating insulin x 10 yr
– Referred to Goodwill for ESL and literacy
• Cheaper insulin
• Low-literacy health education materials
• EMR: SDOH Diagnoses added to problem list – makes
them active problems to be worked on consistently
• HbA1c 14+ down to 8+ in 6 months. Stable.
How do you begin to NOT ONLY treat Azucar with
SDOH lenses, but how to you treat her entire
community?
The 3 “Ms”:
Mission, Masses, Methods
Changing the paradigm of your clinic
operations
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Maria Luisa Ortiz
Women’s Cooperative
Mulukuku, Nicaragua
• OB/Gyn care, Casa Materna
• Medical, Psych, Social
• Mobile clinics
• Dental, Pharmacy
• Political participation
• Traditional medicine
• Legal, Remediations
• Radio/Communication
• Refuge, shelter, self defense
• School based gardens
• Microlending project
Sea Mar’s SDOH Approach
Increased Risk
Poverty
Poor housing quality
Environmental exposures
Poor nutrition/ food insecurity
Safety concerns
Decreased Access
Language or cultural barriers
Geographical barriers
Inadequate health insurance
Lack of benefits
Development
of illness
Severity of
illness
Healthcare
Policy
& Advocacy
Health disparities & vulnerable populations
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Uncoupling Poverty and Poor Health
Improve provider
ability to identify
social determinants
of health
Enhanced
family health
& wellbeing
Family
Empowerment
Medical-Legal
Collaboration
Enhanced
patient health
& wellbeing
Access to
legal
assistance
Collaboration: Sea Mar/NW Justice
Project offices in WA State
Possible protective factors
Non-Hispanic Whites
• Tobacco smoke 15%
• Breastfeeding 78%
• Fertility rate 58.8/1000 (‘16)
• Medicare Living alone 28.8%
• Medicare living w/ kids: 8%
• Suicide rate climbing
• Opioid epidemic worse
Hispanic/Latin@s
• Tobacco smoke 7%
• Breastfeeding 85%
• Fertility rate 70.6/1000 (’16)
• Medicare Living alone 25.3%
• Medicare living w/ kids: 18%
• Religiosity 83%
Building resilience in the Latino
community
Evidence
• Lowest tobacco use
• Highest breast feeding
• Highest fertility rates
• Multigenerational families
• Lower incomes
• Lower education
Thoughts
• Not advertised to
• Secure bond to mothers
• Nuclear family Incentive for
healthy individual habits.
• Kids, parents, abuel@s living
together gives benefit to
health?
• Is it protective vs. inactivity
and eating processed foods?
• Low SES universally seen as
deficit to good health
Don’t Forget Strengths & Assets!
• Community
• Family
• Faith
• Less US intervention
• Cultural pride
• Multilingual
• Self or family with US citizenship
• SDOH-6: “Do you have someone to call in case
of an emergency?”
Sea Mar CHC
clinic-based programs
Sea Mar Clinic Zumba classes
Sea Mar CHC community programs
Organize & Advocate
• Clinic-based organizing
• Promotor@s de Salud
• Direct actions/
Marches
• Latino Legislative Day
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Summary: “Everyone should have
enough, and No one should have
too much”
• The gap between the rich and the poor is the
best determinant of health (income inequality)
• Predi$tribution of wealth is the best way to
solve this (equity of social/political policy)
• Politics and health are in continuum
• We need Healthcare Activists to organize and
educate ourselves, our patients, our
communities to participate in our Democracy
Discussion?
Great. So what do I do now?
This is your moment of truth!
Levels of Intervention: Individual
STATE/NATIONAL
SYSTEMS
COMMUNITY
CLINIC
INDIVIDUAL
UPSTREAM
DOWNSTREAM
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There is plenty of money. It’s just
not where it needs to be.
In case you wanted to know where
it is…
Defining Equality vs Equity
Why is Maria in the clinic?
Levels of Intervention: Community
STATE/NATIONAL
SYSTEMS
COMMUNITY
CLINIC
INDIVIDUAL
UPSTREAM
DOWNSTREAM
Community Medicine
Gun violence: public health problem
Community building: the pill
A case study of the South Park Violence
Prevention Collaborative
Health
Mapping
Where is our
neighborhood
healthy?
Where is our
neighborhood
unhealthy?
Socioeconomic factor
component (rank 1-3):
Percent Below 200%
Poverty Level by
ZIP code
Poverty
Sensitive populations
component (rank 1-3):
Percent Foreign Born
by
ZIP code
Immigration status
Pollution
Environmental
exposures component
(Rank 1-10):
Annual Average Diesel
Particulate Matter in
human breathing zone
(ug/m3), by ZIP code
Public health factors
component
(Rank 1-5):
Childhood asthma
hospitalization
rate per 100,000 by
ZIP code
Asthma
Seattle
Cumulative
Impact
Analysis
Results
Georgetown/South Park disparities
Indicator Georgetown/
South Park
Census
tracts 109
and 112
Laurelhurst
Census
tracts 4100
and 4200
Seattle King County
Life expectancy at birth
(years)
73.3* 86.4* 81.5 81.5
Heart disease death rate
per 100,000
202.9# 89.6* 138.4 137.8
Source: Public Health Seattle & King County
*p=0.05 from both KC and Seattle average
#p= 0.05 for KC average only
+
Cumulative Effects - Imagine
+ +
+ +++++
+
OR
(Fill in Chronic Disease)
+ ++++
++
+
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What are community health
issues?
Anna Schulman, Antioch University, 2012
Reality check...the “Aha moment”
South Park Action Agenda
•Youth Development – Teen programs
•Community Engagement - organizing
•Public Safety – Neighbor-Police relationship
•Business development – Jobs, Vibrancy
•Transportation – prevents stagnancy
•Physical Environment – Sliver by the River
•South Park Plaza – “3rd place”
Levels of Intervention: Systems
STATE/NATIONAL
SYSTEMS
COMMUNITY
CLINIC
INDIVIDUAL
UPSTREAM
DOWNSTREAM
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http://datatools.urban.org/Features/mortgage
s-by-race/#5/38.000/-96.500
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Income inequality vs. Upward
mobility: the American Dream
Take Home #3
Politics and health are in
continuum
Levels of Intervention:
State/National
STATE/NATIONAL
SYSTEMS
COMMUNITY
CLINIC
INDIVIDUAL
UPSTREAM
DOWNSTREAM
US Life Expectancy 1960-2017
3 straight years drop – why?
US Life Expectancy 2014-16
US Age Specific Death Rates 2015-16
Washington Post 171221
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Drug, alcohol & suicide mortality men, women ages 45-54
Case, A. and A. Deaton (2017)
State/National
Interventions
• $15 minimum wage
• Paid paternity/maternity leave
• Immigration reform – keep families together
• Equitable wealth distribution = Predi$tribution
• Education (Pre-K education, subsidized/free higher
education)
• Access to affordable health care
• Prison reform, Re-enfranchisement
• Increased funding for public transportation
• Democratic process – power to the people!
2018 Access to Democracy Package
Signed by Gov. Inslee on March 19, 2018
July 1, 2019 voters can register at age 16 and
will be added to list of registered voters when
they turn 18.
Automatic voter registration when driver’s
license or enhanced ID granted
High school civics classes need to educate
students about their rights!
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CO2 in atmosphere – Yellowstone
We’ve passed +1 degree C
California drought (reported 2012)
Mass conflict/climate migration
Who will control the wealthiest,
most powerful nation in 2020?
Convince yourselves?
Income
• Maria’s Diabetes is a
symptom of an unbalanced
society. Her true disease is
poverty, so I have to treat
poverty.
• Not quite – the real issue is
that a few people have too
much $$/power. The real
disease: Addiction to
control.
Immigration
• We need immigration
reform so she can get a
bone marrow transplant
• Not quite – US empire
needs to end. Extractive
economy must end.
Colonial habits must end or
we will continue to have
economic refugees like her
with other expensive
diseases.
Convince yourselves?
Healthcare (Ill care) system
• Cannot read or write – this
was why her insulin was not
refrigerated and she was
hyperglycemic for 10 yrs.
Teach her to read.
Document illiteracy in ICD-
10 code so we can get
funding to address SDOH.
• Now - We need to end a for-
profit healthcare system.
Organize, Politics
• Before: Fight for $15/hr
(redi$tribute wealth)
• Now: Maximum wage!
(Predi$tribute wealth)
• Women leadership – better
for our health?
What is possible!
Where can you take action?
STATE/NATIONAL
SYSTEMS
COMMUNITY
CLINIC
INDIVIDUAL
UPSTREAM
DOWNSTREAM
Clinical Best Practices
•Support academic excellence
–ROR
–Library card, age appropriate kits
•Support Spanish literacy
–Bilingual preschools
–Visits in Spanish
•Support value of hard work
–Total minutes of exercise/wk massive w/ labor jobs. Very
protective vs. cardiovascular death
•Support exercise (150min/wk; 350min/wk)
•7-8 hrs sleep/night adults
Not using next slides
CVDz Deaths 2014-2016
Latin@s in WA State (M/F 35+)
CVDz Deaths 2014-2016 (M/F 35+)
Non-Hisp Whites in WA State
CHF Medicare hospitalizations
Latin@s. CDC 2014-2016
CHF Medicare hospitalizations.
CDC 2014-2016 Non-Hisp Whites
CAD Deaths Latin@s (M/F 35+)
CDC 2014-2016
CAD Deaths Non-Hisp Whites
(M/F 35+) CDC 2014-2016
World Wealth Inequality: USA
38.6% in 2004 (peak 47.8% in 1928)
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US Years lived w/ Disability, 2016
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05 session ii_julianperez

  • 1. Using a Social Determinants of Health Paradigm to Improve Chronic Disease Management in Latino Communities Sea Mar Community Health Centers 14th Annual Latino Health Forum October 30, 2019 Julian Perez, MD Sea Mar Community Health Centers
  • 2. Today’s agenda 1. Review concept of Social Determinants of Health 2. Review evidence for Income Inequality being greatest determinant of poor health outcomes in a population 3. Latest CDC chronic disease rate differences between Latin@s and White population in USA 4. Birth weight and Mortality differences through economic boom and busts and the political fallout 5. Closer look at US and WA chronic disease using GIS maps 6. Review a series of studies trying to uncover the mystery of the Latin@ paradox 7. End with the sum evidence for theories for Latin@ resilience and what we can and should be focused on in our clinics 8. Discussion
  • 3. What makes Latin@ families healthy? • Employment • Community/Support system • English fluency • Immigration status • Education/Literacy • Environments “Place matters” • Public health policies • Diet • Physical Activity • Habits • Genetics • Preventative medicine • Curative medicine
  • 4. Healthy Sick Outcome Symptoms Access x x Treatment genetics 30% health care 10% Societal determinants: 60% of health
  • 6. “The gap” What’s the evidence? Is income important for health? Is income inequality bad for our health? Is income equality good for our health?
  • 8. How rich is the USA? (2017 World Bank data) •#2 GDP = $17.7 trillion •325 million population •GNI per capita: $55,351 •Life expectancy at birth: 78.5 yrs •Income inequality ranking: #1 (the highest)
  • 11. World Income Inequality: USA 20.2% in 2004 (peak 21.4% in 1928)
  • 16. Take home #1 Sharing is good for your health
  • 19. Infant mortality #/1000 live births CDC 2013-2015 •US Total 5.9 •US Non-Hispanic Whites 5 •US Hispanic/Latinas 5 •WA State Total 4.6 •WA State Non-Hispanic Whites 4.2 •WA State Hispanic/Latinas 4.6
  • 20. US Low birth weights (under 2.5kg) Non-Hispanic Whites •1980: 5.69% •1990: 5.61% •------.Com boom---------- •2000: 6.60% •2005: 7.29% (Recession) •2010: 7.14% •----------ACA------------- •2014: 6.96% •2015: 6.93% •2016: 6.99% Hispanic/Latin@s •1980: 6.12% •1990: 6.06% •------.Com boom--------- •2000: 6.41% •2005: 6.88% (Recession) •2010: 6.97% •----------ACA---------- •2014: 7.05% •2015: 7.21% •2016: 7.31%
  • 21. WA State Low birth weights Under 2.5kg. CDC Non-Hispanic Whites •2000-2002: 5.43% •2011-2013: 5.66% •2014-2016: 5.87% Hispanic/Latin@s •2000-2002: 5.31% •2011-2013: 6.24% •2014-2016: 6.20%
  • 24. WA
  • 25. Summary •Income does correlate with longer life •Inequality is a good predictor of poor population health •Higher income equity is associated with lower mortality (longer life)
  • 26. What makes Latin@s healthy? •My Dad, “I married your mother” •My Dad, “Low incomes make us eat at home more” •Me, “Mexican pride” •My wife, “Telenovelas” •Viejito, “Chile piquin” •Aunt Rita, “Faith in God” •Aunt Margie, “Close family”
  • 27. What makes Immigrant families healthy? • Immigration status • Employment • Community/Support system • English fluency • Education/Literacy • Environments “Place matters” • Public health policies • Diet • Physical Activity • Habits • Genetics • Preventative medicine • Curative medicine
  • 29. U.S. Chronic Disease Rates CDC 2013-2016 Non-Hispanic Whites • HTN 46% (48%M, 43%F) • DM 9.6% (2% undiagnosed) • DM A1c >9 = 16.6% • Obesity 38% (M 37%,F 39%) • Kids Ob 14.7% • Asthma under 18 y/o: 7.1% • Uninsured 7.3% • Health “Fair/Poor” 7.6% • Depression 3.7% (2.9% ‘90) Hispanic/Latin@s • HTN 54% (60%M, 50%F) • DM 17% (4.7% undiagnosed) • DM A1c >9 = 30% • Obesity 45% (M 41%,F 48%) • Kids Ob 23.6% • Asthma under 18 y/o: 6.7% • Uninsured 19.6% • Health “Fair/Poor” 12.4% • Depression 3.7% (5% ’90)
  • 37. WA Less than HS 25+ y/o CDC. 2013-2017
  • 38. WA Poverty all ages. CDC 2016
  • 39. WA Uninsured% Under 65 y/o CDC 2016
  • 42. Inactivity% WA 20+ y/o. CDC 2015
  • 43. Obesity% WA 20+ y/o. CDC 2015
  • 44. Diabetes% WA 20+ y/o. CDC 2015
  • 46. HTN Medicare hospitalizations Non- Hispanic Whites. CDC 2014-2016
  • 47. BP higher in undocumented Latin@s J Urban Health. 2017 Dec;94(6):764-775. doi: 10.1007/s11524-017-0197-3 Legal Status, Time in the USA, and the Well-Being of Latinos in Los Angeles. Young MT1, Pebley AR2. Author information 1 University of California, Los Angeles, Los Angeles, CA, USA. mariaelena@ucla.edu. 2 University of California, Los Angeles, Los Angeles, CA, USA.
  • 50. SOURCE: NCHS, Health, United States, 2017, Figure 8. Data from the National Health Interview Survey (NHIS). Current asthma among children. CDC 2006- 2016
  • 51. Depression equal, but antidepressant use is lower in Undocumented Latin@s Ann Epidemiol. 2019 Sep;37:17-23.e3. doi: 10.1016/j.annepidem.2019.07.007. Epub 2019 Jul 12. Association between immigration status and anxiety, depression, and use of anxiolytic and antidepressant medications in the Hispanic Community Health Study/Study of Latinos. Ross J1, Hua S2, Perreira KM3, Hanna DB2, Castañeda SF4, Gallo LC5, Penedo FJ6, Tarraf W7, Hernandez R8, Vega Potler N2, Talavera GA4, Daviglus ML6, Gonzalez F 2nd3, Kaplan RC2, Smoller-Wassertheil S2.
  • 52. U.S. Causes of Death. CDC 2017 Non-Hispanic Whites 1. Heart disease 23.3% 2. Cancer 21.4% 3. Chronic Lung disease 6.4% 4. Unintentional injuries 5.8% 5. Stroke 5% 6. Alzheimers 4.7% 7. Diabetes 2.5% 8. Influenza/PNA 2% 9. Suicide 1.7% 14. HTN/ESRD 1.1% Homicide #20 at 0.3% Hispanic/Latinos 1. Cancer 20.6% 2. Heart disease 20% 3. Unintentional injuries 8.5% 4. Stroke 5.5% 5. Diabetes 4.7% 6. Alzheimers 3.7% 7. Cirrhosis 3.2% 8. Chronic Lung disease 2.8% 9. Suicide 2% 14. HTN/ESRD 1.4% Homicide #12 at 1.6%
  • 53. Life expectancy at birth, by sex and race and Hispanic origin NOTES: Life expectancy data by Hispanic origin were available starting in 2006 and were corrected to address racial and ethnic misclassification. Life expectancy estimates for 2016 are based on preliminary Medicare data. SOURCE: NCHS, Health, United States, 2017, Figure 1. Data from the National Vital Statistics System (NVSS), Mortality.
  • 54. Mortality Ages 45-54 Case, A. and A. Deaton (2017)
  • 55. 2016 Election swing • Best predictor was combined measure of low exercise, heavy EtOH, diabetes, obesity, low life expectancy = worse health made worse by income inequality
  • 57. Potential Life Years Lost CDC 2016 Non-Hispanic Whites • Total 6715 • Heart Disease 888 • Cancer 1251 • Accidents 1430 – Overdose 756 • Suicide 492 Hispanic/Latin@s • Total 4926 • Heart Disease 574 • Cancer 900 • Accidents 914 – Overdose 402 • Suicide 239
  • 58. Are Latin@s healthier because we use more healthcare services? Non-Hispanic Whites • Medicaid beneficiaries 36% • Medicaid payments/ beneficiary: $6691 • Medicare beneficiaries 75.6% • Medicare payments/ beneficiary: $17,367 Is the healthcare system… Hispanic/Latin@s • Medicaid beneficiaries 17.4% • Medicaid payments/ beneficiary: $2958 • Medicare beneficiaries 9.1% • Medicare payments/ beneficiary: $18,651 bad for your health?
  • 59. Do healthy behaviors decline with greater acculturation? Implications for the Latino mortality paradox. Soc Sci Med. 2005 Sep;61(6):1243-55. Epub 2005 Mar 3. Abraído-Lanza AF1, Chao MT, Flórez KR. Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, 722 West 168 Street, 5th floor, New York, NY 10032, USA. aabraido@columbia.edu
  • 60. Do Healthy behaviors in Latino populations decline w/ acculturation Behaviors studied • Smoking lower • Alcohol use lower • Leisure exercise lower • BMI higher Controlling for SES, age, acculturation associated with • Smoking up • Alcohol use up • BMI up • Leisure exercise up
  • 62. Race/Ethnic Differences in Adult Mortality: The Role of Perceived Stress and Health Behaviors Patrick M. Krueger, 1 Jarron M. Saint Onge, 2 and Virginia W. Chang 3,4,5 Soc Sci Med. 2011 Nov; 73(9): 10.1016/j.socscimed.2011.08.007. Published online 2011 Aug 26. doi: 10.1016/j.socscimed.2011.08.007 PMCID: PMC3816937 NIHMSID: NIHMS322231 PMID: 21920655
  • 64. Tobacco cigarette smoking CDC 2014-2016, age & SES Non-Hispanic Whites • Total: 17.2% • 18-24 y/o: 16.5% • 25-34 y/o: 19.6% • 35-44 y/o: 20.7% • 45-64 y/o: 19% • 65+ y/o: 7.8% • Below 100% Pov: 37% • 100-199%: 28% • 200-399%: 18.6% • 400+%: 8.8% Hispanic/Latin@s • Total: 7.3% • 18-24 y/o: 5% • 25-34 y/o: 6% • 35-44 y/o: 8.3% • 45-64 y/o: 9.5% • 65+ y/o: 5% • Below 100% Pov: 10% • 100-199%: 7% • 200-399%: 6% • 400+%: 5.6%
  • 65. Current smoking, stress, and mortality by race/ethnicity
  • 66. Alcohol consumption and mortality by race/ethnicity
  • 67. Alcohol use. CDC 2002-2016 Non-Hispanic Whites • 2002 55% • 2015 57% • 2016 56% • Binging 2016 25.4% • Heavy 2016 7.2% Hispanic/Latin@s • 2002 42.8% • 2015 42.4% • 2016 42.5% • Binging 2016 24.9% • Heavy 2016 4.5%
  • 68. Sleep hours and mortality by race/ethnicity
  • 69. Physical inactivity and Mortality by Race/Ethnicity
  • 70. Racial, Ethnic, and Gender Differences in Physical Activity J Hum Cap. 2013 Winter; 7(4): 378–410. Henry Saffer, Dhaval Dave, Michael Grossman, and Leigh Ann Leung
  • 71. The Association Between Family Social Network Size and Healthy Lifestyle Factors: Results from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) Rosenda Murillo et al. Journal of Behavioral Medicine. pp1-11. 2019, July
  • 72. Resiliency in the face of disadvantage: do Hispanic cultural characteristics protect health outcomes? Gallo LC1, Penedo FJ, Espinosa de los Monteros K, Arguelles W. J Pers. 2009 Dec;77(6):1707-46. doi: 10.1111/j.1467-6494.2009.00598.x. Epub 2009 Sep 30.
  • 73. Hispanic cultural characteristics Gallo Allocentrism – needs of the many over the individual – may lead to higher level of social cohesiveness and community support Simpatia – drive toward pleasant, non- confrontational social interactions, perhaps fostering socially desirable patterns and responses – leading to better social relationships
  • 74. Hispanic cultural characteristics Gallo Familialism –strong attachments to the nuclear and extended family emphasized Power distance/Personal space – amount of physical space deemed appropriate for interpersonal interactions. Hispanics are more comfortable with close distances Gender roles – machismo (male dominance) vs. marianismo (female submissiveness) defined in 1973 as being characterized by female passivity, dependence, self-sacrifice, and placing family needs first
  • 75. Hispanic cultural characteristics Gallo Religiousness – 94% of Hispanics had a religious affiliation in 2003 and is associated w/ lower smoking rates and lower mental health illnesses and also predicts higher life satisfaction, lower substance abuse rates and higher health seeking behaviors for those that do have substance use problems. Down to 83% in 2012 vs. 80% in general population Fatalism – believing that ones fate or destiny is beyond one’s control
  • 77. Ask different questions Ask better questions
  • 78. Levels of Intervention: Clinic STATE/NATIONAL SYSTEMS COMMUNITY CLINIC INDIVIDUAL UPSTREAM DOWNSTREAM
  • 79. Patient case: Azucar • 45 y/o F, 10+ yrs poorly controlled IDDM • Transferred to me for “non-compliance” • SDOH screen Assets Deficits Employed Unstable housing Had food Mexican Immigrant woman Had emergency contact Uninsured, Undocumented Good health-seeking behavior Non-English speaker Trust in doctors Can’t read/write
  • 80. Azucar’s Treatment Plan • Can’t read – was not refrigerating insulin x 10 yr – Referred to Goodwill for ESL and literacy • Cheaper insulin • Low-literacy health education materials • EMR: SDOH Diagnoses added to problem list – makes them active problems to be worked on consistently • HbA1c 14+ down to 8+ in 6 months. Stable. How do you begin to NOT ONLY treat Azucar with SDOH lenses, but how to you treat her entire community?
  • 81. The 3 “Ms”: Mission, Masses, Methods Changing the paradigm of your clinic operations
  • 83. Maria Luisa Ortiz Women’s Cooperative Mulukuku, Nicaragua • OB/Gyn care, Casa Materna • Medical, Psych, Social • Mobile clinics • Dental, Pharmacy • Political participation • Traditional medicine • Legal, Remediations • Radio/Communication • Refuge, shelter, self defense • School based gardens • Microlending project
  • 84. Sea Mar’s SDOH Approach
  • 85. Increased Risk Poverty Poor housing quality Environmental exposures Poor nutrition/ food insecurity Safety concerns Decreased Access Language or cultural barriers Geographical barriers Inadequate health insurance Lack of benefits Development of illness Severity of illness Healthcare Policy & Advocacy Health disparities & vulnerable populations
  • 87. Uncoupling Poverty and Poor Health Improve provider ability to identify social determinants of health Enhanced family health & wellbeing Family Empowerment Medical-Legal Collaboration Enhanced patient health & wellbeing Access to legal assistance
  • 88. Collaboration: Sea Mar/NW Justice Project offices in WA State
  • 89. Possible protective factors Non-Hispanic Whites • Tobacco smoke 15% • Breastfeeding 78% • Fertility rate 58.8/1000 (‘16) • Medicare Living alone 28.8% • Medicare living w/ kids: 8% • Suicide rate climbing • Opioid epidemic worse Hispanic/Latin@s • Tobacco smoke 7% • Breastfeeding 85% • Fertility rate 70.6/1000 (’16) • Medicare Living alone 25.3% • Medicare living w/ kids: 18% • Religiosity 83%
  • 90. Building resilience in the Latino community Evidence • Lowest tobacco use • Highest breast feeding • Highest fertility rates • Multigenerational families • Lower incomes • Lower education Thoughts • Not advertised to • Secure bond to mothers • Nuclear family Incentive for healthy individual habits. • Kids, parents, abuel@s living together gives benefit to health? • Is it protective vs. inactivity and eating processed foods? • Low SES universally seen as deficit to good health
  • 91. Don’t Forget Strengths & Assets! • Community • Family • Faith • Less US intervention • Cultural pride • Multilingual • Self or family with US citizenship • SDOH-6: “Do you have someone to call in case of an emergency?”
  • 93. Sea Mar Clinic Zumba classes
  • 94. Sea Mar CHC community programs
  • 95. Organize & Advocate • Clinic-based organizing • Promotor@s de Salud • Direct actions/ Marches • Latino Legislative Day
  • 98. Summary: “Everyone should have enough, and No one should have too much” • The gap between the rich and the poor is the best determinant of health (income inequality) • Predi$tribution of wealth is the best way to solve this (equity of social/political policy) • Politics and health are in continuum • We need Healthcare Activists to organize and educate ourselves, our patients, our communities to participate in our Democracy
  • 100. Great. So what do I do now? This is your moment of truth!
  • 101. Levels of Intervention: Individual STATE/NATIONAL SYSTEMS COMMUNITY CLINIC INDIVIDUAL UPSTREAM DOWNSTREAM
  • 103. There is plenty of money. It’s just not where it needs to be.
  • 104. In case you wanted to know where it is…
  • 106. Why is Maria in the clinic?
  • 107. Levels of Intervention: Community STATE/NATIONAL SYSTEMS COMMUNITY CLINIC INDIVIDUAL UPSTREAM DOWNSTREAM
  • 108. Community Medicine Gun violence: public health problem Community building: the pill A case study of the South Park Violence Prevention Collaborative
  • 110. Socioeconomic factor component (rank 1-3): Percent Below 200% Poverty Level by ZIP code Poverty
  • 111. Sensitive populations component (rank 1-3): Percent Foreign Born by ZIP code Immigration status
  • 112. Pollution Environmental exposures component (Rank 1-10): Annual Average Diesel Particulate Matter in human breathing zone (ug/m3), by ZIP code
  • 113. Public health factors component (Rank 1-5): Childhood asthma hospitalization rate per 100,000 by ZIP code Asthma
  • 115. Georgetown/South Park disparities Indicator Georgetown/ South Park Census tracts 109 and 112 Laurelhurst Census tracts 4100 and 4200 Seattle King County Life expectancy at birth (years) 73.3* 86.4* 81.5 81.5 Heart disease death rate per 100,000 202.9# 89.6* 138.4 137.8 Source: Public Health Seattle & King County *p=0.05 from both KC and Seattle average #p= 0.05 for KC average only
  • 116. + Cumulative Effects - Imagine + + + +++++ +
  • 117. OR (Fill in Chronic Disease) + ++++ ++ +
  • 119. What are community health issues? Anna Schulman, Antioch University, 2012
  • 121. South Park Action Agenda •Youth Development – Teen programs •Community Engagement - organizing •Public Safety – Neighbor-Police relationship •Business development – Jobs, Vibrancy •Transportation – prevents stagnancy •Physical Environment – Sliver by the River •South Park Plaza – “3rd place”
  • 122. Levels of Intervention: Systems STATE/NATIONAL SYSTEMS COMMUNITY CLINIC INDIVIDUAL UPSTREAM DOWNSTREAM
  • 132. Income inequality vs. Upward mobility: the American Dream
  • 133. Take Home #3 Politics and health are in continuum
  • 135. US Life Expectancy 1960-2017 3 straight years drop – why?
  • 136. US Life Expectancy 2014-16 US Age Specific Death Rates 2015-16 Washington Post 171221
  • 138. Drug, alcohol & suicide mortality men, women ages 45-54 Case, A. and A. Deaton (2017)
  • 139. State/National Interventions • $15 minimum wage • Paid paternity/maternity leave • Immigration reform – keep families together • Equitable wealth distribution = Predi$tribution • Education (Pre-K education, subsidized/free higher education) • Access to affordable health care • Prison reform, Re-enfranchisement • Increased funding for public transportation • Democratic process – power to the people!
  • 140. 2018 Access to Democracy Package Signed by Gov. Inslee on March 19, 2018 July 1, 2019 voters can register at age 16 and will be added to list of registered voters when they turn 18. Automatic voter registration when driver’s license or enhanced ID granted High school civics classes need to educate students about their rights!
  • 142. CO2 in atmosphere – Yellowstone
  • 143. We’ve passed +1 degree C
  • 146. Who will control the wealthiest, most powerful nation in 2020?
  • 147. Convince yourselves? Income • Maria’s Diabetes is a symptom of an unbalanced society. Her true disease is poverty, so I have to treat poverty. • Not quite – the real issue is that a few people have too much $$/power. The real disease: Addiction to control. Immigration • We need immigration reform so she can get a bone marrow transplant • Not quite – US empire needs to end. Extractive economy must end. Colonial habits must end or we will continue to have economic refugees like her with other expensive diseases.
  • 148. Convince yourselves? Healthcare (Ill care) system • Cannot read or write – this was why her insulin was not refrigerated and she was hyperglycemic for 10 yrs. Teach her to read. Document illiteracy in ICD- 10 code so we can get funding to address SDOH. • Now - We need to end a for- profit healthcare system. Organize, Politics • Before: Fight for $15/hr (redi$tribute wealth) • Now: Maximum wage! (Predi$tribute wealth) • Women leadership – better for our health?
  • 150. Where can you take action? STATE/NATIONAL SYSTEMS COMMUNITY CLINIC INDIVIDUAL UPSTREAM DOWNSTREAM
  • 151. Clinical Best Practices •Support academic excellence –ROR –Library card, age appropriate kits •Support Spanish literacy –Bilingual preschools –Visits in Spanish •Support value of hard work –Total minutes of exercise/wk massive w/ labor jobs. Very protective vs. cardiovascular death •Support exercise (150min/wk; 350min/wk) •7-8 hrs sleep/night adults
  • 152. Not using next slides
  • 153. CVDz Deaths 2014-2016 Latin@s in WA State (M/F 35+)
  • 154. CVDz Deaths 2014-2016 (M/F 35+) Non-Hisp Whites in WA State
  • 156. CHF Medicare hospitalizations. CDC 2014-2016 Non-Hisp Whites
  • 157. CAD Deaths Latin@s (M/F 35+) CDC 2014-2016
  • 158. CAD Deaths Non-Hisp Whites (M/F 35+) CDC 2014-2016
  • 159. World Wealth Inequality: USA 38.6% in 2004 (peak 47.8% in 1928)
  • 167. US Years lived w/ Disability, 2016