HPH NOW, March 18, 2005, International Government Officials Share Views on Ways to Lessen Health Disparities


	Asa Cristina Laurell, Minister of Health, Mexico City

Governments can act to lessen health disparities among their citizens with measurable success, according to health officials from Mexico City, Sweden, the U.K., and the U.S. who shared their approaches at a March 3 symposium organized by an HSPH-wide interfaculty working group on health disparities.

"We are all struggling with the common challenge, which is how to make a dent in health disparities," said Carolyn Clancy, Director of the Agency for Healthcare Research and Quality (AHRQ) at the U.S. Department of Health and Human Services. "We know how to report and describe. We’re really good at that. How do we then transform that into action and evaluate the effectiveness?"

The event, introduced by HSPH Dean Barry Bloom, was the first of three symposia on "Health Disparities and the Body Politic" and is archived for viewing at www.hsph.harvard.edu/disparities/webcast.html. The next talk, "Investigating Health Disparities: New Agendas for National Health Research Institutes," will take place on April 14. For more information, visit www.hsph.harvardedu/disparities/index.html. The symposia are sponsored by the David Rockefeller Center on Latin American Studies at Harvard University and the Harvard Center for Society and Health.


Fiona Adshead, Deputy Chief Medical Officer, UK Department of Health

Health is more than a matter of individual behavior, representatives from all four countries suggested, and policy decisions related to the environment, transportation, labor, housing, and the organization of medical services can have profound effects on health and well-being.

"Despite centuries of evidence, only in the last decade has concern about social inequities in health become part of the mainstream public health agenda," said Nancy Krieger, HSPH Associate Professor of Society, Human Development, and Health, who spearheaded the organization of all three symposia.

Governments face an enormous challenge in reaching, let alone helping, those most in need, said David Studdert, HSPH Associate Professor of Law and Public Health. In this country, the federal government’s share of the national health care bill is increasing, and is estimated to reach 50 percent of total health care spending by 2014. Yet, of low-income adults who are eligible for public health insurance programs and who have no other form of insurance, slightly less than half are enrolled nationwide, and the figure dips to 30 percent in some states, he said.


Carolyn Clancy, Director of AHRQ

The best possible science consistently documents disparities in health care quality and access, Clancy said, citing two National Healthcare Disparities reports published by AHRQ, which provided a comprehensive overview of disparities and tracked progress toward a U.S. government goal of eliminating disparities by 2010. More research is urgently needed to understand the relationship between race, ethnicity and health care, she said, and "we need more interaction among communities of researchers and leaders."

For now, early leadership seems to be coming from the private sector. The heads of nine major health care plans have formed a national coalition to reduce disparities in health care for people with diabetes and other conditions, said Clancy.

In addition to disparities in health outcomes, there persists a gap between the best possible care available and actual care given, according to an annual report by AHRQ. With studies showing that barely half of all people receive the best evidence-based health care, simply "closing the [disparities] gap seems to be a fairly low aim," she said. The quality of health care is improving slowly, but there are areas for major improvements.


	MA State Senator Dianne Wilkerson

South of the border, Mexico endows its citizens a constitutional right to health, which the Mexico City government is working to ensure for its poorest citizens. They make up about half of the population, said Asa Cristina Laurell, Minister of Health, Mexico City. Two broad new programs in the last four years are a major departure from 25 years of underfinancing, corruption, demoralization of health workers, and a loss of confidence in public health institutions, she said.

In the first step toward a universal pension, the city government provides money for food and free health care to about 371,000 people aged 70 and older. "It’s important to point out that health policy is part of a broader agenda," Laurell said, "and the Mexico City government gave the highest priority to social policy."


Irene Nilsson Carlsson, Director of the Division for Public Health in Sweden

Aiming to reduce inequities on a large scale, the city has restructured and expanded public health care institutions. As of December, 710,000 of an estimated 900,000 eligible families had enrolled in a program that helps people with lower incomes, less formal education, and residences in poorer neighborhoods receive free care. The numbers of surgeries, medically supervised births, emergency room visits, hospital admissions, and lab tests have all increased. Ten percent of the city budget is now devoted to offering free health services, a result of budget cutting elsewhere.

In Sweden, a new National Institute of Public Health was established to reach particularly vulnerable groups and to reduce the unequal distribution of health, said Irene Nilsson Carlsson, Director of the Division for Public Health in Sweden. "Generally speaking, Swedes are a healthy people; we are among the top in the world," Carlsson said. But there still are unacceptably large differences in rates of illness and death between the wealthy and the poor, between the sexes, among different social groups, between native Swedes and immigrants, and among different parts of the country.


	HSPH Associate Professor Nancy Krieger

The new comprehensive national policy relies heavily on the coordination of other government agencies from the national cabinet down to the local municipalities, Carlsson said. For example, the public health minister is collaborating with the agriculture department on an obesity prevention program. On another front, it is seeking to prevent regional authorities from selling public emergency hospitals to private owners. "It is so important that we should have free access to all people to emergency hospitals," Carlsson said. "The quality in publicly owned health care services is very high, so there is no reason for even the very wealthy to seek health care outside the public health care system."

The U.K., which has produced some of the most well-known reports on health disparities, has adopted a national policy to improve health and its social determinants, said Fiona Adshead, Deputy Chief Medical Officer for the nation’s Department of Health. As in Sweden, the health ministry works with other government agencies to tackle issues of health care delivery, prevention, childhood poverty, housing, and education.


HSPH Associate Professor David Studdert

The subsequent challenge is to engage people in their own health, Adshead said. "Once [we] provide people with the practical support and opportunities and address some of those barriers of inequities, the engine for change is people themselves," she said. Research and evaluation must be part of the process to show areas of success and to sustain the political will to address areas of continued inequities, she said.

Following their presentations, the speakers fielded questions from event discussant and Massachusetts State Senator Dianne Wilkerson, who co-chairs a state special commission to eliminate health disparities. She also participated in a panel discussion with the speakers and with Deborah Prothrow-Stith, HSPH Professor of Public Health Practice, Kalahn Taylor-Clark, W.K. Kellogg Doctoral Fellow in Health Policy Research, Harvard University, Sofia Gruskin, HSPH Associate Professor of Health and Human Rights, and Ashish Jha, HSPH Assistant Professor of Health Policy and Management and HMS Research Fellow in Medicine.

--CCM

Small Groups Continue Health Disparities Conversation with Officials Day after Symposium


	From left to right, Asa Cristina Laurell, Minister of Health of Mexico City, speaks with HSPH Professor Lisa Berkman, a student, and Assistant Professor Gary Bennett.

In a rare opportunity for informal, face-to-face conversations with top health officials, about 30 HSPH students, faculty, and guests discussed public health over breakfast on March 4 in the Kresge cafeteria with representatives of the Swedish, UK, and Mexico City governments. The gathering followed a health disparities symposium held the day before. See above.

Designed for efficiency, the breakfast’s format mimicked that of a speed-dating event, in which the three health officials moved from table to table after 20-minute intervals to sit with participants and answer any questions they may have.

Fiona Adshead, Deputy Chief Medical Officer for the Department of Health in the U.K., described how her government has been successful in shifting awareness of health inequalities from rarefied academic circles to local governments and private citizens. She said a key part of that success has been the inclusion of health in so-called Regulatory Impact Assessments, or documents published with regulatory proposals and new legislation. In the past, these assessments have focused on subjects like how proposals would impact businesses, but after a six-year lobbying effort by the Department of Health, the assessments must now also predict how regulations would affect the health of people within the community. The current challenge is to train civil servants to interpret that information, she said. There is interest in the U.S. to try a similar approach. HSPH Professor Ichiro Kawachi is lead author on a new paper in Health Affairs that calls for health equity impact statements to accompany government policy proposals.

In Sweden, the national Division for Public Health is trying to expand the involvement of the health care sector in health promotion, said Irene Nilsson Carlsson, who directs the agency. Large-scale information campaigns about health disparities seem ineffective, she said. Instead, the Division is trying to convince regional health care providers that addressing health inequalities and promoting prevention will prove cost-effective.

Mexico maintains a national system that collects, among other things, information on race and ethnicity to help monitor health disparities, explained Asa Cristina Laurell, Minister of Health for Mexico City. Officials use such information to compare areas in Mexico City to enact social programs. One current project is trying to better understand the source and distribution of microparticles of air pollution in the city.

Next Symposium on Health Disparities and the Body Politic

To register, visit http://www.hsph.harvard.edu/disparities/registration.html

"Investigating Health Disparities: New Agendas for National Health Research Institutes"

Thursday, April 14, 2 p.m.-5 p.m.,
Harvard Conference Center,
77 Avenue Louis Pasteur, Boston

Moderator: HSPH Professor Lisa Berkman

Speakers: Elias Zerhouni, Director, U.S. National Institutes of Health; John Frank, Scientific Director, Institute of Population and Public Health, Canada; Mirta Roses Periago, Director, Pan American Health Organization; Sujatha Rao, Member Secretary of the National Commission on Macroeconomics and Health, India

Discussant: Harvey Fineberg, President, Institute of Medicine, and Former HSPH Dean

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