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of Social Work & Social Welfare
Eradicating Health Inequalities for Future Generations
Eradicating Health Inequalities for
Karina L. Walters Teri Browne
University of Washington University of South Carolina
Michael S. Spencer Peter Maramaldi
University of Michigan Simmons College Michael Smukler Darrell P. Wheeler University of Washington University at Albany, State University of New York Heidi L. Allen Brad Zebrack Columbia University University of Michigan Christina Andrews Edwina Uehara University of South Carolina University of Washington Working Paper No. 19 January 2016 Grand Challenge: Close the health gap American Academy of Social Work and Social Welfare aaswsw.org The Grand Challenges for Social Work are designed to focus a world of thought and action on the most compelling and critical social issues of our day. Each grand challenge is a broad but discrete concept where social work expertise and leadership can be brought to bear on bold new ideas, scientific exploration and surprising innovations.
We invite you to review the following challenges with the goal of providing greater clarity, utility and meaning to this roadmap for lifting up the lives of individuals, families and communities struggling with the most fundamental requirements for social justice and human existence.
The Grand Challenges for Social Work include the following:
Ensure healthy development of all youth Build financial capability for all Close the health gap Harness technology for social good Stop family violence Create social responses to a changing environment Eradicate social isolation
Dramatic health inequalities in the United States exist by race, ethnicity, gender, age, disability status, geography, sexual and gender identity, and socioeconomic status. Despite increased attention, our health system has made insufficient progress in reducing these disparities and creating greater health equity. Too little attention has focused on the social determinants of health—economic, social, and environmental factors—whereby health disparities take root, inequalities grow, and inequities reproduce. The American Academy of Social Work and Social Welfare believes that social work is well positioned to lead several multisectoral and transdisciplinary priorities for action to dramatically reduce inequities within one generation. Priorities for action include focusing on settings to improve conditions of daily life, advancing community empowerment for sustainable health, cultivating innovation in primary care, promoting full access to health care, generating innovations in research on social determinants of health inequities, fostering interprofessional workforce development, and stimulating multisectoral advocacy to promote health equity policies.
Key words: community empowerment, health inequity, interprofessional workforce, Patient Protection and Affordable Care Act of 2010, primary care, social determinants of health, social work Tāne, the deity of the forest, lived with his siblings in darkness within the eternal embrace of his parents, Ranginui (sky father) and Papatūānuku (earth mother). Becoming increasingly frustrated at living in the darkness, Tāne successfully pushed the pair apart by planting his head in the earth and using his feet to lift the sky—to expose Te Ao Mārama—the world of light.
Among the Māori, the indigenous people of Aotearoa/New Zealand, Tāne serves as a model for action in the world: His roots are in earth, and his head is in the heavens. Tāne is able to bear the Authors Allen through Zebrack are listed in alphabetical order. Author contributions: K. L. Walters was the lead author for the group and was responsible for conceptualizing the paper, synthesizing authors’ comments, and writing the final publication with M. Spencer. M. Spencer contributed to the conceptualization of the paper and provided leadership in co-writing the final draft with K. Walters. M. Smukler contributed to the literature review, wrote drafts of the paper, and provided final edits. All other authors are presented in alphabetical order, equally participating in various component parts of the paper’s development and product. H. Allen, C. Andrews, P. Maramaldi, and D. P.
Wheeler contributed to the conceptualization and the refinement of the priorities as well as edits to the final paper.
T. Browne and B. Zebrack contributed to the content of the paper and provided edits on the final paper. E. Uehara contributed to the conceptualization of the paper and provided guidance throughout.
Story adapted here from http://www.teara.govt.nz/en/te-waonui-a-tane-forest-mythology/page-1 Working Paper
HEALTH EQUITY: ERADICATING HEALTH INEQUALITIES FOR FUTURE GENERATIONSweight of action to procure necessary change. Similar to Tāne, social work must assert itself, bring new light, and bear the weight of action—in collaboration with allied health professions— to achieve health equity within the next generation. Social work has already had a significant impact on health interventions in the United States—from the health-policy reform efforts of the Progressive Era to the development of innovative community-based prevention interventions in modern times. Social work’s perspective is in line with approaches that go beyond population surveillance, prompting action to address health inequities and social determinants of health.
Specifically, social work has an unyielding focus on lifting the health of a nation by lifting the health of the most indigent and marginalized populations. Also, its historical social-reform efforts have sought to procure health by addressing the conditions in which people live, work, play, learn, and age. These perspectives match the calls by the World Health Organization (WHO, 2014), U.S. Centers for Disease Control and Prevention (Brennan Ramirez, Baker, & Metzler, 2008), and the Healthy People 2020 national strategy (U.S. Department of Health and Human Services, n.d.) to focus contemporary research and intervention efforts on the social conditions that produce health and health inequities. Additionally, the reassertion of social work into the national strategy and debate is timely given the recent passage of the Patient Protection and Affordable Care Act (ACA; 2010) and the bourgeoning national effort to create culturally, linguistically, and communally grounded interventions that affect the upstream determinants of the nation’s poor health.
Although the United States is among the wealthiest nations in the world and spends far more per person on health care than any other industrialized nation, its health is rapidly deteriorating. Over the past three decades, the U.S. population has been dying at younger ages than those of the populations in peer nations and has endured a pervasive pattern of poorer health throughout the life course, from birth to old age (Institute of Medicine, 2013). The United States now ranks 27th out of 34 industrialized nations in terms of life expectancy. Moreover, population health diminishes along a social gradient: Populations that experience high rates of social, racial, and economic exclusion bear the greatest burden of poor health and premature mortality. These experiences lead to the current high rates of racial and ethnic health disparities within the United States.3 Although poor health follows a social gradient, deteriorating U.S. health cannot be fully explained by the health disparities that exist among people who are uninsured or poor; in fact, even the health of relatively elite Americans—those who are White, insured, and college educated, as well as those with high income—is worse than that of their peers in other industrialized countries (Avendano, Glymour, Banks, & Mackenbach, 2009; Institute of Medicine, 2013).
Despite these downward trends, health research in the United States lags behind international research efforts to focus on upstream social and economic determinants of health. Instead, the U.S. health professions have become increasingly myopic, focusing on individualized health care rather than on health. By prioritizing interventions that target individual behavioral change, research tends to neglect upstream opportunities to intervene upon the settings and environments in which health is produced and maintained. Likewise, although the emerging field of genomics For purposes of this document, the term ethnic is inclusive of groups that affiliate in terms of gender expression, sexuality, nationality, and religion.
and “precision medicine” may offer unprecedented prospects for saving individual lives, they will likely yield little impact on population health. Attention to health care and behavioral interventions are important but simply not sufficient to eradicate health inequities (Hood, Gennuso, Swain, & Catlin, 2015). To secure true, sustainable, population-based health changes, the health professions must unite and develop transdisciplinary approaches to examining the multilayered contributions of political, economic, and social determinants of population health inequities. Indeed, the nation’s health depends on the development of this next wave of interprofessional and transdisciplinary collaboration (McGovern, Miller, & Hughes-Cromwick, 2014). Although health researchers have rallied to address this need, questions remain and research is needed to link policy and practice to proximal, intermediate, and distal social determinants (Syme, 2008). Thus, if we are to truly turn the tide, health disciplines, particularly social work, must train professionals in how to invest in the social determinants of good health.
We must also train professionals to develop the practice and research tools, community partnerships, and localized programs necessary to combat social and economic inequities (Hood et al., 2015; Uehara et al., 2013). The social work profession has a unique opportunity to identify and mobilize its resources. Coordinated, collective practice and research will build interprofessional efforts to address the health equity challenge. Moreover, the profession is uniquely poised to address health disparities in the United States because of social work’s history and values. This paper will first provide a brief overview of social work contributions to health and health care. It will then focus on the recent empirical developments in social determinants research. We conclude by outlining some of social work’s priorities for future research and action, and we highlight opportunities for collaboration with allied health professions.
SOCIAL WORK’S HISTORICAL HEALTH-LEADERSHIP LEGACY
Social work is uniquely positioned for a leadership role in addressing health inequities because, as indicated in Jane Addams’ speech at the 1930 National Conference of Social Work, “social work’s special genius is its closeness to the people it serves” (Johnson, 2004, p. 319). Social work’s historical social-justice mission as well as its commitment to serve the most disenfranchised and health-burdened populations affirms the profession’s ability to provide leadership in association with allied health professions. The attributes also speak to the profession’s ability to design and develop community-based approaches to eradicate health inequities. Social work faces an opportunity to leverage its history as calls to address health inequities emphasize the need for community-based innovation. Indeed, social workers have been involved in public health and the health care field for well over a century (National Association of Social Workers, 2005). Historically, social work’s health-focused efforts have centered on making health care services available to the indigent while improving social conditions related to poor health and mortality (Popple & Leighninger, 2005). One of the most impressive examples of social work’s success in public health can be seen in the campaign to reduce infant mortality. That campaign was engineered by social workers at the U.S. Children’s
Bureau and operated from 1912 to 1930:
HEALTH EQUITY: ERADICATING HEALTH INEQUALITIES FOR FUTURE GENERATIONSA dual program of applied research and maternal education: To pursue new knowledge about the extent and causes of infant mortality and engage in prevention and health promotion activities that build on knowledge already gained through the public health work of settlement houses such as Henry Street and Hull House. (Almgren, Kemp, & Eisinger, 2000, p. 9) The Children’s Bureau was led in this ambitious effort by Julia Lathrop, a Progressive Era social worker and former Hull House reformer. Because of this pioneering effort, infant mortality dropped by half and life expectancy improved significantly throughout the 20th century (Almgren et al., 2000).
Public-health social workers have effortlessly incorporated an understanding of social determinants of health in their intervention efforts. They have viewed entire communities, neighborhoods, and regions as target populations across the prevention spectrum (Ruth & Sisco, 2008). In their efforts to directly address social conditions that produce poor health, public-health social work has a strong legacy of interprofessional collaboration with organizers and researchers working in the areas of community development, housing, civil rights, antiracism, and poverty. It also has had important collaborations with organized labor. This legacy provides an ideal foundation from which to launch contemporary health-reform efforts. Additionally, public health threats (e.g., from HIV/AIDS, substance abuse, homelessness, and terrorism) have grown as government funding has been cut over the past 20 years, and social work has developed increasingly involved partnerships with allied health fields, particularly public health (Ruth & Sisco, 2008). Examples of recent social work–public health partnerships can be found in areas such as, “urban health, oral health, tobacco control, and toxic waste activism” (Ruth & Sisco, 2008, p. 487). Now more than ever, public health-oriented social work is needed to address health inequities.
SOCIAL WORK’S ROLES IN LEADING A HEALTH EQUITY GRAND CHALLENGE