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6 Moving Forward T he Roundtable on Health Disparities workshop set out to examine racial, ethnic, and geographic differentials in life expectancy in the United States; clinical and community-development approaches to reducing disparities; and implications of these approaches for develop- ing actionable strategies. Throughout the workshop, Roundtable members and sponsors, presenters, and attendees discussed strategies, and shared o ­ pinions and suggestions, for making inroads into reducing health dis- parities. Their discussions focused on issues regarding data concerns, the importance of place, framing of the issue, racism, policy changes, fostering a broader spectrum of innovation, and funding. This chapter summarizes the salient points from the workshop presenters and participant’s insights and reactions and provides initial steps for strategies to consider for mov- ing forward. DATA CONCERNS Many workshop participants expressed their dissatisfaction with cur- rently available data and worried about policy decisions being made that are based on existing inadequate or faulty data. Dr. Murray, the coau- thor of “Eight Americas: Investigating Mortality Disparities Across Races, Counties, and Race-Counties in the United States” (see Appendix C), Dr. Acevedo-Garcia, of the Harvard School of Health, and Roundtable mem- ber Dr. Bracho suggested that more data should be collected and tracked at the county level so disparities and changing demographic patterns could be more accurately evaluated and monitored. Workshop participants also 103

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104 CHALLENGES AND SUCCESSES IN REDUCING HEALTH DISPARITIES discussed the need for building information and data capacity in the United States. Dr. Lawlor, coauthor of the paper “Community Approaches to A ­ ddressing Health Disparities” (see Appendix D), emphasized that in order for robust ­community-wide initiatives to be built and defended, there must be new community infrastructure and resources developed at the community level. He stressed that communities must bring together an array of social and economic data rather than relying on standard epidemiological data or health indicators alone. Very different traditional sources of data—racial, ethnic, and geographic data—will have to be brought together at the com- munity level so that the health status of communities can be determined, and monitored and tracked, over time. PLACE MATTERS The presentations by Drs. Murray and Acevedo-Garcia stressed that where a person is raised or chooses to live will have a dramatic effect on their overall health and their access to quality health care. Dr. Murray presented his analyses using county-level mortality data, showing how life expectancies varied across the United States depending upon an individual’s county of birth and emphasizing that people living in the United States have increased or decreased life expectancies depending on the geographic areas in which they live. Dr. Acevedo-Garcia also discussed the importance of place, but her presentation focused on U.S. metropolitan areas and how the impact of opportunity across neighborhoods affected the lives and health of the residents. Her presentation specifically emphasized the effect that neighborhood environments have on children and adolescents and how influences during these early stages of life can have long-term effects on their life course and, subsequently, on the long-term economic disparities extant in metropolitan areas. FRAMING Several workshop participants and members of the audience were con- cerned about finding a way to discuss or frame the issue of health dispari- ties using methodologies and terminology that would resonate with policy makers and also capture the public’s attention, both locally and nationally. Ms. Glover Blackwell, of PolicyLink, emphasized this point by suggesting that finding appropriate language for discussing these issues will ultimately determine whether or not there will ever be political and public will to be able to eliminate disparities. She also stressed that efforts to frame health disparities issues should not be limited to the realm of public or community health; they should include politicians, environmental health ­professionals,

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MOVING FORWARD 105 members of the general workforce, and people who work on housing issues. Similar concerns were also expressed for framing issues pertaining to racism and institutional racism. Dr. Rhee, a Roundtable member, stressed that while the term health disparities may not resonate with the general public, terms such as race or institutional racism can be very powerful. He suggested that the language that is used to discuss these issues must be very forceful and specific, but it should not cause people to disengage or make them unwilling to join in the discussion to find solutions for these problems. Ms. Glover Blackwell agreed, adding that the appropriate words, strategies, and framing must be found that allow discussions to take place with key people at the table and in such a way that other people are invited into the discussion. There must be recognition that this is a charged discus- sion which cannot be approached in a way that isolates, accuses, or causes people to want to stay away. Dr. Suggs, of the St. Louis American, suggested that discussions about racism should not focus solely on injustice but should also be considered in social and economic terms. He stressed that racial disparities are a disgrace, but they are also enormously expensive for this country. Ms. Schwartz, of the American College on Diversity, cautioned that all races and ethnicities are going to have to pay attention to the problems of racism and institu- tional racism because the demographics in the country are changing so rapidly and these issues will eventually affect everyone living in the United States. CLINICAL AND COMMUNITY-BASED APPROACHES TO REDUCING DISPARITIES During the workshop, Drs. Horowitz and Lawlor presented their paper “Community Approaches to Reducing Health Disparities,” which assessed the implications for developing actionable strategies and describing ­methods of integrating clinical and community-based approaches to impacting com- munities and reducing health disparities. Hybrid models, which blend clini- cal and community-based approaches, should integrate community voices, community participation, and community ownership into disparities initia- tives, emphasized Dr. Lawlor. They should also incorporate stakeholders from education, housing, employment, and other fundamental areas that are integral to the process of reducing disparities. Developing partnerships will be vital to the success of community initiatives, yet there needs to be a much broader understanding of who the relevant players should be and specifically who should be developing community-level initiatives. Several workshop participants also stressed the importance of looking to international models for solutions to health disparities concerns in the

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106 CHALLENGES AND SUCCESSES IN REDUCING HEALTH DISPARITIES United States. Dr. Murray discussed how other developed countries around the globe have been able to succeed economically without experiencing the health disparities seen in the United States. He suggested that Americans are, in general, unwilling to want to learn from other countries’ experi- ences. Several workshop participants agreed, including Dr. Levi, a member of the Roundtable, who stressed that the challenge is to find a way to frame health disparities issues in this country so that people recognize that a problem exists but to do so without making comparisons that could make people feel that the American way is inferior or that the proposed approach may not be a uniquely American approach. Dr. Lurie, the chair of the Roundtable, added that she would like to see models from less developed countries considered as well. FUTURE INNOVATION Workshop participants discussed several innovative ways to help reduce health disparities. Dr. Murray suggested that policies should be adopted that would foster a broader spectrum of innovation in addressing behavioral and pharmacologically manageable biological risks for noncommunicable diseases that also incorporates rigorous monitoring and ongoing evaluation. He believed that, with these measures in place, successful programs could be recognized, their results could be documented, and their methods could be shared and replicated. Several workshop participants discussed policy changes that could take place within the United States to foster innovation. Dr. Murray and others discussed the importance of public–private partnerships being accompanied by significant resources, local applications, and the need for a strongly embedded monitoring and evaluation program to determine what is work- ing as progress in this area is developing. He also suggested that many new strategies such as pay for performance, conditional cash transfers, or financial incentives are worth investigating. Dr. Lawlor discussed how exist- ing community-development efforts, such as the Local Initiatives Support Corporation (LISC), or community-development investment banks could have a tremendous impact on the health of communities if they were to adopt health disparities concerns as a part of their agenda. Dr. Acevedo- Garcia suggested that modifying policies for Section 8 Voucher programs, fair housing enforcement, inclusionary zoning, and the availability of rental housing could help to reduce residential segregation and create more oppor- tunities for low-income individuals and families. Innovative international strategies should also be considered, sug- gested some workshop participants. The Global Alliance for Vaccines and Immunization (GAVI) was discussed by many workshop participants who

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MOVING FORWARD 107 praised the approach taken by GAVI for supporting innovative strategies for improving childhood immunization rates. FUNDING As was stated earlier, there are many domestic community develop- ment initiatives funding programs, such as LISC, that do not include health disparities concerns among the issues they address. Leveraging existing public–community partnerships and enacting policy changes that redirected their focus to include a health focus, suggested Dr. Lawlor, would have a dramatic impact on health disparities in the United States. Dr. Lawlor also suggested that potential sources of funding could include expanding sup- port for Regional Health Commissions or creating collaborations between people who work on disparities issues and banks and corporations that sup- port community-development initiatives so their collective knowledge and resources could have a greater impact on communities. He also suggested that university–community partnerships should be pursued, with the caveat that programs should be designed so that communities and the universities are both active participants in the planning process and that they work cooperatively to reach shared goals. Additionally, Dr. Lawlor suggested that the Roundtable could promote the idea of bringing together federal funding streams, such as those from the U.S. Department of Housing and Urban Development, so that money could be funneled to address specific areas of concern for disparities. Ms. Glover Blackwell commented that there were many sources of funding for communities including after-school programs, youth develop- ment efforts, or community-development efforts such as LISC, but she sug- gested that communities should take ownership of that money and those programs because the funds being spent belong to the community and could be refocused to also reduce health disparities at the local level. COMMUNITY INTERVENTION AND CAPACITY Several presenters and members of the audience discussed the importance of community involvement in community-focused initiatives. Ms. Kubisch, a Roundtable member, stressed that power, money, resources, and political support are all necessary for driving community initiatives and suggested that community capacity is required at the organizational level in terms of being able to do the data analysis, community organizing, and advocacy to pull the funding streams together and have an impact on disparities. Dr. Lawlor and Ms. Glover Blackwell suggested that organizations should exist in communities with the responsibility of gathering and interpreting community data so that there is a shared sense of what the

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108 CHALLENGES AND SUCCESSES IN REDUCING HEALTH DISPARITIES challenges are, and that knowledge could be translated into compelling, relevant, and effective solutions. Ms. Glover Blackwell also suggested that there needs to be a public commitment to developing strategies to invest in new leadership and encourage young people to become leaders. She believes there should be a commitment to encourage potential leaders and provide them with opportunities to gain more exposure to mentors and to participate in commissions or other hands-on activities so they can become effective leaders in the future. Several of the workshop presentations were presented by ­ individuals who were coordinating local community initiatives or representing com- panies that are committed to reducing health disparities on a larger scale through education and advocacy. The representatives of Racial and Ethnic Approaches to Community Health (REACH) and Steps to a HealthierUS discussed their programs and shared successes and challenges that they have had while working to reduce disparities in their communities. Col- lectively, these presentations demonstrated that there are effective models to emulate and myriad examples of people who are directing programs that are producing results. The challenge going forward will be to implement programs like these on a national scale and learn how to successfully imple- ment initiatives on a large scale. CONCLUSION The discussions at the workshop provided an opportunity for Round- table members, presenters, and attendees to learn about several issues related to health disparities in the United States. The presentations and discourse on the importance of location of residence, framing, funding, data concerns, innovation, clinical and community-based approaches to reducing disparities, and community innovation and capacity, were help- ful in providing several perspectives and viewpoints about what has been done, and what should take place in the future to reduce health disparities in the United States. The information gleaned from this workshop will help inform Roundtable members and workshop attendees so they can initiate, stimulate, or fund initiatives, take actions within their organizations, or share ideas and concepts from this workshop with other motivated stake- holders and partners. Through actions such as these, the workshop can be a catalyst for change and a means of moving closer to reaching the goal of eliminating health disparities.