HEAL SLO 2016 - Dr. Tony Iton

Summary

In a thought-provoking talk at HEAL SLO 2016, Dr. Tony Iton explores the powerful impact of social and economic inequalities on health outcomes. He shares vivid examples from across the United States, revealing how systemic neglect and discrimination shape community health. Central to his message is the idea that a person's zip code can be more predictive of their health outcomes than their genetic code. Dr. Iton passionately advocates for restructuring policies to address these inequities, emphasizing a shift from focusing merely on healthcare to considering the broader social determinants of health.

Highlights

• Dr. Iton's memorable opening about the 'big secret' of health disparities 🌍
• The shocking revelation about Baltimore's 'inner city' and Scott County's opioid crisis 💥
• A deep dive into how poverty and social neglect carve life expectancy maps, even within the same city 🗺️
• The critical contrast between healthcare and social service spending—hint: the latter wins 🏆
• Chronic stress: the silent disruptor of health, passed down through generations 🌿

Key Takeaways

• Your postal code might be more telling about your health than your DNA 🚦
• Income inequality is a hidden health hazard, gnawing away at life expectancy 🍏
• Social determinants and upstream investments in community health are the real game-changers 💪
• Healthcare spending does not equate to health; it's time to balance the scales 🌍
• Chronic stress from social neglect can change your genes and your lifespan ⏳

Overview

Dr. Tony Iton captivated his audience at HEAL SLO with a compelling narrative about health inequities in America. He kicked off his talk by questioning the narratives we choose to remember and the ones we erase, using historical speeches to shed light on how these narratives shape our policies and, ultimately, our lives.

His journey took the audience from the streets of East Baltimore to the rural expanses of Scott County, Indiana, illustrating how systemic neglect and historical social policies impact health outcomes. He underlined the startling disparity between healthcare spending and actual health outcomes, pointing out how deeper investments in social services could be transformative.

With passion and data, Dr. Iton explained the physiological effects of chronic stress on marginalized populations. This stress, largely fueled by a lack of access to fundamental necessities, not only affects individual health but can genetically impact future generations. Dr. Iton's key message urged a united front to change the health narratives and invest upstream, towards systemic solutions that can bridge the gap of health inequities.

Chapters

• 00:00 - 05:00: Introduction and story setup The chapter introduces Tony Ayten, who receives a warm welcome from the audience. He humorously remarks about his long journey, taking five hours on Route 101 to reach the isolated location. His curiosity is piqued by a 'big secret' he believes is hidden in the area, suggesting topics of intrigue and mystery to be explored in the conversation.
• 05:00 - 11:00: Historical perspective on race and policy The chapter 'Historical perspective on race and policy' starts with the narrator explaining that they will share a personal story. This story, described as somewhat lengthy, includes a considerable amount of data and is intended to provide insight into how the narrator has reached certain conclusions. The focus is on identifying significant factors that influence health in society. The chapter is set to delve into these details to highlight the historical interplay between race and policy in shaping health outcomes.
• 11:00 - 21:00: Personal background and health disparities in cities The chapter opens with the speaker suggesting the audience to be prepared, mentioning a quote by Rudolf Virchow. The quote suggests that physicians serve as advocates for the poor because many social problems fall within the healthcare jurisdiction, beyond just managing clinical science.
• 21:00 - 35:00: Insights from data in Alameda County The chapter discusses the importance of understanding the broader context that contributes to the development of diseases. It encourages individuals, particularly those in the healthcare sector, to acknowledge their role in navigating and managing these contexts to reduce the incidence of disease. The chapter also touches on historical perspectives concerning social and political inequalities, referencing a quote that sparks a reflection on the subject.
• 35:00 - 43:00: Financial implications of inequality The chapter titled 'Financial implications of inequality' delves into the repercussions of racial inequalities, particularly focusing on the views expressed against granting equal rights to black people. The speaker explicitly opposes voting rights, jury membership, and interracial marriages for black individuals, asserting a belief in the inherent physical differences between white and black races. This perspective is used to justify the concept of white superiority and the necessity for maintaining a hierarchical social and political structure. The chapter highlights how such discriminatory ideologies contribute to the persistence of financial and social inequalities.
• 43:00 - 52:00: Chronic stress and genetic impact Summary of 'Chronic Stress and Genetic Impact': The chapter begins with a discussion on racial superiority, referencing a historical quote related to the white race having a superior position. The conversation alludes to figures like Dubois and Abraham Lincoln. It highlights the complex relationship between historical perspectives on race and their lasting impacts on genetic and psychological stress factors, suggesting that the legacy of racial thinking continues to influence the stress levels experienced by different racial groups today.
• 52:00 - 65:00: Influence of zip codes and health inequality The chapter discusses the historical context of Abraham Lincoln's political stance, particularly during the 1858 Lincoln-Douglas debates, where Lincoln, despite his skillful oratory and strategic political platform, lost the Senate race to Stephen Douglas. The discussion explores the influence of geographical factors, such as zip codes, on health inequality, emphasizing that such disparities have deep historical roots and can be linked to systemic issues prevalent since Lincoln's time.
• 65:00 - 85:00: Building Healthy Communities Initiative The chapter discusses the prevalence of visits to the Lincoln Memorial and highlights an often overlooked aspect of Abraham Lincoln's speeches. It questions why a particular speech is not inscribed on the walls of the memorial, despite it being publicly delivered and representing Lincoln's stance. The chapter calls for a response to this historical oversight.
• 85:00 - 92:30: Conclusion and Q&A The chapter concludes by discussing the nature of historical narratives and how they shape our understanding of ourselves. It raises a question about why certain aspects of history are not highlighted or memorialized, such as certain words from historical figures. The discussion suggests that this selective memory allows for a more favorable narrative of identity, even if it omits less flattering truths.

HEAL SLO 2016 - Dr. Tony Iton Transcription

• 00:00 - 00:30 sure you will find him incredibly fascinating and thought-provoking so I want to welcome Tony Ayten [Applause] well good morning it's a real pleasure to be here it took me five hours to get here on the 101 so you really are isolated so I'm curious to find out what is the big secret down here why what's being hidden so maybe we can have that conversation a
• 00:30 - 01:00 little bit so I'm gonna I'm just going to tell you a story it's kind of a little bit of a long story that's it involves me and it involves a lot of data and I hope it'll help you get a sense of sort of how I come to some of the conclusions that I come to about what are some of the most important drivers of health in our society so I'm just going to jump right into this and
• 01:00 - 01:30 hopefully you've got enough caffeine in you because I like to start with a little bit of provocation but hold on I'll get there so I like this quote from Rudolf Virchow who says that positions are the natural attorneys are the poor and social problems fall to a large extent within their jurisdiction meaning that when you're in medicine you're really not just dealing with the clinical science of managing physiology you're really
• 01:30 - 02:00 looking at or should be looking at the context that creates the disease that's in front of you and you should be thinking about what is your role in trying to navigate and manage that context so that you see less disease but this is one of my favorite quotes I don't know if you guys can read it but I'll read it to you I will say then that I am NOT nor ever have been in favor of bringing about in any way the social and political equality of the white and black races
• 02:00 - 02:30 that I am NOT nor ever have been in favor of making voters or jurors of Negroes nor of qualifying them to hold office in order intermarry with white people and I will say in addition to that there's a physical difference between the white and black races which I believe will forever forbid to two braces living together on terms of social and political equality and in as much as they cannot so live while they do remain together there must be the position of superior and inferior and I as much as any other man I'm in favor of
• 02:30 - 03:00 having the superior position assigned to the white race they may know who said that anybody know who said that I'm gonna stand here until somebody says something Dubois and no that's an interesting suggestion though Abraham Lincoln why would you say that but Abraham Lincoln is the great Emancipator
• 03:00 - 03:30 well how would you explain that coming from Abraham Lincoln he was a politician [Laughter] so Abraham Lincoln said that in 1858 in the lincoln-douglas debates when he was running for the Senate and he lost despite having such a wonderful white supremacist platform
• 03:30 - 04:00 how many of you been to the Lincoln Memorial okay so everybody's been to Lincoln Memorial but nobody knew that Lincoln had said that and and and at the Lincoln Memorial there's his words are carved into like granite or whatever that is marble up on the walls how come that other speech is not carved into granite up on the walls of the Lincoln Memorial I mean he said it he said it publicly he was asserting his position that's a real question when stand here until somebody answers it
• 04:00 - 04:30 he changed his mind we changed his mind that's interesting it's not a pretty sight of history it's a product of his time so what is it that why do we not carve those words into granite at the Lincoln Memorial I mean seriously why don't we do it nobody wants to remember it so we like to have a narrative a story that we tell ourselves about who we are and that
• 04:30 - 05:00 narrative shapes policy and policy creates real world conditions for people and so if you want to contend with those real world conditions you have to look at the policy and if you want to change the policy you have to understand the narrative that undergirds that policy so that's the whole message of what I'm gonna tell you about I hope okay so this leads me this conversation about place but before I talk about place I want to talk about where I grew up
• 05:00 - 05:30 does anybody recognize this it's a Island City it's an old volcano sits in the midle River it's got about a million people in it nothing nothing at all wow you people really don't get out of san luis obispo video okay it's not in this country people
• 05:30 - 06:00 don't speak English there they speak French and English there I think I heard it yes Montreal yay the veggie prize goes to whoever said that so I grew up in Canada in the 70s and 80s and Canada has a social contract with its citizens it's got universal health care it's got universal dental
• 06:00 - 06:30 care child care highly subsidized post-secondary education I went to McGill University of Montreal which is called the Harvard of the North basically for free and it was strange for me in the mid 80s when I came from Montreal to go to Johns Hopkins Medical School that I stumbled into this environment immediately outside of the walls of Johns Hopkins Medical School I mean
• 06:30 - 07:00 literally you walk outside the door and this is what you see and I was so shocked I mean cuz I didn't understand the u.s. I had never lived there I was shocked when I walked out into this environment in this ostensibly first world country and saw this so shocked but the guy that was turning me around he said what's wrong with you and I said when was there a war here and I'll never forget what he said to me he looked at me with this like look of utter disdain and he said would you expect it's the
• 07:00 - 07:30 inner city and I said I'm supposed to expect this I mean this is normal for American cities and you've got a name for it you call it inner cities if that's where you just put the people you don't care about I mean is that how that works because you don't have these in Canada and you've got huge cities in Canada but you don't have these inner cities and I go back to Baltimore all the time and they and I wonder you know
• 07:30 - 08:00 what this kid is owed he didn't create that environment but he's got to navigate at every single of his life and that environment says to him you don't matter you're not valued and this is Abraham Lincoln's text speaking to this kid and we know what happened in Baltimore if at least I hope we know what happened to Baltimore when I said not moving astray this there we go
• 08:00 - 08:30 you know what happened in Baltimore a few years later and then people were so surprised by this except for those of us who had lived in Baltimore we were like hmm what did he expect it's the inner city and Time magazine even asked the same question they said what's changed and I'm showing you this for a reason how many of you have been to Baltimore by the way oh my god some nobody knows Montreal but you've all been to Baltimore it's a good Montreal it's nice place
• 08:30 - 09:00 it's beautiful it's like a mixture of Paris New York and San Francisco okay so you know the American narrative is full of these inner cities we've told this story before over and over again and we just sort of wall it off and we say yeah that's an unfortunate occurrence of capitalism but how many of you know this place I think this thing is dead I'm gonna give you a few hints this place is in America it's in the
• 09:00 - 09:30 middle of America and it has a higher incidence of HIV than sub-saharan Africa it is 98% white and it's in yes oh okay I gave it away all right so this is Scott County Indiana does anybody know why Scott
• 09:30 - 10:00 County Indiana has been in the news lately other than what I just said yes a big opioid outbreak this drug called opana which people are grinding up and shooting and exchanging needles and getting HIV and hepatitis C and Mike Pence who is now the Republican vice presidential candidate is the governor of Indiana and oversaw this state during the time when this outbreak
• 10:00 - 10:30 was occurring and refused to distribute clean needles until he basically had no choice and had to reverse himself but the reason I'm showing you this is because this is the same thing as East Baltimore this is exactly the same thing the things that are driving this epidemic are the same things that are driving the insurrection that happened in Baltimore and Ferguson Missouri and elsewhere this is income inequality in black and white this is the lack of a social contract so people don't have
• 10:30 - 11:00 universal healthcare they don't have a universal Child Care Benefit they don't have highly subsidized post-secondary education they're contending with essentially the slow deterioration of the infrastructure that they need to be able to pursue the American dream it's happening throughout this country there's an evaporation of the structure the opportunity structure that people need to be able to be successful in that has a profound impact on their health I'm just gonna throw this out this is
• 11:00 - 11:30 not working at all okay so the question for us is really when it comes to your health may need a battery when it comes to your health is your zip code matter more than your genetic code and I'm gonna try to prove that to you with some data so is was Joel mentioned I became that health officer and health director in Alameda County and for those of you don't know where Alameda County is that's San Francisco and this big boot
• 11:30 - 12:00 like thing is Alameda County and we like to say it's a boot that's trying to crush San Francisco now when I became the health director there one of the jobs are the health officers the health officer here by the way she's not here shucks okay well text her and tell her to go visit East Baltimore cuz I would like to know although we have some data on San Luis Obispo I'd
• 12:00 - 12:30 like to know what you guys are doing with your data but when you're the health officer you're the Registrar of all births and deaths and there are about 10,000 deaths in Alameda County every year and I am a total data junkie I just love data so having been in East Baltimore when I came to Alameda County I figured there was a story to be told in these death certificates it was hidden in these thousands of death certificates and I wanted to tell that story so we put all these death certificates into a database we had about half a million death certificates over about 55 years in a in a database
• 12:30 - 13:00 and on a death certificate L what somebody died of what their age was when they died their race ethnicity and where they lived and those four pieces of data can actually paint a very compelling picture it's working on can paint a very compelling picture of of what death looks like in a community so the first thing that we did is we went back in time we wanted to know you know what life expectancy was for various groups
• 13:00 - 13:30 of people in Alameda County over time and the reason we did that was because at the time healthy people 2010 said the first goal should I test this audience and find out what the first goal of healthy people 2010 was anybody know number one goal of the nation's health public health Bible okay so my health department didn't know either and the first goal is to increase life expectancy for all Americans and then the second goal was to eliminate
• 13:30 - 14:00 health disparities amongst various different groups of Americans so we figured we needed to know what life expectancy was in Alameda County so we calculated it with these death certificates and to do that you need the Census and the census only started talking about rooks other than white and black in 1990 so if you wanted to go back before 1990 you could only talk about white black and other which was a ridiculous catch-all category so we just talk about white and black and we found that in 1960 life expectancy difference between
• 14:00 - 14:30 whites and blacks in Alameda County was 2.3 years 20 years later it had more than double to almost five years and forty five years later had almost quadrupled to approaching eight years and this is during a time of revolutionary change in health care you know with MRIs and pharmaceutical wonder drugs and minimally invasive surgery and during this time the gap widened and I was Health Officer for part of this time and I used to say to people I should be fired I mean if we were really holding
• 14:30 - 15:00 ourselves accountable in this community for health and the number one goal of healthy people 2000 s increased life expectancy for all Americans all actually you could argue that we were meeting that goal but the number two goal was to eliminate health disparities and that health dis berry the profound health disparity in life expectancy was growing and it was growing measurably on my watch but nobody ever held me accountable for that so we had to hold ourselves accountable for so what we did is we took those death certificates and
• 15:00 - 15:30 we mapped the entire county at every neighborhood every census tract level and we calculated on average how long somebody could expect to live in each of those neighborhoods and we found in the City of Oakland neighborhoods that were not very far apart within a couple miles of each other had a life expectancy difference of over 20 years and that was pretty shocking but it wasn't just Oakland when I first this ended up on the front page of the San Francisco Chronicle when I first started talking about these maps people
• 15:30 - 16:00 would say oh my god what's happening in Alameda County that's a really you know equitable place and I was like no that's not the message so we went around the country and started doing it in other places this is Cleveland and went back to Baltimore which has neighborhoods with life expectancies of 58 years LA and ended up in the LA Times this is Seattle this is New York City
• 16:00 - 16:30 Philadelphia Minneapolis Boston everywhere we looked everywhere there was no exception we found life expectancy differences on the order of 15 20 25 years in the same city and there was no way to explain that based on access to health care or health behaviors something else was driving these differences and you know I say in public health you don't have to be a rocket scientist but you do have to be able to spot a pattern every now and then and so when you look at these patterns you have to you have to have an
• 16:30 - 17:00 explanation for these patterns and quite frankly we don't have a good explanation for these patterns I mean I think I do but our conventional narrative is that health is about healthcare and other than health care it's about people behaving badly so it's about personal responsibility and if people took more personal responsibility and they had a good doctor then they'll be healthy and that's false it's actually false it's it's not even only part true it's
• 17:00 - 17:30 actually false okay so we actually mapped the entire state of California so we have San Luis Obispo in here somewhere don't ask me to point it out on a map I couldn't do it the other thing to do with these maps which we did if you're a data junkie epidemiologist you're any epidemiologists okay well I have to look at the data junkies what I'm doing this because you know you guys get me so data junkies will look at this and say wow potential for a bivariate
• 17:30 - 18:00 correlation and get really excited about it so it just wouldn't you know that's what's happening so that's what we did you take the map of life expectancy which is at the census tract level and the map of poverty which you get from the census which is also at the census tract level so for every census tract you have a life expectancy in a poverty level and you can correlate those two things and you get life expectancy on the up axis so as you go up your longer life expectancy communities and as you move from left to right you're going from wealthier to poorer communities and so each of those blue dots is a neighborhood in Alameda County and in an
• 18:00 - 18:30 ideal world this would be a completely flat line how poor your neighborhood is shouldn't predict how long you live but we don't live in an ideal world we live in a world where there's a cost to living in a poor neighborhood and you can measure that cost in length of life this is a death tax that people pay as a result of living in poor communities and trying to understand what creates the slope of that line because when you look around the country you see this line in different places
• 18:30 - 19:00 has a different steepness a different slope and the steeper that line the more inequitable as least as far as it goes comes to health the more inequitable that society is so we did the line for the entirety of the San Francisco Bay Area we did the entire state of California unfortunately you can't put this kind of stuff in the newspaper so we had to translate the slope of that line we had to monetize it and for the San Francisco
• 19:00 - 19:30 Bay Area at $12,500 each additional $12,500 buys you a year of life that's the cost of human life in the San Francisco Bay Area and I would encourage people when they're using when they're negotiating their raises with their bosses to bring this kind of data to the table it's like hey boss I need a couple years I've been working hard I got that report to you one time I got Tony I don't know man that report was pretty bad I'm seeing six months for you tops
• 19:30 - 20:00 and so then this question came up when I started doing these presentations I mean I can tell you this is a story about my whole life story is in slides I mean this is what I do I literally carrying around my pocket somebody says something interesting to me I'm like I need to make a slide about that so people used to come up to me and say well Tony you know you're Canadian you don't understand America is a very generous country we reach out to all these immigrants and we bring them you know to our shores you
• 20:00 - 20:30 know tired poor huddled masses and and those immigrants are really sick and you know their health brings down our average and therefore and over time is they become more like us they get healthier and so you really shouldn't be comparing us to any other country in the world because we're unique we're exceptional it's like an apples to oranges comparison looks like that's a challenge I got to make some slides okay so we all know that you've probably
• 20:30 - 21:00 all seen this graph at some point in your life this is looking at per-capita spending across developed countries on health care and we all know the u.s. spends way more than everybody else twice the so-called oacd average so whenever you make this graph and you include the US you have to actually change the axis that fit the US on the graph with the rest of the world and that's somewhat interesting we know that for what we spend we should get much better returns and life expectancy and
• 21:00 - 21:30 we don't so we spend a lot and we don't get a lot that's interesting but not the most interesting thing this is much more interesting to me this was a couple of woman women at Yale and Harvard Lauren Taylor and Elizabeth Bradley who were health services researchers or our health services researchers and they did this interesting thing where they looked at that old graph that we all look at which is per capita spending on health care which is the blue data that you see
• 21:30 - 22:00 there but then they added in per capita spending on social services or social benefits across developed countries and when you do that the u.s. is no longer an outlier the u.s. is actually smack dab in the middle of the pack so they're measuring what we spend on health care per person and then adding in what we spend on social services or social benefits per person and what they found is that those countries that spend more on social
• 22:00 - 22:30 benefits than they do on health care have better health the ratio of social benefits spending to health spending actually predicts health so we literally have the accent on the wrong syllable in this country we're spending an all downstream after the fact and the countries that have good health are spending an upstream before the fact so it's not like the data is not there we actually we're comparing ourselves literally to everybody in the world that
• 22:30 - 23:00 we can compare ourselves to and we come up short the other thing I had to do because people told me that you know well it's because of all the brown people that were not healthy is looking at just white Americans the health status of white Americans and us white life expectancy is about 79 years which is about that of Qatar Costa Rica and now aru anybody know where now rue is you know everything don't you
• 23:00 - 23:30 very good boy this is netiquette so you don't know Montreal but you know now R oh boy I'm insulted okay so us whites are living shorter lives in Belgium Chile Denmark Lebanon Slovenia Austria Finland Germany Greece Ireland Malta Netherlands Portugal UK Canada of course Cyprus France Iceland Israel South Korea Luxembourg Monaco New Zealand Norway Sweden and Dora Australia Italy San Marino Singapore Spain
• 23:30 - 24:00 Switzerland in Japan it's 33 countries in the world that have longer life expectancies than us whites in 1990 there were only 17 u.s. white life expectancy is plummeting compared to the rest of the world plummeting I mean it's it's really kind of it's unprecedented in fact the Institute of Medicine put out this report a couple years ago called shorter lives poorer health and it was comparing
• 24:00 - 24:30 US health in general to the rest of the world and this was their conclusion and this is the IOM they don't get emotional about anything this is about as a Moute this is basically them screaming they're pulling their hair off the panel was struck by the gravity of its findings struck by the gravity of its findings for many years Americans have been dying at younger ages and people in almost all other high open income countries this disadvantage has been getting worse for three decades especially among women the US health disadvantage cannot be fully explained by the health
• 24:30 - 25:00 disparities that exist among people who are uninsured or poor as important as those issues are several studies are now suggesting that even advantaged Americans those who are white insured college-educated or upper income are in worse health than similar individuals in other countries hopefully some of you have seen this data for in case and Angus Deaton at Princeton I just want a Nobel Prize for it and they are talking about white working-class mortality rates which have been plummeting I'll show you the
• 25:00 - 25:30 graphic they looked at mortality rates for populations all around the world and compared them to u.s. whites and that red line there whereas mortality rates are dropping it's good for mortality rates to drop mortality rates you want low ones white more tell us white mortality rates are growing at a time when the rest of the world is dropping including african-americans and Latinos so us white life expectancy in health status is not good it's it's bad in fact
• 25:30 - 26:00 you know when we look at health disparities we should not be comparing low income people of color to white people because the white standard is not a very high standard we should actually be comparing low income people to immigrant Latinos at least when it comes to life expectancy because they actually have higher life expectancy than anybody in the United States and as they acculturate as they become more American their life expectancy drops
• 26:00 - 26:30 America is not good for your health that's a laugh line you're supposed to laugh at that you mess with it's not a cry line so the Californian we've been trying to tell people this we're trying to change the paradigm you know through which people understand health because we still default to health care access to health care bad personal behaviors and those things are true they're just not sufficient there's a there's a much broader context that shapes our health over which we have enormous control we have just for
• 26:30 - 27:00 whatever reason decided not to exercise control over that so these are real ZIP codes in California real life expectancies these are real zip codes and real high school graduation rates when Sacramento built its new airport terminal we decided we were going to have a conversation with the legislators you know on the walls of that terminal and we know that they saw it because they started calling me and asking me when I was depressing property values in their districts at the American Public Health
• 27:00 - 27:30 Association meeting in San Francisco a few years ago we literally festoon downtown San Francisco with this message and then the governor let us put up this huge billboard outside his office for like four months a couple years ago I don't know why but he let us do it and then it was great because we got so much press and attention to this issue so we know that 80% and I think Joel said this or maybe Jim said this 80% of what it effectively
• 27:30 - 28:00 and what happens in these low life expectancy communities that I showed you on those maps and then increasingly really in America's heartland where white working-class mortality is is plummeting and it's it's it people are dying from things like poisonings overdoses suicides these are so-called deaths of despair these are people who
• 28:00 - 28:30 don't see a future there they they don't have the reach any grasp at the lowest rung of the ladder to pull themself up towards the American dream this is this is the people are losing hope in these places and and I would argue it's because we don't have a social compact we don't have we don't have some basic fundamental infrastructure that allows people to get ahead and some of the places that we're working in California
• 28:30 - 29:00 including in the eastern Coachella Valley and South Kern County in the northernmost part of the state Del Norte the schools are bad housing is bad there's no transportation systems or very few jobs people can't get access to health care there's crime and some of the urban areas there police like you know military militarized zones they don't have access to healthy food they don't have access to parks in some cases they don't have access to safe drinking
• 29:00 - 29:30 water all of these things are conspiring against them in one place like literally every system is on life support and and then we tell them with a brochure eat well you know exercise and see your doctor I mean it's it's absurd it's they're living in these surreal environments that are they're conspiring against them at every turn and we're talking about children now we're
• 29:30 - 30:00 experiencing this you know for 20 30 years of their lives they're experiencing these environments and we're handing them a pamphlet saying you know brush your teeth or something like that literally so what happens in these places people basically are bathed in cortisol it's a chronic stress reaction this whole notion of allostatic load and what we've seen is that chronic stress not only changes your physiology I'll show you how that works the body and Turbots of stress are
• 30:00 - 30:30 through the brain it sends a message to the pituitary gland which sends a message to the adrenal glands which releases cortisol in in a cascade of hormones and cortisol has profound effects on you in the short-term it's good for you it actually it's sort of a part of the fight-or-flight response it stimulates your cardiac output at rallies glucose for your muscles in case you've got to throw a punch or run it stimulates your immune system it brings down your in inflammatory system and it stimulates the growth of neurons and the
• 30:30 - 31:00 part of your brain that are responsible for what's called executive function the executive function simply put is basically the ability to choose between short-term intermediate term and long-term options to make a rational choice across a long kind of timeline but in the red when you're constantly awash in cortisol which is what happens to people living in these environments that are conspiring against them and children in particular who are looking around at these environments and and
• 31:00 - 31:30 recognizing that the message from this environment is that you don't matter you're not valued they internalize that and cortisol is constantly circulating in their bodies and it changes their physiology and it doesn't only change their physiology it actually changes their behavior it makes chronic stress makes you crave high-fat high-salt hi sure Foods doesn't only change your behavior it actually changes how your genes express themselves
• 31:30 - 32:00 it causes methylation of your DNA and can actually not only change your DNA but that can be passed on believe it or not it can be passed on to your children so the policies that we're creating are creating disease and that disease is leading to premature death so when you see health disparities you're really only seeing the tip of the iceberg you're not seeing the inequities underneath that or at least you're not
• 32:00 - 32:30 looking generally for the inequities underneath that [Music] what determines how long we'll live is it what we do is it who we are [Music] actually when it comes to predicting how long you'll live your
• 32:30 - 33:00 zip code is more important than your genetic code here's how this works meet Devon Maria they both have jobs they're around the same age they're both married and they both have two kids Deb lives in a town while Maria lives in Beto less than one mile away they're similar in so many ways but here's the thing on average residents of beagle will die
• 33:00 - 33:30 more than 15 years sooner than the residents of a town why because where you live is about more than just your address it's about your opportunities for example Deb and Maria's access to healthy options is really different in a town Deb's family is surrounded by healthy food options including farmers markets specialty shops and grocery stores the arrow in a town is cleaner
• 33:30 - 34:00 and fresher and there are lots of safe clean parks where Deb can exercise and her children can play a town has good public schools for Deb's kids and easy access to emergency and preventive health care on the other hand Beeville has broken badly lit sidewalks and the parks are unsafe the air is filled with truck exhausts from the nearby highway and for food options Maria's only choices are be those many liquor stores fast-food places or convenience stores
• 34:00 - 34:30 the schools in Beeville are overcrowded and under supported and even if Maria can get her kids into better schools far away she needs to figure out how to get them there without access to a car so for Maria having to juggle so much to find healthy options can be an overwhelming source of chronic stress which is a serious health risk factor in fact for all the residents of Beedle chronic stress drives health problems
• 34:30 - 35:00 like obesity diabetes asthma and heart disease how did a town and Bevo get so different well in many cases in cities and towns across California the root cause was racial and economic discrimination over the generations poor white people and people of color were pushed to less desirable parts of town where banks refused to lend money businesses left jobs to schools declined and the
• 35:00 - 35:30 neighborhood crumbled everyone who could move away did and what's more when communities like a town and evil are so Anita Fievel isn't the only one that suffers because it turns out that not only is your zip code a predictor of how long you live so is what country you live in countries with the greatest income inequality have the lowest life expectancy so even Americans like Deb who are white insured college-educated
• 35:30 - 36:00 and upper income die younger than their peers in other countries in fact our life expectancy is 43rd in the world and that number is slipping in the end our biggest health risk may actually be inequality and extreme inequality hurts us all so what do we do well if we're all going to be healthier we don't just need to help the
• 36:00 - 36:30 folks and be they'll beat the odds we need to change the odds for everyone and that's what we're doing there's a movement happening where Californians we don't follow we lead we are building the power to make health happen in communities across the state we are coming together to build one California a smarter more inclusive and equitable state that creates health an opportunity for all us join us to learn more visit
• 36:30 - 37:00 building healthy communities dot org okay hopefully some of you recognized the narrator in that it's mr. Sulu those Trekkies here alright okay so I'm gonna talk a little bit more about that then I'm gonna conclude and hopefully we can have some questions and answers and hopefully can have some questions and answers so I want to talk about a just a
• 37:00 - 37:30 way of trying to understand sort of how to design interventions to try to change some of this years ago in the bay area there's a group of nine barrier health departments that came together out of frustration because we felt like the tools that we had at our disposal and our public health departments were inadequate to the task or the challenges that we were facing but there were all these structural issues around transportation
• 37:30 - 38:00 and housing and education and access to jobs that you know our public health tools just weren't a match for and we wanted to figure out a different kind of practice a way of being relevant to these larger challenges that we're having such an totin timp act on people's health so we created this framework it's called the bar high frame rate which stands for the bay area regional health inequities initiative and it starts with the medical model you've read it from the right to the
• 38:00 - 38:30 left and it starts with this sort of data observation that we have these communities that have high premature mortality rates and when you look at those communities who recognize that there are as a higher burden of disease in those communities and the medical model argues that that's driven by risk risk typically in the form of risk behaviors which are smoking drinking not wearing a seatbelt having unprotected sex etc and risk factors which are you know genetic things that people have no
• 38:30 - 39:00 control over they're just different and so we spend a lot of money in the medical model on health care access trying to change what people know and trying to tinker with their genetics although that literally never works and that's a three trillion dollar enterprise and what we argued in in developing the bar high framework was that yes that is true it's it's not only
• 39:00 - 39:30 true it's necessary it's just not sufficient and that there's all this other upstream opportunity in the so-called socio ecological context which in was referring to that we can actually design interventions and be relevant in that space so we talked about social inequities which are sort of the conditions the East Baltimore's and the East Oakland's and I don't know in San Luis Obispo whether you have these pockets I'm assuming you have these pockets of inequity with farmworkers and
• 39:30 - 40:00 other kinds of people but I'll wait to hear from you about that but those places are are not natural there they weren't created sort of by the people who live there they were created by usually by neglect it's usually by the absence of policy in the face of abject need and so we need to look at the institutions that sort of create the infrastructure for community and and allocate resources and those resources may be things like parks and grocery stores we're not talking about you know
• 40:00 - 40:30 esoteric things we're talking about basic fundamental things that we all know that people need to be healthy kids need places safe places to run around people need access to healthy food that's affordable so as a society we need to try to create those things we don't just say hey you know an individual responsibility it's your fault if you don't have grocery stores and then we have to look at the narrative the narrative that essentially sets this
• 40:30 - 41:00 know of value who matters you know undocumented farmworkers are not entitled to health care why they literally put the food on our table and we say that they're not entitled to health care I mean they're here feeding us and we say they're not entitled to health care what what is the narrative there what are we saying about that population because that creates policies that creates real-world conditions for
• 41:00 - 41:30 people so the world of health disparities lives downstream the world of health inequities lives upstream if you're simple-minded like me you can just take it health out of the equation and talk about inequities producing disparities or if you're really simple-minded like me you talk about conditions producing consequences and we spend three trillion dollars a year in this country on consequence management or damage control and what we're arguing is that we need to start thinking about what do we invest upstream intentionally in an
• 41:30 - 42:00 organized way just like Jim was describing as an intentional set of practices in the socio-ecological context to try to take the demand off the downstream healthcare systems you can take the health consequences out of this equation just start talking about other consequences like educational attainment with essentially school absence leading to grade failure leading to dropout the upstream drivers remain the same so
• 42:00 - 42:30 we're arguing let's figure out how we in an organized way as a society figure out how to make structured investments upstream that we know will reduce downstream disease and I'll put it to you that this is what Canada and most Western democracies do they make structured intentional investments upstream in social benefits and services to essentially offload the downstream
• 42:30 - 43:00 system we ignore the opportunity to make those investments and we pay a huge price downstream so we've developed a practice we call it about narrative policy in place and one of the critical things is this arc of power we think it's really critical amongst the people who are most impacted by inequity to invest in building social political and economic power and a
• 43:00 - 43:30 critical mass of those people so that they can actively hold the systems that serve them accountable for more equity this isn't about smartypants people with a lot of degrees behind their names like me coming in and telling people what to do this is about people setting their own agenda and prioritizing the things that matter to them in their lives we need to facilitate that this is really about optimizing democracy as as fanciful as that sounds this is really about giving people meaningful voice
• 43:30 - 44:00 so very simply the medical model says that bad behavior produces disease produces premature deaths and the socio-ecological model says that there are set of bad societal behaviors Abraham Lincoln notwithstanding there all of these narratives out there and you see this manifesting itself just beautifully I mean I don't even have to say this I should but Donald Trump and Hillary Clinton up here you see this narrative in the presidential debate it's about others it's about lock us
• 44:00 - 44:30 down close the borders deport people don't let in you know people with different religions it's really about a narrative of exclusion and that narrative exclusion leads to a set of policies and those policies create real-world conditions and we need a new narrative one that's inclusive in health that actually invests in people and recognizes that we're all in this together and then if we don't invest in people we pay a big cost downstream a preventable cost so instead of bad
• 44:30 - 45:00 societal behaviors that creates policies and practices that creates communities that are on life support so we have interventions to try to prevent death we call them emergency rooms interventions to try to change the course of disease we call that 15-minute visits and clinical spaces we have interventions to try to change behavior we call that health education we don't have although from what Jim was describing and and Joel was describing this morning it sounds like luis obispo has thought this through
• 45:00 - 45:30 interventions to try to address the can the conditions in communities that are conspiring against people's health we call ours about building power and leadership amongst people living in those places we think that we need to invest in the indigenous populations in those places not in doctors and and and and again academics but actually in those people well we don't think that that's sufficient we think that we
• 45:30 - 46:00 actually have to work on the policies and the practices to bring across these silos the butcher the baker the candlestick maker have to come together to make a meal and we have health we have education we have law enforcement we have all of these silos that are working in parallel we want to bring them together and and foster a common dialogue over time and it sounds like you're doing that exactly with your coalition here and finally we think we
• 46:00 - 46:30 have to change the narrative and we have to start talking about health in different way so people understand that health is not just about health care and personal responsibility although those things matter and they're they're necessary they're just not sufficient we call that the drivers of change and so let me tell you a little bit about building healthy communities so I got hired I never liked philanthropy I always thought philanthropy was sort of dilettante ish and obnoxious you know people who
• 46:30 - 47:00 thought that they were smarter than everybody else and I was a government guy you know I worked in public health and I was on the front lines you know putting out outbreaks of tuberculosis or you know pertussis or what have you and these fancy little California Endowment people and wellness foundation people would come prancing around and sprinkle a few dollars here and say you know here come do what we think and I was like get
• 47:00 - 47:30 the hell out of here you don't know what you're doing and then my boss Bob Ross is the CEO of the Californian diamond who's a pediatrician came to me knee he had a like a face-to-face conversation he said Tony I don't like philanthropy either but we're trying to do something different we're trying to actually make a measurable difference in the health status of Californians and we're not really sure how to go about it so we're gonna be trying to figure out how to do this as we go and we're gonna put a
• 47:30 - 48:00 billion dollars into it over 10 years and he said I'd like you to come and help us design it and I said no and he came back two years later and he asked me the same question and at that point the county's budget was in the tank and we were cutting things right left and center and I said maybe but I'll only do this if we're can if we can talk about power if we can talk about racism if we can talk about sexism if we
• 48:00 - 48:30 can talk about the drivers and the narratives that are creating the status quo conditions and he said sure and so I came over and we basically designed this thing from scratch not because we thought we knew better than anybody else but because when we looked around there weren't really there weren't any models for doing this sort of place-based deep you know multi issue
• 48:30 - 49:00 health improvement initiatives over time that actually was focused on the social determinants of health there were a lot of things that were focused on increasing access to health care and various other approaches but nothing based on on focusing on the social determinants of health so so we designed this thing from scratch and the only caveat was that we would spend a billion dollars 10 years 14 places we try to make a measurable change in the health status of populations but we would not spend a nickel on healthcare because
• 49:00 - 49:30 healthcare is already heavily over invested so that's what building healthy communities is it's basically taking this model and trying to apply it in 14 places and then through a state wide umbrella function across the state and it's it's basically about building social political and economic power and a critical mass of people in places like South Los Angeles East Oakland South Sacramento North Richmond del North County down to the City Heights in San
• 49:30 - 50:00 Diego and various parts of the Central Valley and it's also about policies trying to create health and all policies and much more inclusive and sustainable policies and practices and communities and then finally it's about changing the narrative which is what that animated video is about and all the posters we throw up on buildings and in airports and in the governor's office it's trying to get people to think about health in a different way and we're not alone I mean
• 50:00 - 50:30 we're a billion dollars is like a drop in the bucket when it comes to health in California because what you're doing here what people are doing in other counties and other cities we're trying to align with that so that there's a consistent message we share all of our materials people are free to use them and use them in their own campaigns and our goal is really to create a network across the state of people who are like-minded working together on using examples of
• 50:30 - 51:00 promising practices locally that can filter up to the state to lead to policy change now we're half way through this thing and where I'll tell you what's changed and we think that we contributed substantially to it well first of all there's five million newly insured Californians we invested a lot of money in trying to make sure that every county had outreach and enrollment resources to be able to bring people into médicale and we were literally the
• 51:00 - 51:30 most successful state in the country on that issue we have about a million people that are now eligible to reclassify their felonies into misdemeanors because they were relatively low-level felonies in Prop 47 which we helped create the environment for passed and allows people with certain types of felonies to reclassify as misdemeanors to now be eligible for housing not having to check the box on job applications etc
• 51:30 - 52:00 the thing that I'm most proud of is when we first designed this thing it was a health initiative no broadly she lies but we went to our partner communities and we said this is what we'd like to work on and they said looks good but you're missing something which is schools and kids and the fact that our kids are being pushed into the school to Prison Pipeline and we said literally for two years we said this we said no that's not health
• 52:00 - 52:30 and they kept coming back to us and we finally said okay we'll take a look at this issue and it turns out they were right we were wrong that this school push out issue there about at the time they're about 800,000 suspensions and expulsions in California schools across the state and about for a little bit more than 400,000 kids that were being suspended and expelled and this was having we know that one suspension after ninth grade makes it 30% less likely that you'll
• 52:30 - 53:00 graduate from high school and we also came to know that many of the kids living in these communities these communities that are bereft of all of the infrastructure that's necessary for people to be able to have a shot at navigating a healthy life these kids are traumatized and they bring that trauma into the classroom and when you're traumatized this would happen to any of us with your awash in cortisol you have no control over what's happening to you
• 53:00 - 53:30 you're witnessing violence you bring this into the classroom you act out and you get suspended you get pushed into a highly criminalized system now it's school discipline is highly criminalized with school resource officers on campus making arrests issuing tickets forcing parents to come to court so the social and emotional health of children in the school system is a health issue so we got involved in that and over a process of a couple of years
• 53:30 - 54:00 managed to drive down suspensions in California by over a hundred thousand and in some of our sites they plummeted to near zero and we're continuing to see decreases across the state and this is why and at the same time when Texas is going up Florida is going up other big states are not seeing any change California's are plummeting is that gun done 40 percent over the past three years so we're really proud of that for
• 54:00 - 54:30 two reasons one we know that this directly correlates to people's educational attainment which directly correlates to their health status later in life we also know that because we got involved in this issue we've seen real change and it's measurable change so we're halfway through building healthy communities the benefits we think are many and they're not just in the 14 sites we're seeing policy change at the
• 54:30 - 55:00 state level that's impacting school districts and healthcare and neighborhoods throughout the state it's a lot of fun work and we recognize that we're not in this alone at all so with that I'd love to take any questions and and like I always say I like the provocative obnoxious questions I mean you can ask nice ones but I learned from the questions I'll probably make some slides if you know I have some really obnoxious ones
• 55:00 - 55:30 so thank you very much for having me here today [Applause]