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ISSUE BRIEF Embargoed until Tuesday, December 17 at 10:00 AM ET

Racial Healing and Achieving Equity in the United States

“Of all the forms of inequality, injustice in is the most shocking and inhumane.”

-- Rev. Martin L. King, Jr.

The Truth, Racial Healing & Transformation promote positive and lasting change across (TRHT) effort was created by the W.K. issues — including to: Kellogg Foundation as a national and 1. Find ways to reinforce and honor our community-based process to plan for and common humanity and create space to bring about transformational and sustainable celebrate the distinct differences that change and to address the historic and make our communities vibrant; contemporary effects of racism. 2. Acknowledge that there are still deep Among the many aspects of TRHT is racial divisions in America that must be the need to address serious racial and overcome and healed; and ethnic health inequities — and the causes that contribute to them. Good health is 3. Commit to engage people from all racial, eth- essential to ensuring everyone is able to live nic, religious and identity groups in genuine a high-quality life, be engaged with their efforts to increase understanding, communi- 1 families, communities and workplaces, and cation, caring and respect for one another. have the opportunity to flourish and thrive This issue brief was developed to help identify in everything they do. TRHT’s National and acknowledge health inequities, influencing Day of Racial Healing identifies key steps factors and policy recommendations that can that will help take collective action to help the nation achieve health equity.

“Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as JANUARY 2018 poverty, , and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments and health care.”2 REACHING FOR Health Equity

Reducing health disparities brings us closer to reaching health equity. The programs below are examples of how addressing disparities can advance health equity.

T HEAL T HEAL ES TH ES TH B B

P P OSSIBLE OSSIBLE

Future Strategies

Case management and home visits by Client and provider reminders workers decreased Ongoing and patient navigators increased asthma-related hospitalizations Efforts screening rates

Expanded recommendations Personalized counseling reduced Programs and policies supporting eliminated some disparities in HIV risk behaviors better neighborhood conditions Hepatitis A reduced violence

Curriculum for living well with a Tribally driven efforts to reclaim Lay health advisors reduced HIV improved quality of life traditional food systems facilitated risk behaviors dialogue about health

PROGRAMS

POPULATIONS

Black and Racial/ethnic People living Men who have American Indian Low income High risk Hispanic and Latino Hispanic children minority groups with with men and Alaska Native populations and communities immigrant men populations Alaska Natives

HEALTH EQUITY is when HEALTH DISPARITIES are differences in health outcomes and everyone has the opportunity to be their causes among groups of people. as healthy as possible. EXAMPLE: African American children are more likely to die from asthma compared to non-Hispanic White children.

2 TFAH • healthyamericans.org Learn more about these programs at:

CS262907 http://www.cdc.gov/minorityhealth/strategies2016/ Existing Inequities The causes of health inequities are multifaceted and often intertwined with lower , differential access to opportunities and other factors that influence health, such as quality healthcare, income, education, housing, transportation and others, sometimes referred to as the “social determinants of health.”

Health inequities have a high economic housing provide significant opportunities l Infants born to Black women are 1.5 to cost. A study by the Urban Institute found to be healthier.12 almost 3 times more likely to die than that for a set of preventable (dia- l Low-income neighborhoods are less infants born to women of other betes, heart disease, high blood pressure, likely to have places where children can races/ethnicities regardless of 25 renal disease and stroke), differences be physically active or have access to education level. American Indian and in the rates of diseases among Blacks, fully-stocked supermarkets with healthy, Alaska Native infants die from Sudden Hispanics and Whites cost the healthcare affordable foods — contributing Infant Syndrome (SIDS) at 3 26 system $23.9 billion annually. By 2050, to higher rates of obesity and poor about twice the rate of White infants. this is expected to double to $50 billion a in these communities.13, 14, 15 l Asthma rates for Black children grew year.4 Eliminating health inequities could l Low-income and minority communities by 50 percent between 2001 and lead to reduced medical expenditures also experience higher air , 2009, while the overall asthma rates of $54 to $61 billion a year, and recover 27 which affects respiratory and cardiovas- increased 15 percent. Differences in around $13 billion annually due to work cular health as well as birth outcomes.16 asthma rates between Black and White lost by illness and around $240 billion per children reached a peak in 2011 (with year due to premature (2003-2006 Examples of some health inequities Black children twice as likely as White 5,6 spending). According to the U.S. Cen- include: children to have asthma).28 And, ters for Disease Control and Prevention l American Indians and Alaska Natives asthma-related hospitalizations and (CDC), the rate of preventable hospital- are twice as likely to have diabetes deaths are more than twice as high izations for Blacks is almost double that of as Whites, and diabetes rates among among Blacks as Whites.29, 30 Whites — which contributes to over a half Blacks and Hispanics are more than l Blacks, Hispanics, and American Indians million hospitalizations and $3.7 billion in 17 1.5 times higher than for Whites. and Alaska Natives received worse hospitalization costs annually.7 l Blacks are seven to nine times more care than Whites for about 40 percent The following are a number of examples likely to die from HIV, and are six times of quality measures, according to the highlighting factors that contribute to more likely to die from homicide.18 2015 National Healthcare Quality and 31 inequity: l Black children have the highest rate of Disparities Report. Blacks and Hispanics l Blacks and Latinos have lower median lead poisoning (5.6 percent).19 were more likely than Whites to report poor communication from healthcare household incomes than Whites and l Blacks have the highest death rate 8 providers. Some examples of implicit are more likely to live in poverty. and shortest survival for most cancers bias in healthcare identified by The l Black men earned 70 cents for every of any racial and in the Joint Commission, Division of Health dollar earned by White men in 2014 United States.20 Care Improvement include: non-White and Hispanic men earned 60 cents on l Black women with breast cancer are 40 patients receive fewer cardiovascular the dollar.9, 10 percent more likely to die than White interventions and renal transplants; l People living in neighborhoods with high women with breast cancer, despite non-White patients are less likely to be 21, 22 levels of poverty have a higher risk of less similar incidence rates of the disease. prescribed pain medications; Black men healthy behaviors —such as smoking, l Black men are about twice as likely to are less likely to receive chemotherapy physical inactivity or poor nutrition— die from prostate cancer as Whites. 23 and radiation therapy for prostate which are related to inequities in the l Hispanic women are more than 1.5 cancer; and patients of color are more physical and social environment.11 times as likely to have cervical cancer likely to be blamed for being too passive Access to safe neighborhoods and 32 as Whites. 24 about their healthcare. amenities, supermarkets and quality TFAH • healthyamericans.org 3 INEQUITIES IN

Life expectancy rates vary by as much as As of 2014, five counties had life comprised of more than 75 percent 20 years between counties in the United expectancies below 70 years (the lowest non-Hispanic White. States.33 Race/ethnicity, at 66.8 years) — with four of those l Of the 50 counties with the lowest and healthcare explained the differences counties having high American Indian life expectancy rates (72.6 years and by 74 percent, 60 percent and 27 populations. Two counties had life lower), seven had majority American percent respectively. expectancies above 86 years. Indian populations (with five above 79 l Of the 50 counties with the highest life percent) and 18 had majority Black expectancy rates (82 years and above), populations (with nine at 70 percent 35 of them had a population that was or above).

THE BLACK WHITE MORTALITY GAP Currently, on average, the life expectancy for Black men is 4.5 years shorter than for White men; and 3 years shorter for Black women than White women.34

The mortality gap among Blacks and Whites has narrowed by around half — from 33 percent to 16 percent — over the past 17 years. Blacks experienced a 25 percent decline in overall death rates during this time compared to a 14 percent decrease among Whites.35

Still, Blacks are more likely to die at relatively younger ages from a wide range of causes — including that Blacks ages 18 to 49 were nearly twice as likely to die from diabetes, heart disease and stroke than Whites. However, Blacks ages 65 and older have a lower death rate than Whites ages 65 and older from heart disease, cancer and stroke. CDC attributes the consequences of psychosocial, economic and environmental stressors are the key contributors to these disparities.

4 TFAH • healthyamericans.org Age-adjusted death rates for selected populations: United States, 2015 and 201636

1,200 2015 2016 21,081.2 1,070.1

1,000

881.3 879.5

800 733.1 1728.8 731.0 734.1

1 644.1 637.2 628.9 631.8 600

438.3 436.4 400

200 Deaths per 100,000 U.S. standard population

0 To tal Black male Black female White male White female Male Female Non-Hispanic Hispanic

1Statistically significant decrease in age-adjusted death rate from 2015 to 2016 (p < 0.05). 2Statistically significant increase in age-adjusted death rate from 2015 to 2016 (p < 0.05). NOTE: Access data table for Figure 2 at: https://www.cdc.gov/nchs/data/databriefs/db293_table.pdf#2. Source:SOURCE: NCHS, National National Vital Vital Statistics Statistics System, System,Mortality. Mortality.

AMERICAN INDIAN LIFE EXPECTANCY Life expectancy for a number of counties with high American Indian populations are 20 percent lower than other counties in the United States.37,38 Much of the difference is attributed to socioeconomics and access to healthcare in addition to race/ethnicity. For instance, Oglala Lakota County in South Dakota, which includes the Oglala Sioux Tribe’s reservation, had the lowest life expectancy in the country in 2014 — at 66.8 years, and three other counties with tribal communities were also among the five lowest for life expectancy arindambanerjee / Shutterstock.com rates (Todd County, South Dakota with overall national rates also increased. the Rosebud Sioux Tribe; Buffalo County, For instance, the Oglala Lakota County South Dakota with the Crow Creek Sioux average life expectancy increased by 5.4 Tribe; and Sioux County, North Dakota years during this time, from 61.3 years in which includes the northern portion of the 1980 to 66.8 years in 2014. However, Standing Rock Sioux Tribe reservation). the average life expectancy for those in Life expectancy rates in nearly all predominantly American Indian counties counties with tribal communities is 12.5 years shorter than the overall life increased between 1980 and 2014, as expectancy rate in South Dakota.

TFAH • healthyamericans.org 5

■2 ■ Policy Recommendations

TFAH has issued the following set of and universities, must be taken into recommendation to help the nation account in this process. Proven, achieve health equity: effective programs, such as CDC’s REACH (Racial and Ethnic l Create strategies to optimize the Approaches to Community Health) health of all Americans, regardless should be fully-funded and expanded. of race, ethnicity, income or where they live. All levels of government l Collect data on health and related must invest in analyzing needs and equity factors — including social increasing effective policies and determinants of health — by programs to address the systematic neighborhood. There should be a inequities that exist and the factors priority on improving data collection that contribute to these differences, at a very local level to understand including poverty, income, racism connections between health status and environmental factors. These and the factors that impact health to should include community-driven help identify concerns and inform approaches, including using place- the development of strategies to based approaches to target programs, address them. Collecting and policies and support effectively. reporting data by neighborhood at a zip code or even more granular l Expand cross-sector collaborations neighborhood level are essential. addressing health equity. Improving equity in health will require supporting l Support coverage and and expanding cross-sector efforts to reimbursement of clinical-community make communities healthy and safe. programs to connect people to Efforts should engage a wide range of services that can help improve health. partners, such as schools and businesses, Medicaid should reimburse efforts to focus on improving health through that support improved health beyond better access to high-quality education, the doctor’s office — programs such jobs, housing, transportation and as asthma and diabetes prevention and economic opportunities.39 care management and community- based initiatives, can help better l Fully fund and implement health address the root causes that contribute equity, and to inequities. prevention programs in communities. Partner with a diverse range of l Communicate effectively with diverse community members to develop community groups. Federal, state, and implement health improvement local and tribal officials must design strategies. Federal, state, local and culturally competent, inclusive tribal governments must engage and linguistically appropriate communities in efforts to address communication campaigns that use both ongoing and emergency health respected, trusted and culturally threats. The views, concerns and competent messengers to communicate needs of community stakeholders, their message. Communication such as volunteer organizations, channels should reflect the media religious organizations and schools habits of the target audience.

6 TFAH • healthyamericans.org l Prioritize individual and community resiliency in health emergency preparedness efforts. Federal, state, local and tribal government officials must work with communities and make a concerted effort to address the needs of low-income, minority and other vulnerable groups during health emergencies. leaders must develop and sustain relationships with trusted organizations and stakeholders in diverse communities on an ongoing basis—including working to improve the underlying health of at-risk individuals, sub-population groups and communities, so these relationships are in place before a disaster strikes. Communication and community engagement must be ongoing to understand the disparate needs of various populations. Linda Parton / Shutterstock.com l Eliminate racial and ethnic bias l Incorporate strategies that foster in healthcare. Policies should community agency—or a community’s incentivize equity and penalize collective ability and opportunity to unequal treatment in healthcare, and make purposeful choices—into the there should be increased support design, implementation and governance for programs to increase diversity of multi-sector collaborations. Building in and across health professions. community agency can contribute Some of The Joint Commission’s to improved community health by recommendations for combatting yielding a deeper understanding of implicit bias include: assiduously the challenges and opportunities practicing evidence-based medicine; influencing a community, and relies supporting cultural understanding on an asset-based approach to leverage and avoiding stereotypes; supporting existing community strengths and the National Standards for Culturally resources. Multi-sector collaborations and Linguistically Appropriate Services should include dedicated resources for in Health and Health Care; and fostering and measuring community supporting techniques that de-bias care, agency. Efforts should maximize and including through training, perspective- bolster community voice and power as taking, emotional expression and a means to influencing larger policy- counter-stereotypical exemplars.40 In and systems-level changes (including addition, efforts should be increased those within and outside of the to train more healthcare professionals traditional health sector). from under-represented populations so that the workforce reflects the diversity of the patient population.

TFAH • healthyamericans.org 7 Examples The following examples illustrate several current initiatives of Programs that target the higher rates of preventable injuries, illnesses and deaths. They highlight diverse practices that incorporate Addressing organizations and individuals from multiple sectors including Health Equity education, criminal justice and business as well as public health and healthcare. While every community and effort is unique, they all share an approach of focusing on equity and inclusive work at the local community level.

The California Endowment’s Building Healthy Communities

The California Endowment (TCE) created an undocumented; the promotion of healthy ambitious $1 billion, 10-year project called school environments and altered school Building Healthy Communities (BHC) in policies such as those related to discipline 2010. Its goal is to improve the health and and suspension; the reform of the justice well-being of young people in underserved system; and the implementation of multiple communities by reducing or eliminating local changes that make communities harmful conditions. It has provided funding safer and more walkable. to 14 community-based organizations BHC is noteworthy in its commitment to across the state to undertake activities developing long-term relationships with that were customized to the specific local specific partners, placing the decision- conditions but which had the potential making authority for the usage of the to affect state policies and practices grants at the community level and focusing as well. As a result of its work, BHC on youth leadership and organizing. has seen improvements in healthcare coverage, including for those who were

8 TFAH • healthyamericans.org Minnesota Public Health Department The Minnesota Department of Health Triple Aim of Health Equity prioritized work on health equity. It created Assess & Influence the Crosswalk to the 7 Foundational Practices an internal Center for Health Equity and Policy Context a Health Equity Advisory and Leadership (HEAL) Council as part of a broad effort. Lead with an Equity Focus The Center has awarded scores of grants Use Data to Advance Health to community agencies including ones Build Partnerships Equity that identify and address the social and & Community Develop Workforce via Capacity Implement Health Continuous Learning economic conditions that contribute to in All Policies inequities and ones that support the Use & Target Resources Strategically improvement of the health status of groups with poorer health. The Health Department has taken steps to establish Expand the an open participatory process for this Strengthen Expand Understanding of work, including many members of the Community Understanding Health populations at highest risk of illness, injury Capacity of Health and preventable deaths on the Advisory Council and holding statewide meetings to discuss progress toward health equity. policies, expanding the understanding state including materials on emergency It has developed a framework for of health and strengthening community communications, paid sick leave and health considering the work that is known as capacity. The Health Department has statistics (http://www.health.state.mn.us/ the Triple Aim of Health Equity with three developed a series of reports and resources divs/opi/healthequity/resources/). components: implementing health in all on the topic for those in and beyond the

Roadmap to Health Equity

The health indicators for the Black nutrition and provide them with healthy population of Mississippi are significantly foods. It offers a leadership program for worse than for the White population. Black young students that provides educational residents live on average 4 years less than lessons in school-work, presentation Whites and have more deaths from cancer, skills and beneficial eating and exercising heart disease, HIV and many other chronic practices. conditions. The Mississippi Roadmap For adults, the Roadmap runs a Mobile to Health Equity, Inc., a community- Farmer’s Market that delivers fresh fruit based organization in Jackson, is actively and vegetables to older residents of engaged in improving those statistics with geographically isolated housing complexes. its focus on changing the conditions in the And it runs a fitness center for adults and lives of the low-income Black population. children that is accessible and affordable It has a strong focus on the health of with minimal membership fees. Support children by supporting food and nutrition for the Roadmap has been provided awareness policies within schools. It is by the W. K. Kellogg Foundation. More responsible for multiple school gardens information on the Roadmap is available at that are used to teach children about http://mississippiroadmap.org/.

TFAH • healthyamericans.org 9 Colorectal Cancer Screening

Racial and ethnic minority populations often have lower colorectal cancer screening rates than White populations (U.S. White rates were 65 percent compared to 62 percent, 54 percent and 50 percent rates for Black, American Indian and Latino populations respectively).41 Specialized outreach and education Colorectal Health Colorectal Health programs have been shown to be effective Protect Yourself, Your Family, and Our Community Protect Yourself, Your Family, and Our Community at closing the gap by using multiple targeted approaches such as patient reminders The Washington State program utilized pa- and patient navigators for outreach and tient care coordinators at community health assistance. Two examples of such successful center sites to implement client and provider efforts are the Alaska Native Tribal Health telephone and electronic health record re- Consortium and Washington State’s Breast, minder systems and to provide staff training Cervical and Colon Health program. on the protocols for scheduling of screening. Colorectal Health Colorectal Health The Alaska Consortium collaborated with In both cases,Protect Yourself, colonoscopy Your Family, and Ourrates Community for popula- Protect Yourself, Your Family, and Our Community regional tribal health organizations to hire tions of color dramatically increased, patient navigators to do outreach and one- sometimes doubling what they were on-one patient education and to assist before.42, 43 More information about evi- with transportation and other barriers to dence-based programs to reduce chronic dis- accessing appointments. In addition, they eases that disproportionately affect specific developed an electronic system to send both populations is available at https://www.cdc. clinician and client informational reminders. gov/chronicdisease/healthequity/index.htm.

Healthy Heartlands

The Healthy Heartlands initiative is an the social determinants of health for low- eight-state network of public health income communities and communities professionals and faith-based community of color using a racial health equity lens. organizers working to reduce health Leaders from across the participating inequities through democracy building and Midwestern states gather regularly to policy and system changes.44 The initiative share best practices and advance an combines the research, institutional action agenda for racial and health equity. legitimacy and content expertise of public Past efforts have included campaigns to health leaders with the local voice, power increase employment opportunities for and engagement capacities of community formerly incarcerated persons, expand organizers. Through their collaborative access to healthy food and promote free, actions, the network of interdisciplinary quality early education. leaders works to identify and address

10 TFAH • healthyamericans.org Robert Wood Johnson Foundation of Health Sentinel Communities—Stockton, CA

Located in Northern California, Stockton and community stakeholders to has long been plagued by crime and improve their city’s safety, education, poverty. The crime rate in Stockton housing, job creation, and health. is more than three times the rate in RSSC deploys four outreach workers to California. And there are high levels of build trust and relationships between poverty, which are highest among racial community members and government and ethnic minority communities, where officials, assess community needs nearly 50 percent of Black residents and appropriately connect residents and more than 29 percent of Hispanic to available services/supports. Other residents were living below the federal efforts include a 2014 ¾ cent tax to poverty level (compared with less than increase the capacity of the police force 17 percent of White residents).45 from 400 officers in 2015 to a goal of 485 by 2017. Community members and public officials are collaborating to address these Stockton, CA is one of RWJF’s 30 Sentinel issues by elevating early intervention Communities chosen to collect, analyze and education, fostering cross-sector and disseminate community-level data collaboration, reducing barriers to to provide insight on the best practices housing and homeownership, and and lessons for improving health and strengthening integration of health wellbeing. Baseline data was collected services and systems. In 2015, city in 2016 and future community snapshot council and community members reports will include more in-depth analysis created the Reinvent South Stockton and insight on health equity outcomes Coalition (RSSC) to empower residents and process measures.

TFAH • healthyamericans.org 11 Endnotes 1 W.K. Kellogg Foundation. Taking Collective 18 Cunningham TJ, Croft JB, Liu Y, Lu H, Eke PI, 34 National Center for Health Statistics. Health, Action for Racial Healing. http://healourcom- Giles WH. Vital Signs: Racial Disparities in Age- United States, 2015: With Special Feature on munities.org/ndorh-2018/. Specific Mortality Among Blacks or African Amer- Racial and Ethnic Health Disparities—Table 18. 2 Braveman P, Arkin E, Orleans T, Proctor D, icans — United States, 1999–2015. MMWR Morb Hyattsville, MD: National Center for Health and Plough A. What Is Health Equity? And Mortal Wkly Rep 2017;66:444–456. DOI: http:// Statistics, 2016 What Difference Does a Definition Make?Princ - dx.doi.org/10.15585/mmwr.mm6617e1. 35 Cunningham TJ, Croft JB, Liu Y, Lu H, Eke eton, NJ: Robert Wood Johnson Foundation, 19 Trust for America’s Health, Blueprint for a PI, Giles WH. Vital Signs: Racial Disparities in 2017. https://www.rwjf.org/content/dam/ Healthier America 2016: Policy Priorities and Age-Specific Mortality Among Blacks or Afri- farm/reports/issue_briefs/2017/rwjf437343. Recommendations for the Next Administration and can Americans — United States, 1999–2015. 3 Waidmann, TA. Estimating the Cost of Racial Congress (2015) (available at http://tfah.org/ MMWR Morb Mortal Wkly Rep 2017;66:444– and Ethnic Health Disparities. Washington, assets/files/TFAH-2016-Blueprint-FINAL.pdf) 456. DOI: http://dx.doi.org/10.15585/ DC: Urban Institute, 2009. 20 Cancer Facts and Figures for African Ameri- mmwr.mm6617e1 4 Ibid. cans. In American Cancer Society. http://www. 36 Kochanek KD, Murphy SL, Xu JQ, Arias E. cancer.org/research/cancerfactsstatistics/ Mortality in the United States, 2016. NCHS Data 5 LaVeist TA, Gaskin D, Richard P. Estimat- cancer-facts-figures-for-african-americans (ac- Brief, no 293. Hyattsville, MD: National Cen- ing the economic burden of racial health cessed September 2016). http://www.cancer. ter for Health Statistics. 2017. inequalities in the United States. Int J Health org/research/cancerfactsstatistics/cancer- Serv. 2011;41(2):231-8. 37 Dwyer-Lindgren L, Bertozzi-Villa A, Stubbs facts-figures-for-african-americans RW, Morozoff C, Mackenbach JP, van Lenthe 6 LaVeist TA, Gaskin D, Richard P. The Economic 21 Hunt BR, Whitman S and Hurlbert MS. Increas- FJ, Mokdad AH, Murray CJL. Inequalities Burden Of Health Inequalities in the United ing Black: White disparities in breast cancer mor- in Life Expectancy Among US Counties, States. Washington, DC: Joint Center for Po- tality in the 50 largest cities in the United States. 1980 to 2014Temporal Trends and Key Driv- litical and Economic Studies, n.d. Cancer . Apr 30;38(2):118-123, 2014. ers. JAMA Intern Med. 2017;177(7):1003–1011. 7 Centers for Disease Control and Prevention. 22 Breast Cancer Rates by Race and Ethnicity. In doi:10.1001/jamainternmed.2017.0918 CDC Health Disparities and Inequalities Report — Centers for Disease Control and Prevention. http:// 38 Krul, DU. Life Expectancy Falling in the US United States, 2013. Atlanta, GA: CDC, 2013. www.cdc.gov/cancer/breast/statistics/race.htm — But in Tribal Communities Not So Much. 8 Proctor BD, JL Semega and MA Kollar. Income 23 Prostate Cancer Rates by Race and Ethnicity. Indian Country Today. May 11, 2017. https:// Wash- and Poverty in the United States: 2016. In Centers for Disease Control and Prevention. indiancountrymedianetwork.com/culture/ ington , DC: United States Census Bureau, http://www.cdc.gov/cancer/prostate/statis- health-wellness/life-expectancy-falling-us- 2016. https://www.census.gov/content/dam/ tics/race.htm tribal-communities-not-much/. Census/library/publications/2016/demo/ 39 National Prevention Council. National p60-256.pdf. 24 Cervical Cancer Rates by Race and Ethnicity. In Centers for Disease Control and Prevention. Prevention Strategy: Elimination of Health 9 Wilson, V. “New Census Data Show No Prog- http://www.cdc.gov/cancer/cervical/statis- Disparities. Washington, DC: National ress in Closing Stubborn Racial Income Gaps. tics/race.htm Prevention Council, 2014. Working Economics Blog September 16, 40 The Joint Commission. Implicit Bias in Health 2015. https://www.epi.org/blog/new-census- 25 Centers for Disease Control and Prevention. Care. April 2016. https://www.jointcom- data-show-no-progress-in-closing-stubborn-ra- CDC Health Disparities and Inequalities Report — United States, 2013. Atlanta, GA: CDC, 2013. mission.org/assets/1/23/Quick_Safety_ cial-income-gaps/ https://www.epi.org/blog/ Issue_23_Apr_2016.pdf new-census-data-show-no-progress-in-closing- 26 Sudden Unexpected Infant Death and Sud- stubborn-racial-income-gaps/. den Infant Death Syndrome. In Centers for 41 https://www.cancer.org/content/dam/can- cer-org/research/cancer-facts-and-statistics/ 10 DeNavas-Walt C, Proctor BD. Income and Disease Control and Prevention. http://www.cdc. gov/sids/data.htm colorectal-cancer-facts-and-figures/colorectal- Poverty in the United States: 2014. Washing- cancer-facts-and-figures-2017-2019.pdf ton , DC: United States Census Bureau, 2015. 27 Centers for Disease Control and Prevention. 42 Joseph DA, Redwood D, DeGroff A, Butler 11 Cubbin C, Pedregon V, Egerter, S, Braveman P. Vital Signs: Asthma in the U.S. Atlanta, GA: Centers for Disease Control and Prevention, EL. Use of evidence-based interventions Issue Brief 3: Neighborhoods and Health. Princ- to address disparities in colorectal cancer eton, NJ: Robert Wood Johnson Foundation, 2011. http://www.cdc.gov/vitalsigns/asthma/ screening. MMWR Suppl 2016:2016;65(No. Commission to Build a Healthier America, 2008. 28 Akinbami LJ, Simon AE and Rossen LM. Suppl 1). 12 Meyer PA, Yoon PW, Kaufmann RB. Introduc- Changing trends in asthma prevalence among children. Pediatrics, 137(1):1-7, 2016. 43 Community Preventive Services Task Force. tion: CDC Health Disparities and Inequalities Updated recommendations for client- and Report — United States, 2013. Morb Mort Sur- 29 Centers for Disease Control and Prevention. provider-oriented interventions to increase veil Summ, 2013; 62(3): 3-5 National Surveillance of Asthma: United States, breast, cervical, and colorectal cancer screen- National Center for Health Sta- 13 Powell L, Slater S, and Chaloupka F. The 2001-2010. ing. Am J Prev Med 2012;43:92–6 . Relationship between Community Physical tistics Data Brief, 2012. http://www.cdc.gov/ nchs/data/series/sr_03/sr03_035.pdf 44 Healthy Heartlands. In ISAIAH. https://isa- Activity Settings and Race, Ethnicity and So- iahmn.org/healthy-heartlands/ cioeconomic Status. Evidence-Based Preventive 30 Most Recent Asthma Data — Mortality. In Cen- Medicine, 1(2): 135-44, 2004. ters for Disease Control and Prevention. http:// 45 RWJF. RWJF Culture of Health Sentinel Commu- www.cdc.gov/asthma/most_recent_data.htm nity Snapshot: Stockton, California. Princeton, 14 Bell JF, Wilson JS, and Liu GC. Neighborhood NJ: RWJF, 2017. https://www.cultureofhealth. Greenness and 2-Year Changes in Body Mass 31 2015 National Healthcare Quality and Disparities org/content/dam/COH/PDFs/stockton- Index of Children and Youth. American Jour- Report and 5th Anniversary Update on the National california-full-snapshot.pdf nal of Preventive Medicine, 35(6): 547-553, 2008. Quality Strategy. Rockville, MD: Agency for 15 Why Low-Income and Food Insecure People Healthcare Research and Quality; April 2016. are Vulnerable to Obesity. In Food Research AHRQ Pub. No. 16-0015. http://www.ahrq. and Action Center. http://frac.org/initiatives/ gov/sites/default/files/wysiwyg/research/ hunger-and-obesity/why-are-low-income-and- findings/nhqrdr/nhqdr15/2015nhqdr.pdf food-insecure-people-vulnerable-to-obesity/. 32 The Joint Commission. Implicit Bias in Health 16 Miranda ML, Edwards SE, Keating MH, Paul Care. April 2016. https://www.jointcom- CJ. Making the Grade: mission.org/assets/1/23/Quick_Safety_ The Relative Burden of Expo- Issue_23_Apr_2016.pdf sure in the United States. Int J Environ Res 33 Dwyer-Lindgren L, Bertozzi-Villa A, Stubbs Public Health. 2011 Jun; 8(6): 1755–1771. RW, Morozoff C, Mackenbach JP, van Lenthe 1730 M Street, NW, Suite 900 17 Centers for Disease Control and Prevention. Di- FJ, Mokdad AH, Murray CJL. Inequalities abetes Report Card 2014. Atlanta, GA: Centers for in Life Expectancy Among US Counties, Washington, DC 20036 Disease Control and Prevention, 2015. http:// 1980 to 2014Temporal Trends and Key Driv- (t) 202-223-9870 www.cdc.gov/diabetes/pdfs/library/diabetes- ers. JAMA Intern Med. 2017;177(7):1003–1011. reportcard2014.pdf (accessed September 2016). doi:10.1001/jamainternmed.2017.0918. (f) 202-223-9871