Presentation by Paula Braveman, MD, MPH at the 2009 Virginia Health Equity Conference. Dr. Braveman described the Robert Wood Johnson Foundation (RWJF) Commission to Build a Healthier America and explained the RWJF’s rationale for creating the Commission and for the Commission’s work to focus on the social determinants of health, and its relevance to health equity. She also discussed the Commission’s recommendations.

1. Achieving Health Equity Will Require More Than Equity in Health Care September 11, 2009 Virginia Health Equity Conference Paula Braveman, MD, MPH Professor of Family & Community Medicine Director, Center on Social Disparities in Health University of California, San Francisco

4. And we have huge disparities, e.g.: Higher income, longer life LIFE EXPECTANCY AT AGE 25 WOMEN Center on Social Disparities in Health, University of CA, San Francisco

5. Huge disparities: Children’s health varies by parents’ income % OF CHILDREN, AGE 17 & YOUNGER, IN POOR/FAIR HEALTH Center on Social Disparities in Health, University of CA, San Francisco

6. Disparities in activity-limiting chronic illness, by income. Similar patterns by education and for diabetes & heart disease % OF ADULTS, AGE 25+, WITH ANY ACTIVITY LIMITATION Center on Social Disparities in Health, University of CA, San Francisco

7. Racial/ethnic differences are important but do not explain the income/education disparities % OF ADULTS, AGE 25+, IN POOR/FAIR HEALTH Center on Social Disparities in Health, University of CA, San Francisco

8. Clues? Scarlet fever death rate in children <15: England & Wales Sulpha drugs Penicillin Thomas McKeown, 1974

9. Measles– mean annual death rate of children under 15: England and Wales Immunization began

10. Infant mortality rate: England and Wales

11. Respiratory tuberculosis– mean annual death rate: England and Wales

14. Poverty Poor Health Poor Health Low Educational Attainment Poor Job Poverty Vicious cycle of poverty and poor health Center on Social Disparities in Health, University of CA, San Francisco

19. CRH AFFECTS MULTIPLE ORGANS & SYSTEMS STRESSOR CORTISOL Hypothalamus Pituitary Gland Adrenal Glands ACTH Stress pathway from brain to body Center on Social Disparities in Health, University of CA, San Francisco

21. Income & stress: Lower income means more stressors during pregnancy, e.g.,: separation or divorce during pregnancy Center on Social Disparities in Health, University of CA, San Francisco % OF WOMEN

24. Economic & Social Opportunities and Resources Living & Working Conditions in Homes and Communities Personal Behavior Medical Care HEALTH Finding solutions: Understanding the importance of social factors Policies to promote healthier homes, neighborhoods, schools and workplaces Policies to promote child and youth development and education, infancy through college Policies to promote economic development and reduce poverty Robert Wood Johnson Foundation Commission to Build a Healthier America www.commissiononhealth.org

25. Understanding how health is transmitted by social factors across lifetimes and generations Robert Wood Johnson Foundation Commission to Build a Healthier America

28. Starting Early Ensure that all children have high-quality early developmental support (child care, education and other services). This will require committing substantial additional resources to meet the early developmental needs particularly of children in low-income families. Feed children only healthy foods in schools. Require all schools (K-12) to include time for all children to be physically active every day.

29. Create public-private partnerships to open and sustain full-service grocery stores in communities without access to healthful foods. Fund and design WIC and SNAP (Food Stamps) programs to meet the needs of hungry families with nutritious food. Accessing Healthy Foods

30. Creating Healthy Communities Become a smoke-free nation. Eliminating smoking remains one of the most important contributions to longer, healthier lives. Integrate safety and wellness into every aspect of community life. Develop a “health impact” rating for housing and infrastructure projects that reflects the projected effects on community health and provides incentives for projects that earn the rating. Create “healthy community” demonstrations to evaluate the effects of a full complement of health-promoting policies and programs.

31. Decision makers at national, state, and local levels need reliable data on health status, disparities, and the effects of social determinants of health. Better data must be developed for use at the local level, in particular. Fund research to understand the health effects of social factors and promote application of findings by decision makers. Measuring Progress, Building In Accountability