Health Disparities Course Syllabus

Here is the syllabus, except for individual class assignments, for the course on Health Disparities (Natural Science 209) that Dr. Richard Aronson, MD, MPH, taught at Hampshire College in the fall of 2009:

Social injustice and inequality create conditions that lead to unconscionable health disparities according to race, ethnicity, childhood experiences, gender, income, nationality, and many other factors. How can it be, for example, that while infant mortality in the United States has declined during the past century, the rate at which black babies die is at more than twice the rate of whites? How can it be that roughly 500,000 women in the world die each year of largely preventable causes related to pregnancy and birth? How can it be that in the same city, the average life expectancy for people living in one neighborhood is 10 years less than for those living in another neighborhood just a few miles apart?

This course explores the multi-faceted origins of selected health disparities. It highlights the real potential, vital importance, and urgent need for solutions: health policies, systems, and programs that are humane, culturally respectful, and effective. How do we define health disparities in a public health context? How do such disparities occur and persist across generations? What is the "life course perspective" for maternal and child health? Specifically, how does chronic stress experienced by women of color in the U.S. make them more likely to give birth to premature and low weight babies? And how are traumatic childhood experiences associated with earlier and more severe chronic diseases in adulthood? We will explore research related to these questions, and then consider specific promising disparity-based practices in the U.S.

We critically examine how such practices tend to: 1) Draw on the resilience of individuals, families, and communities; 2) Tap into the potential for social capital to enrich physical, mental, and spiritual health; 3) Foster collaborative action among multiple stakeholders, including the communities directly affected, to trust each other and unite as equal partners; and 4) Emphasize learning how culture and language influence health, and how the need to respect culture and to communicate clearly is essential to effective and humane programs, policies, and systems. Throughout the course, we focus on bringing the voices of people who have experienced disparities into our dialogue. The professor is a public health pediatrician with 30 years of hands-on practical leadership experience in. The course will continuously examine how to translate theory into practice.

Purpose: To inform and inspire students interested in public health from a social justice context to engage in learning and creating conditions under which all people have the full equal opportunity to thrive in body, mind, and spirit.
Background: Public health faces local and global challenges that require a multi-faceted inter-disciplinary approach that addresses underlying root causes of social injustice in order to create a more humane and equitable world for all people. To make progress, we need broad inclusive participation of many stakeholders, which requires new forms of leadership. This course provides students with a foundation to learn and practice such leadership. We draw on research that shows 1) How various forms of inequality, injustice, chronic stress, and trauma influence health and create unconscionable public health disparities, 2) How resilience and other positive resources, such as the use of clear humane language, provide the potential to create health equity, and 3) How inclusive dialogue, collaborative action, and cultural and linguistic competence form the foundation for the new leadership. Through class lectures and dialogue, individual meetings, four papers, an oral presentation, a variety of readings and DVDs, and community engagement, students explore the translation of this research into humane practice and public policy. Opportunities are available for students who seek to learn and practice such leadership. Also, the professor is available to mentor those who have or are exploring a passion for public health and public service as a profession, and support them with tools to express their idealism in action. Our model of choice for this work is Future Search (www.futuresearch.net ), a unique planning process that has been used with success worldwide for 25 years to stimulate action on complex social issues.

This course seeks to equip students with information and tools to unite stakeholders and serve as a catalyst for essential but previously unlikely partnerships. Our intention is to enable people to discover common ground for action that they did not realize they shared. Such discovery can lay the foundation for leadership needed to bring dignity, hope, and equity to women, children, and families. The focus of the course is to move away from systems that primarily thrive on pathology, medical diagnosis, and risk reduction. Instead, we envision systems and policies that derive their power from resilience, trust, respect of culture and language, and community. Our species has a remarkable capacity for healing and cooperating for the common good. The purpose of the course, in its small way, is to mobilize that capacity among interested students. The larger goal here is to equip a new generation of leaders with lifelong tools to actualize their ideals.

Course Objectives
1. To understand public health disparities within a social justice framework.
2. To understand the multi-faceted and deeply rooted origins of health disparities.
3. To explore how chronic stress contributes to health disparities.
4. To examine the impact of adverse and traumatic childhood experiences on adult health.
5. To examine public health policy and practice to address health disparities.
6. To understand how policy and practices rooted in resilience, cultural and linguistic competence, and collaborative action can create health equity locally and globally.
7. To acquire practical experience in applying these ideas in communities.


Classes


Part I Introduction and Overview (Week 1)

What is public health, and how does the challenge of addressing health disparities central to public health?
What is maternal and child health?
What is a health disparity?
What is health equity?
What are the major factors that contribute to health disparities?


Part II Public Health and Social Justice (Week 1)

How are social justice and public health inter-connected?

Part III Health Disparities: Origins, models, examples (Weeks 2-6)

New research and increased focus on earlier research in the natural and social sciences are giving us a deeper knowledge of the conditions that give rise to health disparities. This section of the course introduces and explores some of the areas of such research:

A. Stress, Biology, and the Life Course Perspective: The rationale for the life course perspective lies in the concept of allostasis, which refers to the body’s ability to maintain stability through change. According to this model, in the face of chronic stress, including that of racism starting in childhood, the body loses its natural ability for self-regulation. The biological pathways (hypothalamus-pituitary-adrenal axis) that enable the body to reset itself and maintain allostasis in response to stress become accelerated. This acceleration may shut down the endocrine feedback system that enables cortisol levels to return to normal after successful adaptation to a stressful event. Chronically high levels of cortisol suppress immune function, making women, for example, more vulnerable to a series of events during pregnancy that are precursors to preterm birth and low birth weight. Further, the continued and often exacerbated stresses that occur during pregnancy itself may program the fetus in a similar way, setting up a compromised ability to self-regulate throughout the life span. The inequitable distribution of conditions and resources in which people can be healthy, such as education, housing, and economic well being, are multiplied by the effects of discrimination. Among the take-home lessons from the life course perspective is the concept that high quality health and medical care and healthy individual behaviors are necessary but not sufficient to reduce health disparities.


B. Racism: The interaction of stress and biology has been researched and studied, and it is particularly important to consider the role of racism as a stressor. However, the historical misuse of biology, medicine genetics, and social sciences has unfairly pathologized communities of color. It has led to a false dichotomization that fails to take into account the full strengths and capacity of such communities to survive, heal, and thrive. Racism can be conceived of as occurring at different levels. Personally-mediated racism is defined as prejudice or discrimination rooted in often unconscious stereotypes of different groups of people. For example, studies demonstrate how health care providers apply differential assumptions or attitudes about others according to their race. As a result, a woman may experience feelings of being dismissed, not listened to, and not treated with respect, which may have an impact on her decision to present for care in the future. The health care system may support such biases, whether unconsciously and unintentionally, through policies and other institutional practices. Researchers have concluded that environment, not genetics, is the primary factor in what has become unequivocal, i.e. that race has an independent association with LBW and infant mortality.

C. The Adverse Child Experiences (ACE) Study: Conducted from a database of 17,337 adult enrollees in the Kaiser Permanente Health Plan in California, began to publish its research in 1998. Stated simply, it uses a retrospective design that shows a strong association between 10 adverse childhood experiences (ACEs) and major risk factors for chronic diseases, both physical and emotional, in adulthood. The 10 ACEs include several categories of child abuse and neglect, and home environmental conditions related to substance abuse, untreated mental illness such as maternal depression, exposure to violence, incarceration, and loss of one parent. The researchers found that ACEs are widely prevalent and transcend social, economic and racial and ethnic boundaries. Further, a recent paper, “The Enduring Effects of Abuse and Related Adverse Experiences in Childhood”, reviews data to support the concept that the mechanisms for biological impairment in brain and endocrine function among children with multiple ACES are comparable to the mechanisms from the life course perspective studies.

D. Social Capital: A growing body of research on the concept of social capital and connectedness shows that the extent to which we feel meaningfully connected to each other and to our communities is a powerful determinant of health status. Social capital encourages formal and informal social support networks, civic engagement, and a heightened sense of community. It refers to the processes between people that establish networks, norms, and social trust, and facilitate coordination and cooperation for mutual benefit. Such connections enrich our physical and emotional health, and provide a deep well of protection from stresses and adversity. These connections have been shown through numerous studies to strengthen the immune system. A study by Haggerty more than 40 years ago showed that among a group of children harboring the Streptococcal bacillus in their throats, those living in more stressful households were more likely to become symptomatic. Ron David, a member of the Joint Center Health Policy Institute’s National Commission on Infant mortality, has further elaborated on this concept of social connectedness by hypothesizing that “relationships are primary; all else is derivative.”

E. Resilience: Resilience refers to the ability to bounce back from adverse experiences and to avoid their long-term negative effects; the power of people to recover, heal, grow, and succeed in the midst of stress, often overwhelming in nature. Studies of concentration camp survivors, of people with special health needs, and of children in violent unsafe environments demonstrate the potential for human beings to bounce back from severe hardship and stress. For example, it has been shown that resilient children and youth are highly flexible and adaptive and skillful as planners and problem solvers . They also tend to possess an internal sense of power and purpose, and have an engaging social temperament. Resilient families support individual children through the presence of an enduring and loving relationship with at least one adult; hold high and clear expectations for the child and confidence that she can do it; and encourage and expect children to feel that they are valued participants. Schools that promote resilience have a wide array of resources to affirm the unique learning style and strength of students; tap into their imagination and creativity; involve students in real life experience; strengthen their decision-making skills; and provide teachers who affirm and inspire that spark in a student and tell her again and again, “You can do this”. Resilience promoting communities are rich in social support networks and have active and vibrant associations and organizations. A resilience promoting community has a clear vision for its children and youth and is equipped with the resources essential to support healthy growth and development – health care, child care, parent education, home visitation, family resource centers, job training, employment, and housing.

F. Conditions for Productive Dialogue and Action: Research in the social sciences has resulted in leadership and planning tools that are more likely to bring out the cooperative and collaborative action that is essential to eliminating birth outcome disparities. For example, synthesizing 80 years of social sciences research, Weisbord and Janoff identified four principles that foster the high level of collaboration needed for systems change on complex and tenacious problems such as birth outcome disparities, and especially in communities where racial and other tensions are high. The four principles are: 1) Get the “whole system” in the room—those with authority, resources, expertise, information, and need—all in the same conversation. 2) Explore the whole before seeking to fix any part; 3) Put common ground and future action front and center; and 4) Set up meetings so people can do the work for themselves. These broad principles may help in thinking through further the potential methods by which joint action in Wisconsin can be encouraged effectively, with the obvious caution that this is easily recognized as a need and not so easily enacted in practice for many reasons.

Part IV Principles for Creating Health Equity (Weeks 7-10)

As the foundation for public policy to reduce health disparities, it is important to explore some underlying characteristics that have shown promise in successful efforts to create equity. We will examine the following set of assumptions and practices and consider how they can be incorporated into the various dimensions of work to reduce disparities, whether it is related to policies, systems, programs, and services; research; and teaching:
 Honor and respect the dignity of all people involved, and of their cultures
 Consider that everyone is an "expert" and honor all voices, especially those who have historically not been included in the design of the policies that affect them
 Include families and communities as equal partners from start to finish
 Use simple and clear, non-jargon, and non-bureaucratic language and communication
 Draw on resilience, strengths, and resources of all people involved (.
 Collect, follow, analyze, and use data in an honest, clear, and accurate way that is faithful to the core functions of public health and that serves as the foundation for action
 Build and sustain public and political will for action.
 Stay faithful to the purpose of public health, which is not only to end disparities but also to create equity for all people, regardless of race, ethnicity, income, gender, sexual orientation, physical, emotional, and cognitive ability religion, and nationality
 Be non-judgmental, and realize that behind every statistic, every risk factor, every death is a real human being, with all the complexity, magnificence, and potential for good that is in each of us.



Part V Student Presentations, Group Projects, and Discussions

Resource Materials

Readings will include a variety of journal articles, and selected excerpts from the following books.



Weisbord M, Janoff S. Future Search: An Action Guide to Finding Common Ground in Organizations and Communities. Berrett-Koehler Publishers: San Francisco, 2000.

Weisbord Marvin. Productive Workplaces Revisited: Dignity, Meaning, and Community in the 21st century. Berrett Koehler Publishers: San Francisco, 2004.

Weisbord M and Janoff S. Don’t Just Do Something, Stand There: Ten Principles for Leading Meetings that Matter. Berrett Koehler: San Francisco, 2007.

Berkman, Lisa.F. and Kawachi Ichiro. (eds). Social Epidemiology, New York: Oxford University Press, 2000.

Unnatural Causes: Is Inequality Making Us Sick: A four-hour documentary exploring racial and socioeconomic inequities in health. California Newsreel, 2008. (DVD)

Garinger-Monsen Maren, and Haslett, Julia. Worlds Apart: A Four-Part Series on Cross-Cultural Healthcare. Boston: Fanlight Productions, 2003 (DVD)
Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care Institute of Medicine. National Academies Press, 2003.
Handbook of resilience in children Sam Goldstein and Robert B Brooks (eds) . New York: Kluwer Academic/Plenum, 2005.
GGarbarino James: Children and the Dark Side of Human Experience. Springer-Verlag: New York, 2008.

LeLevy Barry S. and Sidel Victor W. (eds) Social Injustice and Public Health New York: Oxford University Press, Inc. Paperback Edition, 2009.

From Neurons to Neighborhoods:: The Science of Early Childhood Development. Institute of Medicine: National Academies Press, 2000.
Block Peter. Community: The Structure of Belonging. Berrett Kohler: San Francisco, 2008.
Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective Matern Child Health J. 2003 Mar;7(1):13-30.
Kotelchuck M. Building on a life-course perspective in maternal and child health. Matern Child Health J. 2003 Mar;7(1):5-11.
Geronimus AT. Black/white differences in the relationship of maternal age to birthweight: a population-based test of the weathering hypothesis. Soc Sci Med 1996;42:589-97.
Lu MC, Kotelchuck M, Hogan V, Jones L, Jones C, Halfon N. Closing the Black-White gap in birth outcomes: A life-course approach. Accepted for publication in Ethnicity and Disease 2009.
Lu MC, Kotelchuck M, Culhane JF, Hobel CJ, Klerman LV, Thorp JM Jr. Preconception Care Between Pregnancies: The Content of Internatal Care. Matern Child Health J. 2006 Sep;10(Supplement 7):107-122.

Halfon N, DuPlessis H, Inkelas M. Transforming the U.S. child health system. Health Aff (Millwood). 2007 Mar-Apr;26(2):315-30.

Raphael D (2002). Social Justice is Good for Our Hearts: Why Societal Factors – Not Lifestyles – are Major Causes of Heart Disease in Canada and Elsewhere. Toronto: CSJ Foundation for Research and Education. Available free via www.socialjustice.org.
World Health Organization (WHO), Commission on Social Determinants of Health (2008). Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health. On line at WHO Web Site.
Kristenson M et al. (2004). Psychobiological Mechanisms of Socioeconomic Differences in Health. Social Science & Medicine. 58: 1511-1522.

Syme SL. (2005). Historical Perspective: The social determinants of disease – some roots of the movement. Epidemiologic Perspectives & Innovations. 2:2

Beauchamp DE. Public Health as Social Justice. (RH) Chapter 10. 267-284.

Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP & Marks JS. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The ACE Study. American Journal Preventive Medicine. 14:4, 245-258.






Course Requirements:

1. October 1, October 22, November 12: 3-5 page paper.
2. December 10: Term paper: 10 page paper.
3. Class attendance (Three unexcused absences will result in no evaluation)
4. Class assignments
5. Ethical scholarship
6. Ground rules




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Richard A. Aronson, MD, MPH
Adjunct Assistant Professor of Public Health
Richard A. Aronson, adjunct assistant professor of public health, received his B.A. from Amherst College, his M.D. from the University of Rochester School of Medicine, and his M.P.H. from the University of North Carolina School of Public Health in Maternal and Child Health (MCH). He has a wide range of leadership experience and community involvement in public health at the local, state, and national levels. He has served as the State MCH Medical Director in Vermont, Wisconsin, and Maine.

As a pediatrician, teacher, mentor, and maternal and child health leader, he seeks to put into practice the highest ideals of public health, public service, and medicine. His work focuses on social justice as the foundation for public health and on research and action to end health disparities and inequalities locally and globally.
His leadership has contributed to public policy that frames public health within an ecologic context that is rooted in family and community empowerment, resilience, social connections, cultural and linguistic competence, physical and emotional safety, and human rights. His focus on racial and ethnic disparities in infant mortality, child abuse prevention, and the impact of childhood experiences on adult health has helped unite multiple diverse stakeholders to discover common ground and improve health outcomes. He has concentrated his recent work on teaching, mentoring, and inspiring students who are interested and excited about public health as a uniquely inter-disciplinary field of study and community engagement. In 2009, he helped a group of Five-College students form a Public Health Collaborative at Amherst College.
His honors include the John C. MacQueen Lecture Award of the Association of MCH Programs (2004), the Ray Helfer MD Award from the Children’s Trust and Prevention Funds and American Academy of Pediatrics (2007), the Sydney S. Chipman Award of the University of North Carolina School of Public Health (1995), and the Wisconsin Outstanding Pediatrician of the Year (1999).