Putting Public Policy under an Equity Lens

By Ted Wheeler of Portland, Oregon. Ted is the Multnomah County Chair. Previously, he contributed "Can Twitter, Social Networking Lead to a Renaissance in Civic Engagement?"

We pride ourselves on living in a progressive community that values equity, social justice and fairness. The hard truth, unfortunately, is that the reality too often fails to measure up to our values. Information collected by Multnomah County and others suggests that home address and skin color are disturbingly good predictors of whether someone will drop out of school, be unemployed, wind up in jail, or die from (an often treatable) health affliction.

In 2007, the Multnomah County Health Department highlighted deeply troubling disparities in health outcomes based on race and ethnicity. For example, African American men in Multnomah County are nearly 40% more likely to be diagnosed with prostate cancer than White non-Hispanic men, and nearly twice as likely to die from it. The HIV mortality rate for Native Americans is nearly three times higher than for White non-Hispanics. The rate of new cases of gonorrhea infections among African American residents is 6.5 times higher. These disparities are not “natural.”

Racism and social class play an important role.

There is much more to our health than bad habits, health care or genes. Health experts are increasingly telling us that social factors we don’t usually associate with health – good jobs, affordable housing, a clean environment, recreational opportunities, sick leave, and a quality education – are just as important for health outcomes as efforts to get people to eat right, exercise more and stop smoking.

Armed with this knowledge, I directed the Health Department to pursue an initiative to better understand the root causes of racial and ethnic disparities in health outcomes and devise means to eliminate them. The resulting Health Equity Initiative has gained national attention for its efforts to combat the root causes of health disparities in our community. (This effort dove-tailed nicely with a nationally televised series called “Unnatural Causes: is inequality making us sick?” which aired last year on PBS. Multnomah County hosted several community dialogs around this series.)

So, what else can we do? Multnomah County is now looking beyond health disparities to other differences in outcomes based on race and ethnicity. We are currently in the early stages of developing an “equity lens” that will consider disparities related to exposure to hazards, access to open space and recreational opportunities, availability of jobs and public transportation, and educational achievement. We are also building on our efforts to reduce the disproportionate representation of youth of color in the criminal justice system.

I am particularly interested in working with our community partners to reshape the way we think about urban planning and transportation planning to address issues of equity. The conversation has already benefitted from the engaged leadership of community partners representing the Coalition for a Livable Future, Metro, the PDC, and others. Ideally, we will agree on quantitative measures of equity and publish our progress toward reducing them. (As a starting point, we should build upon the Coalition’s outstanding Equity Atlas). When it comes to allocating funds, projects that benefit underserved areas and address disparities in our community should be prioritized.

This is not just a theoretical idea - other communities are engaged around similar initiatives, including King County, which recently completed its own equity lens and now uses it as an integral part of its policymaking process. King County not only developed a framework for evaluating equity in its decision-making process, but it also developed an equity training curriculum (pdf) for its employees and strengthened its outreach efforts to underserved communities. King County’s efforts have created the basis for a mutual understanding of the underlying causes of inequity and specific plans to address them which reach across jurisdictional boundaries. Their next step will be to develop a means of measuring their progress from year to year.

I believe that only by being deliberate in our efforts to track and eliminate disparities will we be able to bring our community into better alignment with our values. I’d like to know who else you think should be included in these early conversations and what other factors we should consider. Ideas? Thanks in advance for your thoughts.

  • Kurt Chapman (unverified)

    Ted, an interesting topic and set of examples you have used. Taken in macro it might appear that socio-economic, cultural or other disparities might be in play. I offer the following: 1. A 40% higher diagnosis rate for prostrate cancer in non-hispanic men of color could be directly related to diet and/or genetics. Barring common industrial exposures, the cited example is meaningless unless the study were really stating that non-hispanic men of color were 40% more likely to be denied adequate care for prostrate cancer once diagnosed. But you didn't posit that. 2. The HIV mortality rate for Native Americans; at roughly 3 times that of white non-hispanics is a problem for sure, however lifestyle, cultural issues and decisions made by idividuals to engage in non-nmonogamous sexual activity plays the dominant part in the equation. Should anyone think I'm bashing anyone, the opposite is true. Having family members in the hemophilia population, I'm critically aware of how the blood supply is infected and how 'innocent' people can become infected by HIV, HCV, HBV, CJD, parvo virus, etc. Again, if the mortality rate is directly related to lack of care, appropriate modality of care or the population just not taking care of themselves is not reported. 3. Gonorrhea infection rates 6.5 times higher than the population norm again is troubling, but something that the comunity studied has COMPLETE control of. There is only one way to get STD's and that is through unprotected sex in non-monagomous sexual situations. This isn't a quality of care issue, rather a quality of the poopulation 'caring' issue. The cited population has numerous other cited problems regarding sexual activity, single parent families, failure to get free offered health care, secrecy and other issues that directly impact the cited gonorrhea rate. I suggest that the reported finding is more symptom of what the group finds socially and culturally acceptable than a presdisposition concerning treatment or medical care outcomes.

    finally, citing King County (I assume WA) is a bit out there. That County is currently running an almost 40 Million Dollar deficit looking into the coming fiscal year. Certianly Multnomah county can do better without looking north to another failed 'progressive' County.

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    I appreciate your leadership Ted.

  • Assegai Up Jacksey (unverified)

    If posters to BO could stop shouting about Ayn Rand and letting people starve for a moment, they might find it interesting that "Putting Public Policy Under an Equity Lens" is the sine qua non of radical libertarianism.

  • Assegai Up Jacksey (unverified)

    how 'innocent' people can become infected by HIV, HCV, HBV, CJD, parvo virus,

    Are you a cat? Relevant actually, as all these syndromes, all our lifestyle diseases, are conditions that are peculiar to domesticated animals.

    Human domestication is the root of all evil. Literally.

    And let's thank kitty while we're at it. If feline leukemia hadn't been on the radar screen and taken seriously, you would have started the HIV battle, knowing even less than was known, by at least a decade, if not two. Maybe three. Without feline leukemia research, "retrovirus" wouldn't have even been a known entity! They're not straightforward, and when you think that you would have had to discover they exist, then the mechanism by which they work, BEFORE you would even be at the state we were in 1980, it can only be concluded that caring for sick cats saved millions of human lives.

  • jamie (unverified)

    You want equity in housing?

    Eliminate the artificial shortage of land caused by Metro's land use decisions. Only when there is plentiful buildable land will housing prices approach those of areas with out our draconian land use rules. That means a new 2000 sqft home on 5000 sq ft lot for well under $200k.

    You want equity in "availability of jobs and public transportation"?

    Fast, efficient trips commutes to work over a wide geographic range allows people to choose a higher paying job than they could get with a their choice of jobs limited to a smaller area due to a slow commute. For commute speed, and economy, the private car is unmatched. Solution: 1) Increase road capacity to match population increase. 2) help low income people get a car. For example see Wheels to Wealth.

    The goal should be fast door to door transportation for all. That means subsidizing low income people and letting the upper income people pay their full share, instead of the 20% they now pay on Trimet.

  • (Show?)

    Bowled by Uboko for naught again, AUJ ;->

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    "being deliberate in our efforts" — that's the key phrase, Ted. when govt has to be pushed by interest groups, legislation or court orders, it's not going to do a good job on any issue, much one as difficult as this. by taking the approach that it's the County's responsibility to approach this proactively, that the County has to be a leader & a partner, then there is a real possibility of change.

    those are very encouraging words to read. now, of course, you have to deliver....

  • Assegai Up Jacksey (unverified)

    like your take, jamie...

    chis has my number. but i've taken my score up to 1/2 and not run away!

    Seriously, is pure libertarianism dead, where this should be their bread and butter?

  • Boats (unverified)

    Multnomah County should be stripped of all powers and remain a just a name on a map. It is an increasingly irrelevant and useless layer of big government just looking for reasons to exist. Its powers and facilities should be devolved to the cities in the area and Metro could have a tri-county corrections system, electoral duties, etc.

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  • Mike (unverified)

    Ted, we need a new Mayor. Are you willing?

  • Mary Anne (unverified)

    Health disparities have also been documented in the LGBT community. Although the focus has been around racial and ethnic disparities, lets not forget the reality of disparities for LGBT as they access care, recieve care etc.

    In addition I think it is critical, that individuals vulnerable to health disparities ask of their providers, hospitals, and health plans what are their plans to address health disparities.

  • Dianne Riley (unverified)

    I deeply appreciate this informative and thoughtful post from Ted Wheeler. The questions he poses for our collective consideration and comment deserve responses of similar caliber. Indeed, it feels to me like this is, in fact a critical function of government at all levels and scales …that is, to facilitate intelligent public discourse about the issues we face as a whole.

    More and more, people are beginning to recognize that the impacts of racism, poverty and all forms of oppression have a way of eating into our collective prosperity and power—not just the prosperity and power of those directly enduring the abuse.

    On Monday, I met with a group of community and agency leaders to discuss this very issue. I shared with them emerging research that indicates systemic and structural oppression takes a heavy toll on the health and productivity of marginalized populations. While this is not news to people experiencing oppression, what is news is that these types of health impacts do not necessarily shift by changing ones lifestyle or cultural practices. For example, eating better and/or exercising may not prove to be enough for many people suffering from stress induced illnesses like hypertension. The stress and aggravation of oppression can actually be toxic enough to counter the healthy lifestyle choices that people do, in fact in many cases make.

    None of us need apologize for personal health crises we face. At the same time, we can imagine a much more prosperous society if we were able to avoid those health crises that are preventable…including those that are related to oppression. The burden of higher taxes coupled with simultaneous under-resourced government may actually be the product of our system’s chronic habit of indulging oppression. Oppression creates unnecessary, socially-manufactured hardships that ultimately, weigh on all of us in one form or another. I conclude that oppression is—more than taxes are—the source of inefficiency and a drain on our economy and hence, an option we literally cannot afford.

    So, who else needs to be included in this discussion? I would say the people who are most impacted by systemic oppression first and foremost and those that understand the dynamics of racism, poverty and all the other myriad of obstacles to basic respect and basic health.

  • Judith Mowry (unverified)

    I deeply appreciate the work the county is doing on this issue. It's critical and long overdue. The long term consequences of ignoring this issue are a system that remains ethically and financially intolerable.

    Thank you for your work and sharing your insight Chair Wheeler.

  • Jesse Beason (unverified)

    I think that the Chair has hit the nail on the head. I even think Kurt Chapman reinforced his point.

    We DO know that such statistically significant differences in population norms from disadvantaged communities exist. We also know they exist for multi-faceted reasons that are borne of historical, environmental, economic and cultural conditions and, of course, personal decisions. But we can't assume that personal decisions are made in a vacuum without being informed, influenced and sometimes nearly controlled by these external conditions.

    <h2>So, when we address multiple determinants of health and well-being, we are addressing the institutional and personal conditions behind them. More equitable services. Better decisions. Healthier people.</h2>
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