 Good afternoon. I'm delighted to welcome you to the 22nd McLean Fellows Conference. The conference is a conference in memory of Dorothy Jean McLean, who is the early benefactor and supporter and developer of the McLean Center. Also, Mary Ann McLean is here and Barry McLean is close by, and we thank them for their ongoing support of the Center. The first day of the conference, as you know, is devoted to health care disparities, both from a national global perspective and also in the second half this afternoon from a local perspective. There is one important change that I have to tell you about the first group of speakers, and that is that Dr. Peter Singer from Toronto has been ill for a few weeks and was unable to travel. What we will do is hear from Dr. Daniels, Jim Heckman, and then Gene Washington, and then we will show a short video by Dr. Singer's colleague from Toronto, Dr. Dar. And then the panel, when it gathers up here, will include the three speakers and Dr. Fumio Lappati, who has been in touch with Dr. Dar, who will be sitting in for Dr. Dar on the panel. Well, with that background, let me introduce our first speaker. Professor Norm Daniels is the Mary B. Salt install, Professor of Population Ethics and a Professor of Ethics and Population Health at the Harvard School of Public Health in their Department of Global Health. As many of you know, Professor Daniels is perhaps the foremost philosophical scholar in the world on issues of social justice and allocation of health resources. This is a topic that he's worked on for the better part of 30 years, Norm, 30 plus years. He formerly had been the Goldwaith Professor and Chair of the Philosophy Department of Tufts, has published widely on topics of philosophy of science, medical ethics, social philosophy, distributive justice. It's a great pleasure to welcome Norm to the University and to the conference. It's a pleasure to be here. I wish I could see you better, but so I could make a little more eye contact. But in any case, it's a great honor to be here and I thank Mark for the invitation and I have had the pleasure of meeting the McLean's and some of the sponsors of fellowship, so it's been a very nice visit for me. I wanted to talk today about a topic that I've been concerned about for many years. I wanted to talk about several related issues. The first part of the talk will focus a little bit on domestic health issues and the account of distributive justice that I give was largely aimed at trying to work out the implications of how we should think about what we owe each other within a particular society. I then began to think more about what this meant or this view meant for our attitude towards health disparities domestically and that's what the third bullet is about. But we have global health disparities that are at least as large and often larger than our domestic disparities. And I wanted to conclude by saying a few things about those since the conference bridges all of these areas. I won't be saying anything very specific about local disparities. I'm sure there are people who will address that topic themselves. What I'm drawing on in this are some ideas from a book that came out in 2008 called Just Health which is an attempt to integrate views I've developed over 30 years around justice and health. So let me start with this particular intuition and go to the first topic. What do we owe each other by way of health and protection of health and health care. And when I use the word health care or the term health care I usually am thinking about things that fall in the health sector. So I actually would like to include both traditional public health measures and personal medical services which are two rather different areas. But I distinguish them from a lot of the rest of the work on the causes of health that we'll hear more about today. The fundamental idea goes something like this. Why do we think health is of particular moral importance? And what put that question into my mind is the fact that in many societies, perhaps including ours but certainly many of the developed countries and some middle income countries there is a concern to distribute health care, personal medical services especially more equally or equitably than many other goods in those societies. And this contrast could be viewed in part as a kind of schizophrenia on the part of those societies or we might look for justification. And I began by trying to look for something that might make sense out of that attitude since I too for many years wanted health care to be distributed more equally or equitably within our society than it was. So the intuition I had is that departures from good health, let's think of those as departures from normal functioning and I know there is controversy about how to understand the notion of normal functioning. Perhaps we have time in discussion for that. But I'm just going to take departures from normal functioning to be a way of characterizing what we measure and study in schools of public health such as the one that I belong to and what much of the health sector pays attention to. So why are departures from normal functioning so important? The answer I came up with is they have a limited but distinct implication or impact on the range of opportunities open to individuals in a given society so that if we meet health needs we keep people functioning closer to normally and that has a positive effect on the range of opportunities they can exercise. This idea is not dissimilar in content to Amartya Sen's discussion of capabilities and an exercise of opportunity is something that I find it hard to distinguish from his notion of capability. So if health shortens our lives or reduces the range of functioning within our life then it makes certain choices of plans of life less reasonable for us and that as far as I'm concerned is a reduction in our exercise of opportunity range. So this then raises a general question from the perspective of justice whether we have social obligations to protect that opportunity range. I'm going to make a conditional claim today, I've tried to flush it out a bit more in the book I mentioned but the conditional claim is this, if we have social obligations to protect opportunity in a society then we have a framework for thinking about the fair distribution of health care resources and I think of that in a fairly broad way. So that's the first point I want to make. So if we have social obligations to promote health then we want to address the departures from normal functioning as resources reasonably permit and I have a whole discussion in some of my other writings, I'll return briefly to it later to how we might go about making decisions about resource allocation given that reasonable people will have many disagreements about when a resource allocation is fair. So my general point today is that this opportunity account gives us reasons for wanting to promote population health and to distribute it fairly. It's not simply making health care more equal or health more equal among the population but improving the range of health functioning in the society and that is because if we make people bring people closer to normal functioning whether we do that equally or not across the whole population we are meeting individual claims to have their opportunities range protected. I think we have further obligations to try to distribute that health more equitably. I'm going to turn in a second to the question when our health inequalities in a society unjust and not simply unequal and there we might think when they are unjust we have extra reason perhaps to reduce them rather than simply just bring up aggregate measures of population health or reduce other health inequalities as resources permit. We have extra reason because as I'm going to argue the inequalities that I count as unjust are the ones that are the result of an unfair or unjust distribution of the socially controllable factors that affect health and so the picture that I have is that in some sense social practices have helped to bring about the ill health of Warsaw groups and that gives us perhaps an extra reason to try to mitigate those effects so that's the picture I have and we can discuss whether I'm right later. So let me turn to the question when our health inequalities unjust. Now I used to think there was a fairly simple answer to this question and that was because I was in the grip when I first wrote the parts of a book called Just Healthcare that came out 1985 and I was not very aware at that time I'm not at all aware of the literature on the social determinants which had just started to become apparent. The black report in England had been published in 1980 but the Thatcher administration quickly shoved that under the rug and it often didn't attract attention elsewhere. So the myth I was in the grip of basically said well health care, public health and medical services were the main determinants of population health and if that was true then it seemed to me that unequal health could largely be attributed to unequal access to health care and that seemed an implication that was fairly simple of course biological factors are involved as well but if we want to talk about population groups having differences in health status that were the result of access to health care then that arguably was grounds for viewing those inequalities as unjust. After that time however I rather quickly became aware of the literature on the social determinants of health and by the mid 90s was working with some people at Harvard to try to think through what did this broader view of the social determinants as causes of health and its distribution in a population. What did that mean for concerns about what we owe each other? So I want to bring out a particular way of thinking about that. So the general point I want to make is that health inequalities that are then viewed on my view as unjust if they're the result of an unjust distribution of the socially controllable factors affecting health. Now I know some of you will immediately pounce on the fact that the word unjust appears twice in that characterization but I'm going to try to illustrate what I mean by the second appearance shortly. So this is a graph familiar to many of you who've looked at the literature on social determinants of health and I wasn't sure how much to presuppose about that. When I came here I know Professor Heckman is going to talk about the social determinants soon so I won't say much but I did want to at least introduce a basic idea. This is from a graph of the relationship between occupational status and health in one of the Whitehall studies which is a study of the British civil servants in England. This is from an old paper 15 years old by Marmot and Shipley and what it suggests if you look at the bars in this and draw a slope across each group of bars what you'll see is an upwardly sloping line which in effect represents what's in the literature known as a socioeconomic gradient of health and in this particular case what you have here is a measure of occupational status in the British civil service. The tallest bar are the people at highest risk. On the vertical axis you have a relative mortality rate so the two is roughly twice as high a mortality rate as the one which is the horizontal middle point of the graph and that tall bar in each of the groupings is other workers and that largely means who color and the lowest occupational status in the British civil service. The graph that extends most below the bar will be high level administrators in the British civil service so they have a much lower than average mortality rate and so what this represents is the inverse relationship between wealth and health or in this case mortality but this relationship is very robust across many measures of health outcomes and also across a relatively broad measure of SES indicators so education and so on work as well. So this socioeconomic gradient of health is particularly interesting in this graph and that's what I in the heels of American health reform wanted to emphasize to you is that this was done decades after the introduction of the National Health Service in the UK so this population has access to universal coverage. Not only that it doesn't contain any people who are impoverished and further it contains only people with a relatively high basic level of education so we're not talking about the contrast between impoverization and being well off in the society. This is not a dichotomous relationship between the haves and the have nots but it's a spectrum of health that is connected to some of the social factors that are distributed in various ways in different societies outside the health sector so occupational status is not particularly a health related issue but you can see it's correlated and this is only a correlational study it doesn't talk about mechanisms it's correlated with health. This is of extremely great importance and very suggestive because one wants to find out why does this happen and what do you do about it and that's what I take a lot of the discussion today is going to be about. So what this whole body of literature put in mind to me was the following slogan which goes something like this remember my remark earlier that justice that I will consider a health inequality on justice if it's the result of an unfair or unjust distribution of the socially controllable factors affecting health how socially controllable is a matter for discussion what do we do about occupational status is there a way to mitigate the consequences of that on health if that's working in some direct way on health we don't know and we probably don't have an awful lot of data on exactly how to do that but the general slogan that emerged in my mind was that social justice that is the fair distribution of those determinants of health is good for our health that's an interesting result and I'll try to show you why that's interesting in a minute so remember I made a conditional claim that if we have social obligations to protect health protect opportunity then we have a framework for thinking about how to deal with health well at the time that I first developed these ideas there was only one prominent theory of justice that really emphasized talk about quality of opportunity and in the late 70s when I did this that was John Rawls' theory of justice so I want to make the following claim and this is more developed in the book I mentioned but John Rawls articulates and I'm not going to argue for them several principles that he considers to be the principles that we would agree to as fair terms of cooperation in a kind of social contract position that he articulates among those principles are a principle guaranteeing equal basic liberties including fair participation rights to all and he very explicitly attacked an earlier version of the Citizens vs United ruling of the Supreme Court namely the Buckley vs Vallejo decision in which he said that there was in the interpretation of that court which in effect said individuals have freedom of expression to spend all their money including rich individuals like Ross Perot Mitt Romney and others on their own elections because that was tantamount to their freedom of expression and the Constitution protects that and Rawls argued against that so he was very interested in protecting what he called the fair worth or value of political participation rights to all individuals so this was a fairly robust principle not very easily understood in some of the ways we view constraints on financing in elections in the United States Rawls' second principle after this equal basic liberties has two clauses one of which is the fair equality of opportunity principle and by that he meant a principle that corrected for say through public education measures the inequalities in the development of talents and skills that people would bring to market so he wanted jobs and offices to be open to people based on their talents and skills and not other irrelevant factors about them but he wanted those to be the talents and skills they would have if they were corrected for by these institutions okay now the other part of Rawls' principle second principle is a principle severely constraining income and wealth inequalities in society he said we should allow inequalities not just in income and wealth but as measured by what he called an index of primary social goods this so we would allow inequalities on this view only if they made the worst off groups as well off as possible and that's a very significant constraint on inequality if you add all these things up then you've got the basis for the thesis I'm making namely if we distributed the goods in the ways that these principles suggested with severe constraints on income and wealth inequality with robust protection for access to health and public health measures with fair distribution of education in the society with guarantees of political participation rights then his claim is that one then my claim is that one would in fact be flattening the socioeconomic gradients of health very significantly compared to anything we see around us and so there might still be residual inequalities and we could then discuss are those on fear or not I'm going to leave that aside as a matter of discussion but it's a question of some theoretical interest we're nowhere near conforming to these principles so I'm not viewing this as a matter of real practical interest but the basic idea is that we could distribute health much more equally and according to some views of the social determinants doing that we create a climate in which we actually promote population health in the aggregate as well I don't want to put any weight on that hypothesis but it is an empirical hypothesis in the field so that's my claim is that we could flatten these gradients but now I want to pose a problem the problem is whenever we invest resources whether they're healthcare or education and so on and they're not divisible in certain ways like money but we're talking about programs that do something and so the money that's involved in setting up a program then on my view we encounter a range of distributed problems we don't know how to address and reasonable people will disagree about how to address those problems because this kind of reasonable disagreement pervades many of the resource allocation decisions we make then on my view we actually need to retreat from an effort to find a principle basis for resource allocation to a kind of fair process a deliberative fair process for resolving disputes so that's my thesis and we can come back to that in questions but it's in general the claim that when we try to redress inequalities in this way we don't avoid a set of problems such as this the priorities problem how much priority do we give to individuals who are worst off we might take extreme positions and say none no priority cost effectiveness analysis has that as an implication or we might say we give maximum priority certain views and ethics have that implication kind of prioritarian view I find both views implausible and so do most other people who have a kind of middle range position but that middle range is not describable by principle and reasonable people will disagree about the tradeoffs say between how much weight to give as priority to worst off individuals and how much good we can do by treating them so reasonable people disagree about this and thus I think we need a fair deliberative process for resolving this dispute now let me in the last three minutes or so that I have available turn to global inequality so far I've only been talking about a framework for thinking about domestic inequalities but the global inequality inequalities we face are severe and there is some controversy in the philosophical literature about them are these questions of global justice or are these simply questions about humanitarian responses we ought to have and what I'm going to suggest is that we ought to adopt a kind of middle ground that views these as concerns about justice but of a special sort so the inequalities I'm referring to are very familiar to many of you life expectancy in Swaziland is half that of Japan where I was yesterday child under 5 mortality is 100 times as great in some Saharan Africa as in any of the OECD countries and the intuition that many of us have is that the gross inequality in health prospects is unfair now we could get around this claim and try to flesh out accounts of justice in various ways one prominent view is one articulated by Tom Pogge philosopher now at Yale and he wants to argue that we are under general moral obligations not to harm other people and that many of the health inequalities we can see in the world are traceable to the harms that rich countries impose on poor countries this itself is an empirically questionable hypothesis and I actually want to suggest a slightly different view if one looks at the sources of global health inequalities and I don't mean this list of three categories to be exclusive we find that some of the global inequalities are contributed to by domestic injustices and then the question is to what extent are other countries responsible for injustices that are promoted domestically in some country if one country is racist for example then do other countries have to make up for it by contributing more that's an interesting question so does Norway owe us more support because it's less racist than we are perhaps but then some of the inequalities we see are inequalities and other conditions that affect health like natural vectors for diseases and other considerations and we might think of that as something that gives rise to global obligations to share resources more fairly the third body has to do with international practices and some of these might be thought of as harmful and others as not intended to be harmful and maybe even helpful so if we look at this graph which is an old version of a graph that many of you have seen it plots life expectancy by country against gross domestic product per capita on the average and you see what you typically see is a concave curve rapidly rising at low income levels and flattening out but what strikes me as most important about this graph is the enormous variance that one sees even in the left part of the graph very poor countries that are equally poor will have very different health outcomes and so the conclusion I draw from that is that policy matters what you do with your resources even at low levels matters a lot and you can see the same variance among richer countries so the implication of this is that policy matters at least as much as wealth and this is true even in very poor states or countries in the US the contribution of social practices on top of lack of insurance and access to health care contributes to the lower outcomes that constitute some of America's gap with other rich countries now as far as international harming goes which was Tom Pogge's claim I think that's not implausible with regard to some things like the brain drain of health workers from the south to the north and the active recruiting of those workers I think it's less plausible when one looks at some other goods like pharmaceuticals where I think the situation is that our incentives to producers of drugs are not as good as they could be and we don't address some of the kinds of burden of disease that appears in other countries I want to restructure some of that but that's a case not of harming those other countries since their essential drug lists are all composed of drugs that have spun off of these products of the pharmaceutical companies over years but rather that we're not doing as much as those companies could do so we need a different account about the robust production of an obligation to help and so that's what I've sketched here is that Pogge's minimalist account works better for some cases than others but I don't think is in general adequate and I think and this is my last point is that we need to find a middle ground between certain philosophical views that basically view citizens as citizens of the globe or the cosmos or wherever they are and regardless of any kinds of institutional connections that they have to each other and on the other hand, statist views which only want to view justice as in the domain of nation states and I think there's a kind of middle ground my friend Josh Cohn and Chuck Sable at NYU have argued that there are at least three kinds of middle ground institutional relationships that could give rise to concerns about justice and I think that these need to be explored more and we need to work out what we think justice means with regard to them so that's my set of remarks on justice and health disparities I tend to view the domestic disparity as clear but still problematic because of the distributive issues that I raised or disagreements about how to reduce those inequalities and the trade-offs we might have between equity and maximization of population health I think those are significant ethical issues and that's domestic and then global I view these inequalities as in many cases not necessarily all but in many cases giving rise to concerns about global justice but I don't want to found them on some of the traditional views but want to try to find a middle ground for thinking about them Thank you for your time Thank you very much Our next speaker will be James Heckman Jim is the Henry Schultz Distinguished Service Professor of Economics at the University of Chicago His work has been devoted to the development of a theoretical and empirical framework to create a scientific basis for economic policy evaluation and in terms of substantive issues that he's looked at recently they include job training programs, education and also early childhood interventions Professor Heckman has received many awards for his work including the John Bates Clark Medal in 1983 the Jacob Mincer Award for Lifetime Achievement in 2005 and the Nobel Prize in Economics in 2000 Today in conjunction with Gabriella Conti, a post-doctoral scholar in the Department of Economics, Jim will present a talk on following up on some of Norm's thoughts about social determinants of health on social determinants of health Jim, welcome I'm very pleased to be able to speak here today I want to attest from my personal experience that Mark Siegler is not only a very good medical ethicist and a good organizer of workshops but a good personal physician So the work today that I'm presenting is with Gabriella Conti As I said, it's on social economic determinants of health disparities but it focuses on one particular aspect which gets partly at what Professor Daniels was talking about which is maybe avoiding some of the issues about the trade-off between what's called efficiency and equity in economics Let me start with a report that I think has already been alluded to or a series of studies and Michael Marmot recently presented a report to the British public It was a large panel called Fair Society Healthy Lives the so-called Marmot Review but it was a panel of many distinguished scholars in England And you can see this position, I think you can see it which is that essentially it was what we already heard that essentially those with higher socioeconomic position have a greater array of life chances and they have better health This is a correlation that's been observed that he talks about one dimension of education and I want to focus on that kind of dimension of education today But the key question in any of these areas and especially in going out and designing policies is what can we do? How can we sort of move beyond the observation that we've already seen and I'll show a little bit more of today to make tangible policies that actually go towards reducing health disparities and one that is based on evidence and that one that will compete in an environment where funds are very, very tight today And the key theme of this talk is that to design effective policy we need to infer causation and to understand mechanisms I think that will be a term that will be coming back to us all throughout the sessions today but we need to understand the mechanisms that produce the cause and where it's most effective which interventions and which mechanisms are likely to be most effective So let me just kind of add to the set of facts you've already seen This is directly from the Marmot Report and there are two dimensions The uppermost figure is life expectancy in England measured against a measure of deprivation going on the left-hand side the most deprived, the right-hand side the least deprived And another measure on the bottom curve is a measure of disability-free life expectancy at birth and this is all these show the same kind of gradient we previously saw namely that there is an association between social economic status and health conditions in a variety of measures And just to look at one example from the U.S. data if we look at people below the poverty income level so the solid green bar those people at the highest level lowest level I should say in terms of family income and those at the highest we see the incidence of people who have poor or fair health decreasing rapidly as you move to the higher income levels So this is an observation that's received a lot of attention and I want to talk about today and this may seem facetious but it's not because it's playing going to play a role in my talk today this kind of gradient also shows up in monkeys and a lot of other animals who have been experimentation we actually have a body of data which I'm going to summarize briefly monkeys and a particular rhesus monkeys that have many of the same genetic predispositions genetic endowments I should say as humans and we get a notion which is very close to the marmot notion we go to the bottom of the herd to the top we essentially go down now you're going the opposite direction from the other grass but basically you find those who are at the top status they're very substantial and well documented matriarchal hierarchies in the monkey tribes and we can actually see that the monkeys higher up do very well in terms of health even though they have equal resources but now the question always becomes what are the causes of these empirical associations and the world health framework where marmot also had a hand so marmot's going to play a role I'm not trying to attack or defend marmot I just simply want to say that marmot's a major figure we'll hear probably a lot more about him but marmot who engineered this basically said why treat people and send them back to the conditions that make them sick and so this is a picture from the world health organization report and in particular this framework which I'll come back to but it's basically a position there's a framework that kind of captures what's out there in a lot of the literature namely the socio-economic and political context play a role there's a very large set of cohesive factors not all fully documented where education, occupation income, gender feed in to material resources the health care system and produce the distribution of health and well-being now what are the proposed solutions and this now takes me back to the first slide the marmot review framework and the marmot review framework really features exactly as we've heard the notion of trying to reduce inequality so the idea is to create a society that's just create a society that reduces inequality and to create in various places in society a framework for integrating people redistributing resources creating fair employment giving children the best start in life and creating healthy and development sustainable communities and so this is kind of a very broad brush approach and this is taken directly from the 2010 marmot report where he talks about a dynamic approach hence the theme today is a very broad approach that we want to think about sustainable communities standard of living but also recognize how skills and capabilities the very term that we heard introduced from Marcia Sin and you'll hear again in a minute essentially develop over the life cycle and relate it to the early years the school years the years of employment and then into aging so that's a very broad framework but the question what do we really know about this where to intervene in this and that's the issue and so somewhat in a deliberately provocative way the marmot report simply says and raises this point and puts it out there ready in your face if you hadn't noticed it that these inequalities do not arise by chance they can't be attributed simply to genetic makeup bad unhealthy behaviors or difficulty in access to medical care and that's one of the issues that it's really social inequality and in fact some people have made this argument more strongly but here's Marmot actually deciding in the introduction to his own Marmot report which I'm happy to provide anybody if you haven't seen it that he Marmot chaired this previous session previous commission on social determinants of health and he said well that was attacked as being ideology with evidence and he would gladly accept the same charge on the current report and he feels that these health inequalities are unfair and they really do produce a low productivity society but I think we have to be a little bit cautious I completely agree with the correlations I completely agree with the evidence that there's a lot of evidence for correlation or for inequality being a determinant but we have to understand what aspects of inequality and which aspects might in fact be more readily addressed and where we might see social policy being most effective so a somewhat more sober and more specific approach came from a recent symposium that was produced at the New York Academy of Sciences called the biology of disadvantage and a paper, one of the concluding papers in that special issue did point out that despite all this wealth these notions of association the evidence includes few studies this whole evidence base that's out there in 1985 includes very few studies that rigorously established he affected us in particular policies and so what can we make out of the evidence on SES health gradients what can we say what are the factors that are most important and can we really understand what's going on here and so I think what's important to put on the table is that we have to move beyond these associations to understand the nature of the causality of things like the income health relationship or the education health relationship and we have to understand that there is a lot of controversy some of the peers of Marmot people like George Davey Smith and United Kingdom and many others have criticized this report and reports our criticisms are going on asking is it really inequality or is it the resources associated with inequality that plays a fundamental role thinking about how we might redesign society or redistribute resources within an existing society so what I want to talk about in the rest of my presentation is a framework that helps us think about this it doesn't go the full route because I don't think anybody has gone the full route I wish I could say I'd completely integrated all this or point to the work of another scholar it hasn't been done but it's undergoing transformation and we will see it the economics of human development provides some way to think about these problems and I want to summarize some of the studies from this work so recent studies have established the following facts a core low dimensional set of capabilities explains a variety of diverse socio-economic outcomes and I would use capabilities in exactly the sense of a march of sin these are personal traits but embedded in the larger society and we think about early conditions cognitive, non-cognitive capabilities as well as early health conditions they play a very powerful role in explaining not only adult behaviors but also adult health and what we've also come to understand and this is something that I think is really important to understand is that they're critical and sensitive periods and that we have a sense I can't go into it in all detail but for certain traits for certain things like cognition the early years I mean talking about the years before age 10 and maybe even before age 5 are particularly important because there's a lot of stability in the rank terms of IQ and cognition after the early years for social and emotional skills what are sometimes called non-cognitive skills those gaps open up early as well they persist strongly but there's more variability there's more move there's more malleability more flexibility and what I would argue is that a policy that's focusing more on early childhood interventions or at least addressing getting the capability base correct or getting it setting it off on the right trajectory is a very effective strategy I'm not going to argue that it's the whole strategy but it's one that has not received enough attention and I want to talk about this today so let me just lay out a framework so I've been set up sorry I know there's a risk economists right this there aren't many many equations this is just notation so I really want to get that this formalize the idea of capability so capability is state and we can think of things that are large dimensional bundles, vectors of traits so cognition, personalities and health traits the genetics of the human being but what we come to understand is this second relationship that health depends on these capabilities and the environment and the investments that individuals make into these capabilities and so I think and I want to just sort of lay out this mechanism and this framework essentially is what I want to point to, I don't know if this pointer works it does so for example if you use the same notation we want to think about what a life course development trajectory would look like and it would look like we have prenatal conditions which are being studied we have many people here in the audience here at the university and around the world looking at the importance of early environments early poverty, the effects of poverty and disadvantage in getting under the skin and affecting the whole trajectory of life course so what we see is prenatal conditions matter I as a member investment, it's what the family and the society is putting into the individual here we actually see the parental environment playing a role feeding in and a dynamic process it's this dynamic process that I really want to focus on and talk about where in this dynamic process the evidence seems to point to the most effective interventions so what we can argue is health disparities have early origins that is something that's been fairly well documented so it's not just the origins in not all disparities certainly living next to a toxic waste site is not a good thing but on the other hand at any stage in life but it's particularly dangerous when you're very young and living near lead and growing up and insulting the brain and the other parts of the biology early in life so let me talk a little bit about one trait education because that receives a lot of attention so it's only a piece of the story it's not the full global story but I think it's an important piece as I'll try to show you and this gives you an idea of not only the disparities by education and health outcomes but a lot of other measures in society so we know this is a measure of education taken from English data so to match the Marmot report we actually can look at the gradients the differences by for males and females and this is a very low level of education not the level of the Marmot report was talking about college education this is just do you stay in school past the school leading age this is basically dropping out of school or not and what you can see for example on the left most side is hourly wage differences they're not exactly the same by educational status they're not exactly the same for males and females but they are most substantial full time employment again educated and more likely to work consuming healthy diet fruits exercise not consuming fattened foods obesity definitely negatively related to education and measures of fair and poor health and smoking which we know to be a major determinant of poor health very strongly related to education but what do we make of this we certainly know I'm here with a group of doctors and you know that among recent studies smoking, tobacco use and poor diet two of the items on the agenda that I just on the previous slide are some of the leading causes of preventable causes of death things that are modifiable or at least we think it might be modifiable so education plays a fairly substantial role in these factors which actually are causing disproportionate numbers of deaths but the real question is are these differences causing can we really just say go out and give people more education or for that matter give people more money is this really a basis for policy or are they arising from some other factors and there are a lot of other candidate factors we can imagine that traits, the genes that individuals have the early environments even the schools environments may in fact be needed so what's needed is to really try to produce solid evidence here and that's what I want to talk about today but let me just talk briefly about an anecdote which is a medical anecdote about correlation and causality and I think there's a real danger here it's something that American social policy is frequently confused and I want to try to just give you an example so there's a great story told by an economist with a Russian origin some 60 years ago picked it up from him, his name was FC Domar who talked about a cholera epidemic that occurred in Russia and the government sent the doctors out to help the peasants because they thought the doctors could help prevent the cholera and help treat the patients now the peasants in the particular province observed a very high correlation between the number of doctors and the incidents of cholera in the area and they banded together and created the social policy of murdering the doctors so this is the kind of thing we want to avoid I'm sure in this room we have a very receptive audience to this story but I think that's the danger we've had it in other areas not just in health care policy and poverty policy in many other areas so let me just give you a very simple graphic you know we can argue and many people have and I think that's the thrust of the Marmot Report that education really does cause causally affect health so you see an arrow pointing education to health but it could also be sick early on there could be serious issues of impairment may children might get educated and early health could be correlated with later health there's a comparable discussion about income and health sick people typically aren't earning much income at the same time people who have more resources are probably healthier so the question is which way is this causality go or is there some third factor sitting out there these factors these personal factors which could also include early environmental factors and the society-wide factors that Marmot was talking about so that's really the question so let me just talk very briefly about a study that we did again looking at the same British data that constitute the essence of the Marmot Report and what we do is we have very detailed measurements so we go over the full life cycle of inequality and inequality development in Great Britain so we have a group of people who are all born on the same week in 1970 in Britain these people are now 40 years old and they're being followed into the over their whole lifetimes unless the budget cuts get them I don't know maybe it will but we do have detailed measurements very detailed measurements on cognition on personality and on health so I'll just summarize very briefly without getting into the details so what we can do is we can control in a very rich way for what that association is how much of the education difference is actually how much of the difference is by education that you observe just like the doctors there in the provinces of Russia how much of the education gradient those people have more educated have better health less smoking and so on how much does education constantly explain how much can we say changing education policies that promote education will actually reduce that gradient and what we argue is education itself constantly will explain about 100% of the smoking behavior just the smoking behavior early life factors however play an important role and it depends on the kind of condition it's not a one size fits all and so what we can argue and let me just go through and show you a visualization this is back on the same chart I showed you we shrunk it a little bit because we had a little bit of it's basically the same set of outcomes and if you look at the components this is just decomposing the components that are causal that are real causes where policy can act and how much of it is just due to some conditions that already existed at age 10 that we can see that a substantial part even of the wage effect of education arises because of selection effects effects that occur before the age of 10 things to do with early family conditions all the conditions that children face by age 10 early conditions on the other hand was still a lot of room for improvement and so in particular if you look at smoking behavior if I can find it here I have an angle here but you can see smoking behavior is here a substantial part that black band is actually caused is a causal effect of education and so here we can see across different kinds of outcome wage inequality even two thirds of the difference in educational returns on wages so this kind of notions yes there is room for policy and education can actually reverse some of that difference that we observe for this level of education and so this is just maybe easier to see about how what fraction of these outcomes can be really attributed to factors that we know and we have effective policies and we know how to think about policies to promote this kind of education the question is does everybody benefit and that's a non-trivial issue and the answer is no no in several senses even if we look at what the distribution is we can see that when you look at the effect of smoking what a lot of people call the average treatment effect the average effect that there is a negative effect on education but some people actually go to school and smoke more we know that that's pure effects and all of that and there's also a lot of people who smoke less and a lot of people who smoking behavior isn't effective so there's a distributional issue that's one distributional issues I want to talk about for obesity there's a similar thing so there are benefits but then we can go further and then we can say okay if we think about the developmental origins to kind of supplement the framework of sin and sort of move beyond this kind of static notion about inequality but how inequality emerges over the life cycle how we can look at the life cycle dynamics this figure which may be way too busy sorry about that but basically it's telling you that if we give this educational intervention who are the people who benefit the most now this is smoking and if you look at this you can see this dashed blue line is personality skill so these are people very low in the personality skill and what we're finding is that people with low sort of self control and so forth for them the education has the greatest most negative effect for those people who are high already in the social and emotional skills the education the effect is very weak is a negative effect over the whole spectrum but it's particularly strong it's reversed by interestingly enough for those with high levels of cognition high level of cognitive skills also seem to benefit as a complementarity with education so we can see that in the society each of these policies will have distributive benefits and will affect different people but there's another what is the effect of early endowments well this is the part where early family conditions play a very important role or can play a very important role so here we can actually say okay we have a set of endowments that more or less are fixed by the time kids are 10 years of age and we do a comparable analysis at age 5 so it's not 10 is kind of a conservative notion but we ask what factors are most important in terms of reducing smoking so just if we go within that category of factors that seem to be important and are already informed by age 10 and are beyond policies that might take after age 10 what's most interesting is that the traits that are most important are early health conditions and conditions related to social and emotional skills cognition plays much less of a role so let me skip past that and let me talk briefly about one aspect of inequality which I haven't talked about which is really important because I think it gets to Professor Daniel's talk that if we think about policies that go before age 10 and we ask now suppose we want to reduce the gradient we can see that for smoking we have a lot of optimism that we can even start addressing the inequality after age 10 but for some of the other traits maybe I should just skip show you if I can get back to them quickly let me get to this yes that we can see for example things like a wage inequality even things like obesity those early factors are playing a very important role now the question is can we do anything about those early factors and the answer is we can and let me just conclude and then talk a little bit about research about this I will argue that there's an analog of all this these disparities in monkeys and maybe they're even cleaner so let me just talk very briefly about monkeys I've been working a lot with monkeys but monkeys are these interesting to analyze because we can experiment with them in ways we can't with human beings they're very detailed health histories more detailed than anything we can get on human beings and Steve Sumi working with us and several people who are in the room here graduate students and postdocs have looked at monkeys that have reared in various conditions and these now are looking at very early rearing conditions and so three categories of monkeys those are those who are monkeys that are reared with their normal mothers in the usual conditions a way to engineer disadvantage among monkeys is to have them reared by peers without any kind of parental input without the kind of stimulation of the mother and then ask what happens to them later in life and then we can take an even more draconian condition which is surrogate pure reared they're raised in a nursery they're left 22 hours a day alone in a cage and then they're basically given a surrogate mother so this is kind of like putting them in an isolation ward this is extreme conditions if you've heard about the Romanian infants this is the monkey version of the Romanian infants so what you see when you look at measures of physical health is that early life conditions are playing a huge role I'm gonna probably run out of time you can call you can call me out at any time two minutes okay so let me just talk briefly about this but what we can see from these studies let me just give you one slide and then conclude that the early life conditions play a major role they play a major role and we can actually see the gradient that the mother reared monkeys are playing are having exhibiting the best health pure reared somewhere in between and those put in the isolation ward if you will the worst health but it's more than just some measure of health you can actually look at the methylation of the gene you can actually see exactly how genes are methylated how genes are methylated by putting them into these three conditions and so without I mean if you gave me another 20 minutes and they had 10 minutes or 5 minutes I could show you some of this but you don't want to do that but anyway the discussion period fine but the point is that this truly gets under the skin and so what we find is that 22% of all the genes are differentially methylated depending on what condition without any further remediation so the early life conditions are playing a huge role so yes there are things we can do after age 10 there are powerful things we can do with education but if we look at different outcomes we have to understand that there is a complex structure but as a complex structure that we can begin to understand and we do these longitudinal studies we have a whole series of intervention studies experiments and observational studies that all point in the same direction that the early years play a very important foundational role and so this Sunday I'm actually going to be at a panel on neuroscience in San Diego discussing the impact of the early years discussing the work of neurosciences and the impact of poverty and the inequality and extreme deprivation but even moderate deprivation in moderating brain structures of cognition and the structures that play in to determine health through exactly these mechanisms through the process that I showed you so I'll just conclude by saying this is a very active area of research I think we can in some sense begin to understand how we can develop effective policies early childhood policies for example a study that I've been reanalyzing the so-called Perry preschool study which essentially tried to address the status of very disadvantaged African American children in a city outside of Detroit small city outside of Detroit Epsilon in Michigan their longitudinal studies were done an experiment was conducted enriching the lives sort of taking kids out of an extreme deprivation to a situation of being more near having full parental resources and what we found from that study following these children now for a close to 40 years actually it's up to 50 years what we can actually see is we can compute the economic rate of return to investments in the preschool years exactly like taking these kids out now none of these kids are put in extreme isolation but they're the analog and human conditions of deprivation many of those children the Epsilon study who weren't in the treatment group are living in very desperate conditions measured by any measure of parental stimulation and parental environment and that study has been followed we've looked at the effects the economic rate of return on that investment is substantial so you get an efficiency you get actually a cost effectiveness criteria the rate of return is 7 to 10% per annum for each dollar invested which is higher by the way than the average return on the US stock market between 1945 and 2008 no forget the melt then this is the most recent year forget the last two years it's still higher and some of the mechanism is on preventable treatment conditions so at age 40 you see less drug use less tobacco use less in a number of dimensions of health and the exciting part of the work some of the work that Gabrielle and I are doing is essentially talking about how we can intervene and studying a whole variety of these interventions from around the world so to conclude but there isn't such a stark trade off as you were saying I would argue that actually we can in some sense have our cake and eat it too some part of social justice is actually economically efficient so we can essentially have policies at least those that are directed towards the early years that seem to have a very high economically return much higher by the way than things like job training much higher than even reducing classroom size all the traditional investment programs and reduce inequality in the larger society so I think that's the good news what the nice news from a research perspective is a lot more to know and we're actively engaged and we just formed a network around the globe trying to study health inequalities and I hope we can work actively with all of you so thank you very much fabulous thank you it's like we plan these two talks side by side but I take no credit for that our third speaker today is Dr. Eugene Washington the Vice Chancellor of the UCLA Health Sciences and Dean of the David Geffen School of Medicine at UCLA Dr. Washington is an internationally renowned clinical investigator and health policy scholar whose wide-ranging research has been very important in shaping national health policy and practice guidelines at UCSF where he spent many years he chaired the department and reproductive sciences from 1996 to 2004 and also co-founded the Medical Effectiveness Research Center for Diverse Populations at UCSF he also has done work at the CDC it's a pleasure to welcome Dr. Washington who will speak on eliminating health care disparities in the context of national health reform please join me in welcoming him okay while she's preparing that I'd like to say first of all I'm delighted to be here in Chicago on this risk-clear fall day and most of my colleagues would consider me to be a reasonably modest person but I'm feeling pretty damn good about my decision-making related to this trip first Mark called me in I accepted the invitation at a time when I was particularly busy but Mark I have to tell you I was making that decision under duress we have at least three colleagues I don't know if she's an audience one of them is Dr. Nita Stewart who I have an IOU that I was going to come to University of Chicago probably for the last five or six years and I will you for too long another is Dr. Eric Woodaker who was applying pressure even more recently and then one of my former fellows Dr. Ernst Lingle Lingle is here and so when you call I was easy prey but the second important decision that I made was that again when you're busy you're trying to use time efficiently and I had planned to take a night coach last night which I do these days when I'm flying east and my wife said just go the day before and just try and relax and I said no I'll take a night coach but then an invitation arrived to dinner and fortunately I came and had at just a wonderful time last night at Mary Ann and Barry McLean's house stimulating conversation delicious food and just a spectacular view of Chicago my decision making on the third account was questioned Wednesday night when I was with Jeff Bluestone some of you would know him I had dinner he's a former faculty member here and I told him he said where are you staying I said I had a choice between the four seasons and the quadrangle club and I chose a quadrangle club he said bad choice but but he didn't realize that I am such a sucker for old buildings and being on college campuses and I loved to my stay there and my breakfast this morning the final decision was Mark and his colleagues they were insisting that they pick me up and drive me here and I said well it's on campus that's one of the reasons I chose they said no it's too far you're going to get lost and so last night arguing with him on the sidewalk I convinced him working at CDC I've traveled around the world I've been in some dark spots I can make my way to the mall school and unquestionably if it's a quarter mile it is a magnificent walk particularly this time of year I did not want to stop walking however I did and I'm here and I'm delighted to be here with that as a background for how I arrived here I'd like to start with the title and point out a couple things I'm going to ask you shift gears we've been talking big picture we've been talking about determinants of help as someone with a public health and a policy background in terms of health just in terms of overall health status I've got to make much much more difference in terms of the populations health than the health care in the aggregate no question about it however in this country while we should be spending more on those determinants the truth is we're spending most of our money related to health on health care as of last year we were over $2.5 trillion and so when we talk about disparities in health care we're talking about justice we're also talking about the economic losses as a result of that we're also talking about some contribution to the overall health status so this focus is rather than talking about health in the context of national health reform is going to focus on really health care disparities and by disparities we're talking about the delta or the gap between health care that's received for the most part the reference group is white population but in some cases it's by age or in some cases it's related to gender men versus women some cases it's related to people with disabilities versus those who don't have disabilities for the most part I'm going to be using examples as related to disparities related to racial ethnic disparities there's considerable overlap between racial ethnic disparities and disparities related to socioeconomic status but you're going to see that there's going to be considerable overlap here and so with that as a background I'm going to plan to cover address three questions one has to do with the question of what are the goals of national health reform I'm going to particularly focus on the national act itself the patient protection and affordable care act two in the context of this act which is just really one component of national health reform I would emphasize that to you because people often ask me what happens if aspects of the national health reform law is repealed is health reform dead the answer to that is definitely not health reform started before the enactment of the law in March and it will continue regardless of what happens in Congress over the next year or two years and then I will make a comment about what I think the priorities should be this is rather than thinking of this as a really this is a data driven presentation in that I will provide you with data but I can't tell you that it's particularly evidence based in that we don't have in the case of ending the cost curve that really tells us where we are with health disparities so that as a result of the interventions that are inherent in the current act we could say we've been the curve however we do have some measures that we are tracking to let us determine whether or not and I'm going to show you some of those data so let's start with the first major goals of it most people would agree that the three major goals relate to expanding coverage so that the argument is that this is really about health insurance reform second goal would be improving sorry second goal would be improving quality of care and third would be reducing health care costs so before I question for the group everyone in here you've read something about it in the paper or you have been involved yourself here in Chicago or you've got a friend that has always been in your ear about what's happening and what's not going to happen based on what you've heard how many of you believe that the Patient Protection and Affordable Care Act is going to overall in the next nine years going to expand coverage in the US and particularly in a favorable way for health disparities how many of you think it's going to worsen okay and so the rest of you think it's going to how many of you think it's going to be the same how many of you are uncertain what about improved quality of care how many of you think that again we're talking about now health disparities so those measures in the bill designed to improve quality care what effect are they going to have on the disparity sort of equation in other words that gap and quality that currently exists between the reference population and whatever the other group is particularly racial and ethnic groups how many of you think it's going to these measures are actually going to improve the disparities gap quality of care how many of you think it's going to worsen okay you know I need to control for those who are raising their hand and worsen as to who are the pessimists and the optimists in the group but we'll do that at a later time and then how many of you when it comes to reducing health care costs and this is a tricky one but how many of you think the measures that are designed to reduce costs will lead to an improvement in health disparities how many of you think it will worsen and how many of you think it will be the same okay so this talk is going to be about trying to get at what is in here to give you some additional information about how you might judge that this is what I came up with and I'm going to come back to it and throughout it you're going to see before check marks for each row and I distributed them based on sort of the emphasis with the belief that overall everything about this convinces me that it is going to expand coverage and I think the numbers are going to reflect that very clearly I'm with the group that I think it's mixed when it comes to quality and that will come out in a minute in the case of reducing costs it could be it could be balanced and there are two dimensions to the cost and I will explain that to you as I go along okay expanding coverage we know what the problem is the problem is we talk about about 47 or so million people in the US that are uninsured and we talk about the non-elderly and particularly because for the most part the elderly should be covered by Medicare okay but what this graph shows is that while 30% of these racial and ethnic groups constitute 30% of the population they make up more than 50% of those that are uninsured in the US so we start talking about coverage and we start talking about insurance it's going to disproportionately advantage underserved and minority populations who for the most part suffer the disparities or at least are related to the disparities we see in healthcare okay but those of you who are wondering what this is I discovered this only when I was putting this data together this is Native Hawaiians and other Pacific Islanders I did know that we were using such a category okay so let's look at this there are really three dimensions to the coverage when I think about it now I know many of you are going to say you don't have individual mandate on there so let's inherit it here and let's start with the implications and again we're talking about the implications for healthcare disparities and let's start here with the employer mandate and the experts in here are going to immediately say Eugene there is no mandate that employers provide health insurance and that's very true however there are penalties on employers if in fact they're employees if you're an employer and you have more than 50 employees and your employer can obtain coverage through this exchange because you do not provide options then you get penalized so in that sense this group of employees with 50 more employees are being incentivized to provide coverage now how does that benefit in terms of the racial particularly racial ethnic minorities when you look at the groups that I just say were the least covered in general unemployment rates are higher but even when they are employed they're employed in lower level jobs in smaller companies and so they would have been the ones in the group disproportionately where the insurers or where the companies didn't provide insurance now you're going to have more of those individuals being covered right here by the employer mandate just from a coverage perspective let's take the health exchanges this is the idea now that you're going to be one of the groups of insurers participating through an exchange where citizens can go and get health care what's important when you look at the exchange is that in this category they're going to be premium benefits and they're going to be cost sharing for any individual that has an income up to 400% of the federal property level federal property level is about an individual and it's about 22,000 for a family that's up to 8,000 minimum in this case for a family is going to be about 20,000, 26,000, 27,000 it now means that many individuals will have in fact the exact number that falls in this category that I just described from 133% to 400 it's about 19 million individuals and 6 out of 10 over half of that group are those ethnic minorities that I just talked about so by definition you can do the numbers there as a result of these exchanges you're going to see more coverage the same would be said here it's an even simpler equation we talk about Medicaid expansion right now Medicaid already covers women pregnant women those with disabilities and children under 133% of the poverty level in this group alone it's about 22,000,000 individuals all of that 46,47 that I just talked about so now all of a sudden they're all going to be covered or at least half some coverage so if you just do the arithmetic then you can see that we're talking about as a result of this probably half a more of those underserved individuals who weren't covered now being covered as a result of the health reform legislation but coverage is one thing those of us who work in the field know that coverage does not mean access and there are some measures in here that are also going to help to improve access this just dramatizes the problem again in terms of the number it's one of the ways that we measure access and it's just a graph showing the number of a percent of individuals in a population who have what we call usual source of care sorry and usual source of care in this case has to do with the fact that you've got a primary care doctor or there's some clinic or some place you go to on a regular basis rather than the episodic care where you just shortcut into an emergency room and what I'll show you is that the rates are significantly higher for African Americans for American Indians and Native Alaskans and for Hispanics and for Asian compared to white population same thing this is also getting at the issue of access to care and this is quite simple it may look complicated but AHRQ which is Agents for Healthcare Quality Research it's a federal agency analogous to the National Institutes of Health they collect data on some measures of access so in fact one of the measures is what I just showed you what percent of the population actually has an ongoing provider another measure might be of individuals who come in they collect data on how many of those individuals delayed care because in fact they didn't have regular so that would be and what this just shows is that when you look at those measures and in this case that would have been five measures if we look at the black as improving and this would be the African American group compared to the white just as an example two of those measures we improved one of the measures remain the same and over this period of time there are two different periods two of those measures worsen so you can see that just in terms of access when you look in the rear the impact of different policies that have been in place have been variable over a period of time but that still remains a problem of access even with coverage and while I think that there will be improvement here there will still be some areas where there's not other provisions when I'm going into detail I'll just direct you to that are related to access is for the populations that we just talked about particularly the populations that suffer disproportionately from disparities and health outcome those are the populations that frequent sorry I keep doing that the community health centers in this country by definition have to be located in underserved areas or at least they have to be in some proximity to underserved populations or populations that in fact are in the law wrong in terms of outcomes there are many provisions in the new health reform legislation that are going to enhance community health centers without going into detail is what they are there are also many provisions in here that are aimed at increasing the health care workforce we tend to think of that as applying to increasing primary care doctors but it's more than just focused on primary care doctors and on doctors in general it's focused on nurses it's focused on dentists it's focused on dental hygienists as well and so that these are very very important provisions and there are policies in place geared toward trying to strengthen access for these vulnerable populations and these populations who disproportionately share the burden of disparities through these two mechanisms I would underscore that I think this is one of the most important and possibly understated goals within the whole health reform movement and to some degree I'm joining the crowd that's not arguing that there should be four major goals beyond expanding coverage and beyond improving quality and reducing cost this should be a goal in itself and that is in terms of increasing the health care workforce improving quality here this is the definition that we use pretty much across the country it's a definition developed by the Institute of Medicine so when I say quality I'm broadly referring to these six measures or these six aims quality should be safe effective patient centered timely efficient and equitable and you've heard discussions this morning from both of our previous speakers about this notion of justice and and being equitable I'm going to just share with you what again some data about what has existed and then talk for a few minutes about the current provisions in the law so going back to the same data set that comes from the agency for health care research and quality and what this shows is that when you look at two periods of time and if we were to take one group in African-Americans I'll slow down a little bit so this is African-Americans compared to whites and in this case 16 different measures and you say okay what are these quality measures they would be measures like some of them related to preventive health care percent of women getting mammograms percent of individuals receiving colonoscopy they're also related to quality measures in the hospital intravenous I mean site infections number of individuals coming into emergency room and medical hospitalization they receive aspirin readmission rates and so there's probably 50 measures there but there's some core measures for health to really constitute sort of basic quality of health care and what this shows is over this period of time at least these two periods of time that six of these for six of these measures there was improvement in terms of the disparity gap for blacks compared to white for nine of these there was no change and for one of these it was worse that's actually quite good that scores the point that as we think about implementing these policies those of you who say that the quality could lead to some worsening that is true and I will tell you the mechanism in a minute that I think by which that would happen and one of the reasons why I think it does happen here's some of the provisions there are two that I'll just bring to your attention there are many in there that have implications for quality and cost in fact many of the ones related to cost are trying to reduce cost while at the same time improving quality the two that I mentioned though are first national quality improvement plan that includes the status of key national indicators of quality to be tracked by race and ethnicity the reason why this is important is because in our case which we should be improving quality overall to some degree we forget that some of the interventions that we are going to make in populations that are at the upper end of the socio-economic status won't have the same impact in fact could have an adverse impact on some of the ones that at the lower socio-economic level I'll give you an example would be the emphasis on pay for performance is exactly where I think it should be focusing on city A midwest city where the population in poverty is 34% where the median income is 23,000 and where the graduation rate is 12% literally versus in city B where 4% have been poverty and the median income is in this case from college is over 50% then you're going to have better outcomes and if you're a great doctor in the first city you may be a great doctor but you are practicing with a healthier population and you're going to get rewarded as you should but you could be a great doctor in the second city I'm flipping my cities but you could be a great doctor in the city where the population already has poor outcome and in the end because you don't show the same change you could be penalized and as a result of those penalties disincentivize the practice in those areas and it could have a paradoxical adverse effect on the population the last thing here is many of you have been hearing about the comparative effectiveness research more to come I have to be in the group that think that this is an important undertaking as a broad area because I think patients, providers, policymakers want to know and should know what works and what does not work and so I see this as an initiative that geared toward providing yet another piece of information and it's a decision assisting tool as individuals and groups make decisions regarding their choice for different therapies as well as for providers reducing cost many argue that the entire health reform legislation is about trying to bend this curve and most of you are familiar with the data this is just showing percentage but we are over 2.5 trillion dollars as I said we're spending close to 8,000 dollars per US resident and Dr. Daniels actually his last slide he showed how our life expectancy was right up there with Luxembourg what he didn't show was how much we pay for sort of citizens compared to what they pay in Luxembourg we pay more than anyone anywhere in the world and in many of those countries we have comfortable income outcome but more importantly and I have some economists in here but no one that I've heard would argue that this is sustainable or we wanted to be sustainable because we're looking at close to 18% of the GDP and that is quite a bit of money with not real evidence that as we continue to invest more that we will see better outcomes so it's a question of value here are I would say just broadly speaking again the approaches to trying to deal with the cost but they are connected to quality as well in the first case the idea is is that if we can we talked about this last night we can real line incentives right now the incentive is on value doing as much as we can for you when you come in to see it because we get reimbursed for each test that we provide you right now also we have more medical students and somebody asked me recently all the medical students they come in, they're so idealistic and they go into primary care and they go and conquer the world and they say what happened to them, why aren't they going I said medical students can count they get there and discover by the second year that the loans or two, three hundred thousand they see what the conditions are in which the primary care providers are working and they also see reimbursements are and so a great deal of emphasis is being placed on not just reimbursement but improving working conditions for primary care providers and I applaud those and so do most in the country and in fact I suspect that we are going to see some redistribution of funding across sort of the provider spectrum the second is the idea of trying to move us away from being incentivized to just do things related to volume and so this would be a step beyond what we would call just individual item care to more episodic care rather than seeing a patient being reimbursed for the visit and for whether or not you get x-ray in this case it says if we have a patient that's coming in to see us or coming to the hospital let's for an elective cardiac angiography or something like that we're going to get paid for an episode of care everything that's associated with that patient receiving that procedure operation through some period of time so any complication for the next 90 days just as an example you're going to get one payment some people prefer to this is bundle payment but we're just going to get one payment we're incentivized in that case to ensure that we provide quality effective care but that we also be efficient it's still focused on the patient that comes in the higher order of this which is I believe one of the ultimate goals of the health care legislation is to shift the emphasis more to population centric care in this case accountable care organization forces or incentivizes systems of care the doctors the nurses the dentists in terms of the providers but also now we're talking about the hospitals even the long term care institutions are now joined in a collaborative in a consortium because they're now being given payment to take care of a population of individuals if this succeeds it is definitely going to not only shift I believe ultimately the cost curve but I think it's going to shift emphasis more to prevent it and to a wellness more of a focus on some of these determinants of health and away from some of the curative medicine I continue to emphasize to people the curative medicine is always going to be there we're going to always need the state of the art premier high technology cutting edge care that's provided at the University of Chicago and I don't think you're going to ever run out of the need for that but at the same time it would be great even more emphasis on wellness and on health promotion prevention and this is what accountable care organizations are designed to achieve along with reducing costs but also improving quality and this isn't there because of time I'll just say there are some specific items in there related to health disparities they mostly focus on ensuring that we have data so that we can monitor it this is a big one for me and I go back to health workforce it's not just improving the number of providers but it's also improving their core competency and dealing with this diverse population that we just alluded to the same thing here only the focus is on individuals particularly many of the individuals who are now for the first time have coverage provided with them is ensuring that the language use and registering them but also providing the care the language is culturally and linguistically appropriate some prevention related priorities just you know which is good news for the prevention and health promotion orange and individuals in the audience here you can see that there are some features in there related to that as well so I come back to the original question I asked you I think most of us and most of you did raise your hand would agree that from again health disparities health care disparities perspective I think that this will improve there's no reason logically just thinking analytically why it should worsen it you know but there are always unique circumstances that could lead to worsening unpredictable at this point here improved quality of care I just want to explain the one here which is this one I put that there because I think that this is going to be driving a great deal by our ability to in fact expand the workforce and to expand the workforce to include individuals who in fact have the right core competency if for example in short run all of a sudden we have an expansion of coverage so we have many individuals who didn't have coverage before and many of those individuals are not in low socioeconomic status many of those individuals in fact are not in these racial ethnic minorities what would happen is that many of these individuals who are currently suffering from these disparities will get pushed down a little further and will have an even worse access problem despite the coverage in the short run the people are just not going to be there to provide the coverage and those that are going to be there are going to be available without considerable emphasis on these workforce are just not going to be prepared to handle this new major influx of individuals so I could see in the short term that there could be some worsening overall in the quality that's one the other has to do with just putting emphasis which is the right place on value and pay for performance if I'm a provider and I know that I'm going to be measured by the outcomes in this population then I'm going to want to start with the healthiest populations and some of the others are going to get marginalized because you're not going to want to add I mean this is what insurance companies do or have done just in terms of a risk pool so that would be no different from this so I would put a question mark or really a concern I think it will worsen in the short term in the cost I certainly don't put all the checks here because I don't think it's going to improve overall I think a great deal would be the same you know the only reason I didn't put one here the truth is because I'm an optimist and I struggled with that one and optimism in me says that curve can't continue we're intelligent people in this country we've always been ready to respond before we went over the cliff and I think we're going to respond in this case and in the end we are going to have the will to bend the cost curve in this country so I do not think that nine years from now and 29 at the end of this legislation that things will be worse as it relates to cost you know I usually I've used it a couple of times in the context of really innovation we've got to think out of the box this is one case where I'm saying you know most of it is right there and it's right there in the legislation but I point out to my colleagues the legislation is really a framework it provides broad policy guidelines it's going to get shaped over the next really 10 years it's being shaped now by individuals across the spectrum of providers and policy makers and consumers but what needs to be done it doesn't really require that we get too far out of the box because most of the out of the box thinking has been done and I'm just going to work just very quickly five things for a month we need to strengthen the data again this is from a help this care disparities perspective we need this data so we know exactly where we are so in fact we could constitute something like a health disparities curve and know whether or not we're bended in and know what the projectory looks like this is a key point for me we've got to get the adequate number of providers this one is a key because it relates to the countermeasure organization and these new models CMS which is a center for Medicaid services billions of dollars new dollars are then made available to test these models the models can't be tested just in those health care systems that have proven to be effective they've proven to be effective quite often in populations that are already reasonably served and with reasonably good outcomes and then the final two I would just mention here is advanced best practices for health promotion and disease prevention we just haven't done much of that from a health care perspective and that should be done there are funds in this new legislation to do that and then finally which is what I see as one of the major outcomes of a seminar and gathering like this is to continue to raise awareness about the issue my last slide is to reiterate the point that my colleague in his presentation is that this really is a global problem talking about health disparities and health care disparities thank you it's a great pleasure and honor to be here and thank you very much for inviting me and the timing is pretty interesting considering the elections yesterday and particularly with the connection to Chicago I'm going to be talking for about 35 or 40 minutes and right up front I want to say that 70 to 80 percent of the work that I'll be describing here involves my dear friend and colleague Peter Singer who is unfortunately not so well this week he was due to come here next week to give a talk at the fellows conference but won't be there we are hoping that we'll be able to reproduce some of my comments so consider this as a presentation from both myself and my colleague Peter Singer so I will describe our work mainly some of it is not yet in the literature or it's not in an accessible form and so it'll be quite new and I hope that we'll have a lot of time afterwards to discuss that so let me first of all start with the definition of global health it's one of those things that's a little like the elephant and the blind men it hasn't settled yet as to exactly what it is my favorite definition is this one from the institute of medicine report health problems issues and concerns that transcend international borders maybe influenced by circumstances or experiences in other countries and are best addressed by cooperative actions and solutions and that packs a lot of implications which I hope will emerge as we as we discuss issues today so look at this picture on the right you have people living in North America in Europe and the rich countries of the world expecting to live 80 years after at birth on the left you have sub-Saharan Africa mainly and other places in the world but mainly sub-Saharan Africa where life expectancy is still 40 years and to some extent in a few countries actually dropping and so that immediately raises two questions how can this be acceptable we are one species, we live in one planet how can this be fair how can it be sustainable and the second question is what can you do about it so that's partly why Peter and I got involved in global health look at the disparities in global health and I want to enumerate many of these because the list can go on for hours every second of every day four women will give birth and every minute one of those women would die for every woman who dies another 30 suffer lifelong consequences as a result of complications of their pregnancy or the delivery and that's not to mention the kids who grow up in utero with malnourished mothers or who grow up in very constrained circumstances which then leave lasting legacy of being exposed to metabolic and cardiovascular diseases and mental health problems so it's a huge problem predicated on poverty as one of the issues I also want to highlight a human rights element to global health so some of you may be familiar with an article maybe 10-12 years ago in the New York Review of Books about 100 million missing women and those missing women what you would have expected in a particular country to exist but don't exist because the human rights situation particularly vis-à-vis of the rights of women are such that those women die early somehow disappear now poor health affects the poor predominantly including in the United States some of you may be familiar with this statistic that in Washington DC as you go down the subway from the richer parts of the city to the poor parts of the city for every 2.5 kilometers along that path life expectancy drops by 1.5 years so this is a problem between the developed and the developing world but even in the developed world there are disparities and some of the talks that you will be covering including here in Chicago will highlight those issues now infectious diseases have received a large part of the attention in the past decade or so HIV, tuberculosis, malaria neglected tropical diseases and that has actually attracted some significant funding from the biggest sources the biggest source being the Gates Foundation to address some of the real big challenges facing us with regards to infectious diseases part of this is humanitarian impulses and part of it as I will show you in a minute is national security considerations so viruses do not carry passports and that has been one of the factors that I said but then neither does climate change or environmental degradation so people think about infectious diseases but do not give as much attention to the health implications of climate change and environmental degradation and those too don't respect borders now our consumption patterns in North America and in the rich countries of the world are such that directly or indirectly harm people in the developing world take our meat consumption the fact that we have to use good land to produce feed crops to feed the kettle with all the environmental implications of that to the rest of the world and all those greenhouse gases released but also we export things like tobacco aggressively the markets here are saturated people are smoking less so what do we do? we export that to the developing world and that's a huge problem as we will see in a minute and then a focus of my work over the past four years on chronic non-communicable diseases so let me just now begin to talk about this idea of grant challenges what is a grant challenge as it has evolved in mathematics about a hundred years ago that led to departments of mathematics all over the world focusing on those grant challenges but as it has evolved particularly with our work with the Gates Foundation and more recently a grant challenge is a specific critical barrier so for example if you don't have a vaccine against malaria the answer is the question is what is the critical barrier and why haven't we done that we've been researching this for 50 years so it is about focusing on the barriers the critical barriers that if removed would help solve an important health problem in the developing world with a high likelihood of impact globally through widespread implementation and implementation is now becoming a science in its own right more money is going to go into research in the future in the next few years and perhaps in any other area of global health research so I'm going to describe four initiatives that have the name grant challenge connected to them one is the Gates Foundation grant challenges in global health initiative which was launched seven years ago then the grant challenges in chronic non-communicable diseases grant challenges Canada which I've just talked about and I'll say more in a few minutes and then lastly the work some of the work that I'm involved in at the moment with NIH and the Wellcome Trust and others in identifying what are the grant challenges in global mental health and I think for me and I'm sure for many people that's the next big big challenge to address so this approach of grant challenges which is quite different from funding research in the traditional way you're all familiar with the NIH where you put in your ideas it goes through peer review etc here it's a rather different approach it's more hands-on it's based on those critical barriers that we need to do and we will fund the best ideas without bureaucracy and if someone comes with a great idea if they can take it to the next stage that kind of approach and it's brought in very significant resources Bill Gates put in Bill and Melinda Gates Foundation put in 450 million dollars to address 14 grant challenges and funded just 44 research projects just 44 450 million dollars or more secondly let me talk about chronic non-communicable diseases so just let me paint the scene here for you so about, I'm sorry I don't know what I did there okay so about 60 million people die every year and people imagine that a lot of people in the developing world die from infectious diseases well it's not so of the 60 or so million people who die about half die from cardiovascular disease 30% die from cardiovascular disease cancer kills about 15% chronic respiratory diseases 7% and diabetes although it looks like 2% actually diabetes causes cardiovascular disease causes stroke and so on so it's grossly underestimated what diabetes does and then if you look at communicable diseases continental conditions and nutritional deficiencies which are big killers all that amounts to only 30% so chronic diseases which are cardiovascular diseases mainly heart disease and stroke certain cancers not all of them doesn't include infectious cancers chronic respiratory conditions which kill more than 2 million people just from indoor pollution alone and diabetes and malaria that has been totally neglected in the developing world understandably partly because they have to deal with with tuberculosis malaria, HIV other neglected diseases and what's the budget the budget in many sub-Saharan African countries for health is 20-25 dollars per person per year which is remarkably low so how do you deal with these problems the risk factors are actually pretty well understood not exactly how they interact and what you can do about them but it's tobacco so smoking will kill 1 billion people this century if we don't do anything about it 1 billion people unhealthy diets so both over nutrition and under nutrition and harmful use of alcohol so at the end of that paper we said chronic non-communicable diseases must urgently receive more resources research and attention as mapped out in these grand challenges in action is costing millions of premature deaths throughout the world so you can't just end with that what do you do having identified the actual need so we went ahead and got together NIH, Canadians Australians, Chinese and we created this global alliance for chronic diseases and you can read about it in a piece of science at the time we launched it so that's Betsy Nable a visionary who was at the time the director of NHLBI at NIH National Heart, Lung and Blood Institute of Brigham and Women in Boston the head of the Canadian body which is equivalent to the NIH the head of the British body Chinese, Australian and we've also got India now coming aboard in South Africa so what is this global alliance about it's a funding agency it's an alliance of funders together these six agencies account for about 80% of all research funding available for biomedicine and health it's the first of its kind it focuses on chronic diseases in low and middle income countries and low income populations of high income countries it supports collaborative coordinated research at global scale on low cost interventions and capacity building and it identifies common approaches to provide the evidence that policymakers need in order to put in programs so that's what that's about and we can discuss a little more about what are the priorities what are we going to be funding first when we come to the discussion now let me transition to Grand Challenges Canada which in some ways is even more exciting because it is a policy development of a government which is very creative as you will see so Grand Challenges Canada is an organization it's a funding body it's not for profit organization Peter Singer is the CEO and the chief scientist it's a consortium with two government related bodies in Canada the International Development Research Center which has amended to do research for development for the developing world and the Canadian Institutes of Health Research which is our NIH equivalent it's governed by a very tough and strong Board of Directors it's advised by an International Scientific Advisory Board which I happen to chair and is hosted by the McLaughlin-Rotman Center as we heard its mission is to identify Grand Challenges so from an idea you test it you say well this is important you then go and talk to content experts and you go through scientific advisory board identify a Grand Challenge so phone me and I after this talk will be discussing one of these in the area of cancer to see whether it's something worth funding and then you get the board to say well this is great put in this much money and develop an RFP so it's a really exciting kind of of work and we will support implementation and commercialization of the solutions that emerge we are building a capacity to actually support commercialization which is not an easy thing to do so we've got 225 million dollars for five years to just do five programs one of them is going to be in chronic non-communicable diseases one is going to be in a point of care diagnostics and another one in maternal neonatal child health and we are working on others but just five in its budget 2008 talked about supporting the best minds in the world as they search for breakthroughs in global health and other areas so that other areas they haven't yet funded they might be funding of equivalent amounts for let's say energy or agriculture but those have yet to unfold now here's the clincher and the most important part of all this this money comes out of the foreign aid budget of Canada about five percent of the foreign aid budget and this is the first time that any country in the world has taken the risk of taking money out of foreign aid budget and putting it into this kind of grand challenges approach to solve problems for the benefit of the developing world and that's controversial we can discuss that whether that's the right way to spend foreign aid money or not if other countries did take this up then this could be a way to get a lot of money into global health and other areas environment, energy agriculture etc to solve real problems rather than simply hand out money which sometimes doesn't work so the floor is now open for questions and comments yes, yes please it was a very interesting talk that the Washington was giving but I completely agree across my mind as you were saying how can we actually be sitting here on the same panel and I do think there has been an over emphasis a huge amount of expenditure has been on treatment and much less on prevention and I think part of it has been because the determinants of what determinants are probably less securely established and I think maybe in medicine in epidemiology we have such a focus on just on health and how early health behaviors affect later health behaviors and how this disease is treated by this drug and only recently are we coming into this kind of developmental process of understanding what it is, how disease is interacting with a larger social system and how changing other parts of the social system will affect the health care system so I do think there is a tremendous imbalance and I was a little sad that the discussions this last six months or so emphasized too much health care and too little prevention it could have been more money spent for example on early childhood and educational interventions that I think could have prevented the problem I guess I'm a little less optimistic than you are about the bill as I've understood it to this day because I didn't see where they were really bending the curve and this is one way to bend the curve from the out, from the get go so I think it's a great question and I would turn it over to you so my view is that yes there was an imbalance and there is right now and I think it's partly just the way fields get set up that people say okay so we have a group of people studying education over here we have a group of people studying health over here we have some personality psychologists standing over here there aren't very many people putting all these three ingredients together and those are the ingredients you need to understand how to build a healthy society and get the people so we probably would need less disease well sorry we'd need less treatment of disease if we actually had made those kinds of investments so I do think we have to prioritize I think you're going to find a very tough sell to find anything near 7-10% rate of return in terms of anything that I've seen discussed in a specific way in the current health care bill we've had six to seven months and I simply can't understand one thing you said which is how it is possible to treat 20 to 40 million new people and not increase cost and increase it in a fundamentally powerful way and as an economist I would say we have a relatively fixed supply and you've shifted the demand the price has to go up maybe not as much as some people say and one way to do it is to sort of get rid of the problem so I would have thought that professor President Obama Professor Obama again this is one of his classrooms and I knew him in that role but it would have thought maybe a little more comprehensively about health care and social policy because it was part of his budget it's part of his campaign pledge and you know a lot of things have happened in the last two years but I would argue that anything I didn't really say and given the opportunity to say is we want to be much more comprehensive and so we say that we have complete details but I would say we actually know more about the health effectiveness of these early interventions and other types of interventions than we might know about certain kinds of cost reduction strategies in the health care policy arena I could just comment that I haven't seen the latest estimate but it's estimated I mean it's in the billions maybe hundreds of billions of dollars that are estimated to be wasted in the health care system and so one way that many who work within that system believe that you are going to be able to provide more services, better services to a population is to eliminate that waste right now there is no incentive for us to eliminate that waste and even if I put on my societal cap I'm currently in charge of a one of those state-of-the-art academic health centers with over two billion dollars in revenues a year that feeds our entire academic health enterprise and I mean I would get hauled into the town square tomorrow and then shot if I were talking about okay let's give back the money so this is a problem across the country and if I am an optimist maybe too polly-annish because I think we need to bend that curve but more importantly if in fact it could happen it's going to happen in the next nine years but if in fact it could happen such that we've seen it happen in some other areas of the time to in fact focus more on the prevention and on the promotion then I think we would see better quality overall just in terms of what we do for patients and prevention is a great deal much cheaper than actual cure I'm going to take two quick questions quick questions and then let the panel wrap up I'm an expert on the this literature as Dr. probably is but from what I know the cross-country studies of income inequality that exists the initial ones were quite flawed I mean Wilkinson did a study of the OECD countries and did a very select group and showed a result and then it disappeared when you looked at a broader group Subramanian and Kowachi have looked at some of the international studies and their suggestion is that you have to have be above some threshold of inequality before you start to get any difference at all that shows up in the cross-country studies so for example they see some effects in Chile and we're looking at some middle income countries where perhaps income inequality might be very small in some middle income countries but at least as large as Chile and others you might see some differences I don't know of those studies specifically that bend the countries by income levels you suggested that it's going to be very challenging and I agree with that however I do think that it's doable I mean some of the data that I showed you from the Agency for Health Care Quality and Research and again I only stumbled on this data as a result of preparing for this talk but I was impressed that they have improved in the last five years since they've been developing this report and the emphasis has been on increasing the metrics there's some very smart people working in this arena how do we validate the metrics that are being developed across different populations and I tend to think of this whole metric mapping similar to the Human Genome project where you've got lots of different people working on it but once you can agree up on sort of some standards for how you go about testing various pieces different groups can test the pieces so eventually you've got a metric map for the country that people agree on with some baseline measures so I think it's doable and I certainly believe that an important step is the investment that's being made through the current health reform legislation I don't think I should add much to what you say quite a bit about the literature I would simply say that I'm a little bit worried about stopping there with just the income and equality health so there is a relationship Puckett and Wilkinson have been probably the most active in advocating this and there has been exactly the kind of controversy that Dr. Daniels was talking about but I would make the following statement that there is a real issue about whether or not it's income and quality per se that's arising so even if you took the facts the simple facts even without the subtlety that was just given I would wonder and I think that's been the issue that's been heavily contested Angus Deaton for example has written on this and many people have written that it may not just even be income there's the Christian of reverse causality people who actually happen to be very sick generally have low incomes and so forth and so on and so I think we probably need a deeper understanding of just the nature of social inequality than just looking at income and I think what I worry about to be honest is an episode that occurred in social policy in the United States some 50 years ago there was a tremendous amount of income inequality not just racial inequality but various kinds of inequality and so the idea was well what we should do is give people more income and redistribute income and we did it and we did it very effectively for 15 or 20 years and we reduced the measure of inequality in the society and then some 20, 25 years later about the time President Clinton was president we had this welfare reform that came precisely because many people recognized that just transferring income just reducing inequality was not reducing poverty and wasn't even really having that much of an effect on health and many other determinants and so the notion was we have to think more broadly about just what inequality stands for and that's what I think the thrust of it is and so the welfare reform act is one of the results I don't think we want to make the same mistakes we made in the 1960s and just say redistribution per se will do the job I think it's deeper and I agree but disagree so I agree that it may not be just income and the story may be more complex I disagree with the last remark because my understanding of American studies of inequality in general don't quite match the dates that were just given that we had a period in the United States of decreasing any social economic inequality overall from roughly the mid-40s to the mid-70s and then we began a long slide of inequality increase and the Clinton welfare reforms was in the middle of a period of very significant inequality increases and it may have been driven by the particular ideology about dependence that was true and for all I know there may be some basis to it but that was not an attempt to correct inequalities in the society if you had wanted to do that you would have changed the tax cuts that began with Reagan and you would have increased the degree to which the working class participated in productivity increases in this country wait just one last remark I I lost control of our country no but if you look at the data income transfers reduce inequality we do know that I mean Lampman and a whole group of people at the University of Wisconsin studied that and you're certainly correct though starting in the 1970s with globalization with the onset of what many economists have described as a technical change the demand and technology for more skilled workers there's been a secular increase towards widening wage inequality in the labor market that's a force on top of it all I was talking about with the Clinton reforms was simply that the idea that somehow we were going to end poverty by giving transfers I think that failed that I think we understood but I'm not suggesting that poverty and that inequality did not increase we're a much more unequal society than we were say in 1970 but there are a lot of societies that play that role our genie coefficient is close to that of Mexico for example and it wasn't anywhere near that in 1970 but many people would blame or would at least attribute that to the rise to global economic factors which have to be combative and then I get back to kind of closing the circle and say how do we then say if the skill is in greater demand what should we do we produce more skill and yet as of this day the high school graduation rate is actually declining we're having more dropouts in the US society now that we did in 1970 and again I think we have to put these pieces together health inequalities in part due to these same educational inequalities so we have to think more deeply I don't think just a transfer will do it we have to create the skills, the motives and to use the word of sin the capabilities I think that really expand the opportunity set more than just a transfer of income no disagreement