Our writing has appeared in a wide range of scholarly journals and publications.
Responding to the COVID-19 Pandemic: The Need for a Structurally Competent Health Care System
Jonathan M. Metzl, MD, PhD; Aletha Maybank, MD, MPH; Fernando De Maio, PhD
Journal of the American Medical Association, 2020
The coronavirus disease 2019 (COVID-19) pandemic has exposed the consequences of inequality in the US. Even though all US residents are likely equally susceptible to infection with SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), the virus that causes COVID-19 disease, the resulting illness and the distribution of deaths reinforces systems of discriminatory housing, education, employment, earnings, health care, and criminal justice.1,2 The patterns of COVID-19 illuminate centuries of support systems that the US did not build and investments it did not make.
Priority Issues from a Health Implementation Plan: A Qualitative Study of Local Foundation and Nonprofit Leaders’ Perceptions
Daniel J. Schober, Shannon M. E. Bowers, and Anne Posner
Journal of Public and Nonprofit Affairs, 2019
The purpose of this article is to examine how local leaders of health foundations and nonprofit organizations perceive key health issues (such as violence, housing, and chronic disease) included in a municipal health department’s implementation plan. Specifically, we examine how these leaders prioritize health issues and what their ideas are regarding how to address them. To do this, we used a semistructured interviewing strategy to gather feedback from 10 senior leaders of health foundations and 13 senior leaders of nonprofit agencies in the City of Chicago. We conducted a content analysis of these interviews and found that participants emphasized the importance of addressing broad conditions related to violence, economic development, and education across the lifespan using multisector collaboration strategies. These findings suggest that these foundation and nonprofit representatives consider social determinants of health to be key in promoting population health.
‘Looking Outside Their Walls’: Exploring Health Needs Assessments from Hospitals in Chicago
Fernando De Maio, Raj C. Shah, and Kerianne Burke
Navigating the Health System: Experiences of Patients, Doctors, and Policy-Makers (Karen Willis and Fran Collyler, eds.), 2019
The 2010 Patient Protection and Affordable Care Act requires not-for-profit hospitals in the United States to conduct a community health needs assessment (CHNA) every three years. Hospitals are also required to develop an implementation plan addressing the needs observed in the CHNA, or provide reasons for not addressing these identified needs. The extent to which CHNAs account for the structural and social determinants of health is open to investigation, particularly when doing so may call on hospitals to go beyond a narrow focus on individual behaviours as the source of preventable morbidity and premature mortality. Our work examines CHNA reports from hospitals in Chicago, Illinois. Our analysis contrasts the first wave of reports (published in the 2012-13 period) with a second wave of reports (published in the 2015-16 period). Our results reveal considerable differences in how hospitals met their CHNA requirements – with only a small number of hospitals offering historically deep and community-driven reports in the first wave of CHNA. Important differences also existed in how hospitals conceptualised causality of health inequities in their service areas – in the first wave of reports, most hospitals focused on individual behaviours rather than the root causes of poor health in Chicago, including economic inequality, racism/discrimination, and other aspects of structural violence. By the second wave of the report, a more collaborative approach was taken, and a substantially different message emerged, with more hospitals adopting the language of the structural determinants of health. We argue that CHNA reports – which are created at the link between public and private health systems – are an important vehicle through which to understand health inequities in the United States.
Structural Racism — A 60-Year-Old Black Woman with Breast Cancer
Kristen Pallok, Fernando De Maio, and David A. Ansell
New England Journal of Medicine, 2019
Many hospitals in Chicago’s largely black neighborhoods lack an American College of Surgeons Commission on Cancer Center designation. This designation provides a quality framework to guide cancer care. Of the 12 Chicago hospitals with this designation, only 2 are located on the city’s predominantly black South Side.
Association of community-level inequities and premature mortality: Chicago, 2011–2015
Brittney Lange-Maia, Fernando De Maio, Elizabeth Avery, Elizabeth Lynch, Emily Laflamme, David Ansell, and Raj Shah
Journal of Epidemiology and Community Health, 2018
Substantial disparities in life expectancy exist between Chicago’s 77 defined community areas, ranging from approximately 69 to 85 years. Prior work in New York City and Boston has shown that community level racial and economic segregation as measured by the Index of Concentration at the Extremes (ICE) is strongly related to premature mortality. This novel metric allows for the joint assessment of area-based income and racial polarisation. This study aimed to assess the relationships between racial and economic segregation and economic hardship with premature mortality in Chicago.
“As Natural as the Air Around Us”: On the Origin and Development of the Concept of Structural Violence in Health Research
Fernando De Maio and David Ansell
International Journal of Health Services, 2018
This article examines the concept of “structural violence.” Originating in the work of Johan Galtung in 1969 and popularized by Paul Farmer, structural violence is increasingly invoked in health literature. It is a complex concept – rich in its explanatory potential but vague in its operational definition and arguably limited in its theoretical precision. Its potential lies in the focus it gives to the deep structural roots of health inequities; in contrast to the more passive term “social determinants of health,” structural violence explicitly identifies social, economic, and political systems as the causes of the causes of poor health. It is also evocative in its framing of health inequities as an act of violence. Yet the formulation of structure used in this literature is largely atheoretical and, by extension, apolitical. Development of the concept hinges on clarifying the precise aspects of structure it points to (perhaps through using the concept in conjunction with larger theoretical frameworks) as well as improving operational definitions to enable its use in quantitative social epidemiology. We argue that the concept of structural violence can provide a useful lens for understanding health inequities, but its full potential is only realized when combined with larger theoretical frameworks.
Fernando De Maio, David Ansell, & Raj C. Shah
Ethnicity & Health, 2018
Comparisons of communities across cities are rare in social epidemiology. Our prior work exploring racial/ethnic segregation and the prevalence of low birth weight (LBW) in communities from two large urban cities showed a strong relationship in Chicago and a very weak relationship in Toronto. This study extends that work by examining the association between racial/ ethnic minority segregation and LBW in total of 307 communities in ﬁve North American cities: Baltimore, Boston, Chicago, Philadelphia, and Toronto. We used Pearson correlation coeﬃcients and OLS regression models to examine potential variability in the association between racial/ethnic minority segregation and LBW, controlling for community-level unemployment. In a combined model with community-level data from all cities, a 10% increase in minority composition is associated with a 0.7% increase in LBW. While racial/ethnic minority segregation and unemployment are not associated with LBW in Toronto, these social determinants have strong and signiﬁcant associations with LBW across communities in the four US cities in the analysis. Subsequent models revealed opposite eﬀects for percentage non-Hispanic Black and percentage Hispanic. Across communities in the US cities in this analysis, there is considerable similarity in the strength of the eﬀect of racial/ethnic segregation on LBW. Future work should incorporate communities from additional cities, looking to identify community assets and public policies that allow some minority communities to thrive, while other minority communities suﬀer from a high prevalence of LBW. More work is also needed on the generalizability of these patterns to other health outcomes.
Integrating Principles of Positive Minority Youth Development with Health Promotion to Empower the Immigrant Community: A Case Study in Chicago
Maria J. Ferrera
Journal of Community Practice, 2017
Growing vulnerabilities among immigrant families are further complicated by the context of US health care. This article discusses the critical need for health promotion initiatives that integrate principles of positive minority youth development. Mixed methods, including a CBPR (community-based participatory research) approach, are used to highlight narratives of immigrant youth who have participated in a health-promotion program infused within their high school curriculum. These narratives underscore contributing contextual influences and pathways to conscientization, civic action, how programming can effectively facilitate positive minority youth development, as well as individual and community-level empowerment that leads to increased health literacy.
Changes in the racial disparity in breast cancer mortality in the ten US cities with the largest African American populations from 1999 to 2013: The reduction in breast cancer mortality disparity in Chicago
Dominique Sighoko, Anne Marie Murphy, Bethliz Irizarry, Garth Rauscher, Carol Ferrans, & David Ansell
Cancer Causes & Control, 2017
The purpose of this analysis is to compare the breast cancer mortality disparity in Chicago to corresponding trends in mortality disparities in other large urban areas with significant African American populations and to the United States as a whole, so as to assess progress made in reducing the racial disparity in breast cancer in Chicago, compared to other cities and the US.
Fernando De Maio, Raj C. Shah, Kellie Schipper, Realino Gurdiel & David Ansell
Critical Public Health, 2017
We examined the association between racial/ethnic minority segregation and low birth weight (LBW) in Chicago and Toronto communities. While previous work has documented the importance of contextual effects on LBW, these studies have usually been conducted within a single city. We used Pearson correlation coefficients and OLS regression models to examine potential variability in the association between racial/ethnic minority segregation and LBW in Chicago (N = 77 communities) and Toronto (N = 140 communities). Results indicate that racial/ethnic minority segregation, unemployment, and low educational attainment are not associated with LBW in Toronto, while these indicators have strong and significant associations with LBW in Chicago. In a combined model with data from both cities, a 10% increase in minority composition is associated with a 0.5% increase in LBW, controlling for the effects of unemployment and low educational attainment. Stratified models show that this effect is only significant in Chicago, and subsequent models revealed opposite effects for percentage non-Hispanic Black and percentage Hispanic. Future research should consider additional cities for comparative analysis. Such work could test the notion that Chicago and Toronto represent opposite sides of a spectrum, reflecting variability in how social determinants map on to public health outcomes. Future research should also examine the significant heterogeneity observed in highly segregated communities, particularly in Chicago.
Fernando De Maio and Raj C. Shah
American Journal of Public Health, 2016
When does a population at risk become a risk population? This February 2015 billboard by the Chicago, Illinois, Department of Public Health is aimed at promoting fl u shots. It features an African American infant beside the message: “I am an outbreak.” The billboard was part of a larger advertising campaign, with other billboards placed throughout the city.
Embedded mistrust then and now: findings of a focus group study on African American perspectives on breast cancer and its treatment
Maria J. Ferrera, Rebecca T. Feinstein, William J. Walker & Sarah J. Gehlert
Critical Public Health, 2015
The risk of African American women dying from breast cancer is estimated to be 41% higher than that of White women throughout the USA. Using a community-based participatory research (CBPR) perspective, this qualitative study elicited attitudes, beliefs and concerns about breast cancer and its treatment amongst African Americans living in Chicago. Five hundred and three women and men were recruited from 15 of Chicago’s predominantly African American South Side neighborhoods. Participants were interviewed in 49 focus groups, 2–3 focus groups representing each neighborhood. Grounded theory was used to analyze data. A prevalent theme in the analysis was a general sense of mistrust amongst African Americans towards breast cancer treatment and the health care system at large. This theme involved notions of being treated like a guinea pig; living in the legacy of Tuskegee and other forms of historically rooted experimentation on African Americans; and being maltreated because of race. These findings suggest that historical and contemporary incidents remain a point of debate. Findings warrant the promotion of increased cultural sensitivity amongst health professionals regarding this historically rooted mistrust and its present-day implications.