How Does Class Affect Public Health?

By Tiffany Huang, MPH, Program Analyst, Assessment and Planning, NACCHO

“The commodification of people is the biggest issue we face in public health,” stated Kathryn Evans, MPA, a trained community organizer with United Community Services of Johnson County, during the closing general session at NACCHO Annual 2015. Evans spoke compellingly about the roles of power, class oppression, and racism as determinants of health inequities, and along with her fellow panelists, called for public health to act upon them.

Public health has long acknowledged that socioeconomic status is one of the strongest predictors of health outcomes across nearly all diseases and risk factors.1 However, socioeconomic status alone does not adequately capture the meaning of class. As an analogy, consider the distinction between the terms “health disparities” and “health inequities”: Health disparities refers simply to differences in health status that exist between populations, whether by race, ethnicity, socioeconomic status, age, etc;2 health inequities refer to differences in health status that are systemic, patterned, unjust, unnecessary, and actionable.3

By using the term health inequities, we acknowledge more than the mere existence of differences in health status between groups. We acknowledge that these differences are the result of systemic, historical injustices. Moreover, because we also acknowledge that they are unjust, we are compelled to act in order to confront them.

Similarly, socioeconomic status is not the same thing as class. Socioeconomic status measures whether an individual or family is higher or lower on some characteristic, often income level, educational level, or employment status;4 in contrast, class refers to a structure of economic and social power, in which politically powerful groups are able to influence the use of economic resources and aspects of social life that influence living and working conditions.5

That is, rather than thinking of socioeconomic status as simply an individual characteristic (e.g., “Mrs. Smith is white, 67 years old, married, retired, and of low SES”), the idea of class examines relationships among groups of people with varying socioeconomic statuses, as they relate to economic production. Some groups control the means of production (i.e., capital, land, and other resources) whereas other groups provide labor. Thinking about these relationships means thinking about power: Which groups control resources? Which groups control working conditions? Which groups provide labor? Which groups control labor? Power, in turn, affects health and health outcomes.

While many public health professionals are used to thinking about the relationship between socioeconomic status and health, class is a less common consideration. NACCHO’s Roots of Health Inequity Web-based learning collaborative offers public health a starting point for conversations about class, racism, and health. The course provides interactive modules and discussion points for developing common definitions and understanding of the root causes of health inequity. Preview an animation describing how class works at

To take the Roots of Health Inequity course, visit and create a free account. For questions, contact Tiffany Huang at


  1. Winkleby, M.A., Jatulis, D. E., Frank, E., & Fortmann, S. P. (1992). Socioeconomic status and health: how education, income, and occupation contribute to risk factors for cardiovascular disease. American Journal of Public Health, 82, 6: 816–820.
  2. Meyer, P. A., Yoon, P. W., & Kaufmann, R. B. (2013). CDC Health Disparities and Inequalities Report – United States, 2013. Morbidity and Mortality Weekly Report [supplement], 62, 3:3–5. Retrieved July 13, 2015, from
  3. Whitehead, M. M. (1992). The concepts and principles of equity and health. International Journal of Health Services, 22, 3: 429–445.
  4. Centers for Disease Control and Prevention. (2015). Factors That Contribute to Health Disparities in Cancer webpage. Retrieved July 13, 2015, from
  5. National Association of County and City Health Officials. (2014). Exploring the Roots of Health Inequity: Essays for Reflection, pp. 38–50. Washington, DC: NACCHO.

CDC’s Morbidity & Mortality Weekly Report Seeks Local Health Department Articles

By LaMar Hasbrouck, MD, MPH, NACCHO Executive Director

Morbidity & Mortality Weekly Report (MMWR), published by the Centers for Disease Control and Prevention (CDC), is seeking article submissions from local health departments, Editor-in-Chief Dr. Sonja Rasmussen told me in a recent meeting at NACCHO.

The weekly publicationproduced in hard copy and available online at itself as CDC’s “primary vehicle for scientific publication of timely, reliable, authoritative, accurate, objective, and useful public health information and recommendations.” It describes its readership as predominantly consisting of “physicians, nurses, public health practitioners, epidemiologists and other scientists, researchers, educators, and laboratorians.” Continue reading

NACCHO Annual 2015: Charting a Path to the Future for Local Health Departments

_N9F9266-editMore than 1,300 local health department leaders and public health partners attended the 2015 NACCHO Annual Conference, July 7–9, in Kansas City, MO. Drawing a record number of attendees, the conference provided participants with access to public health thought leaders, innovative strategies and evidence-based practices, and unmatched opportunities for networking with peers.

The theme of the conference was “Envisioning the Future: Creating Our Path” and focused on the critical role of local health departments in the wake of healthcare reform. Several additional themes emerged during the conference, including promoting linkages to care, implementing continuous quality improvement, leveraging partnerships and collaborations, and maximizing the use of new technology. Sessions also focused on a variety of topic areas such as maternal and child health, tobacco, violence and injury prevention, emergency preparedness, chronic disease, and informatics. Continue reading

Supreme Court Ruling on Affordable Care Act Will Benefit Millions

lamar-hasbrouck-headshot-2015By LaMar Hasbrouck, MD, MPH, NACCHO Executive Director

The recent U.S. Supreme Court decision allowing federal subsidies to continue for people buying health insurance on federal exchanges under the Affordable Care Act (ACA) is a historic one that will enable millions of Americans to live longer, healthier and more productive lives.

The National Association of County and City Health Officials (NACCHO) supports implementation of the ACA because of the strong commitment of our members to protecting and improving the health and safety of the American people. The ACA puts the highest priority on promoting good health and preventing people from getting sick in the first place. Continue reading

NACCHO Annual 2015 Preview: Wellness Coalition Partners with Pediatric Care Providers to Increase Healthy Lifestyle Behaviors among Children

By Lindsay Tiffany, Communications Specialist, NACCHO

The following post is part of a series of interviews with local health department (LHD) staff who will present at the 2015 NACCHO Annual conference. This post offers a preview of the session “Pediatrician Perception of the LiveWell Greenville “At the Doctor” Toolkit in Improving Patient Communication Regarding Healthy Lifestyle Behaviors,” which will explore a successful collaboration between a healthy living coalition and pediatric care providers aimed at lowering rates of overweight and obesity in children. NACCHO Voice spoke with speakers Sally Wills, MPH, Executive Director, LiveWell Greenville; Melissa Fair, MPH, Evaluation Coordinator, LiveWell Greenville; Alicia Powers, PhD, Associate Professor of Health Sciences, Furman University, and Principal Investigator, Evaluation Director, LiveWell Greenville; and Rhonda Felder, PhD, MPT, Program Evaluator, LiveWell Greenville.

  • Thanks so much for speaking with me. To start, please describe both LiveWell Greenville and the At the Doctor Toolkit.

Sally Wills: LiveWell Greenville is a community coalition made up of over 150 partners in Greenville, SC. We focus on healthy eating and active living and try to impact those areas by creating policy, systems, and environmental (PSE) change in five settings: healthcare, schools, after-school programs, at the workplace, and faith communities. Our partners have been together since 2010 working toward PSE changes to help make the healthy choice the easy choice. Continue reading

Baltimore City Health Commissioner Dr. Leana S. Wen Discusses Her Department’s Response to Civil Unrest and Suggests Ways LHDs Can Tackle the Root Causes of Structural Racism and Oppression

Interview by Ian Goldstein, Web and New Media Specialist, NACCHO

On April 12, Freddie Gray, Jr., was arrested by the Baltimore City Police Department. He died on April 19, due to spinal cord injuries. In the aftermath of this death, citizens held a variety of demonstrations; while most were peaceful, the city saw several days of violence and unrest. NACCHO interviewed Baltimore City Health Department Commissioner Leana S. Wen, MD, MSc, FAAEM, about her department’s response to the unrest and about the ways local health departments (LHDs) can address the root causes of health inequity and structural racism. This interview was originally conducted as part of NACCHO’s podcast series. See the notes after the interview for two additional opportunities for engaging in this important conversation.

  • NACCHO: As someone who is charged with ensuring the health and safety of the community in Baltimore, could you share with us your perspective on the civil unrest and the role of the city health department during that time?

Dr. Wen: I have to say that in the beginning, I didn’t even know that there was a role for the health department in civil unrest. If you look at our emergency plan for civil unrest, the lead agencies are fire and police­­­­–IT even, because they do the 3-1-1 and 9-1-1 call systems. When I was initially asked to go to our emergency operations center as one of the lead agencies, I was surprised because I didn’t know what the role of the health department would be. This was on Monday, right after things began happening. The reason that we got involved in the first place was because one of our health clinics is right across from the CVS that burned down. It’s at North and Penn, right where the “purge” was supposed to happen. We heard about the purge happening and that it was a credible threat. We had to make a decision about whether to close the health center, which actually is a difficult decision because we want to make sure that we serve our community. We have to serve our patients who are most in need but we also have to keep our staff and our patients safe. We were activated immediately to go the emergency operations center (EOC). I was asked to be one of the lead agencies and then things began unfolding. Continue reading

Opioid-Associated Outbreaks: Preparation & Prevention Lessons from the Indiana HIV/HCV Outbreak among People Who Inject Drugs

19090293 needleBy Hilary N. McQuie, MA, Senior Program Analyst, HIV, STI, & Viral Hepatitis, NACCHO

This post originally ran on NACCHO’s Preparedness Brief blog. For more preparedness news and information, visit

The HIV and related hepatitis C (HCV) outbreak among people who inject drugs (PWID), particularly oxymorphone (OPANA®), in Scott County, IN, is an unprecedented situation. However, the conditions that led to the outbreak are not unique to Scott County, which highlights the potential for a similar situation to occur elsewhere. Since December 2014, 160 new HIV cases have been diagnosed among the Scott County town of Austin’s 4,200 residents, representing a “higher incidence of HIV than any country in sub-Saharan Africa,” as CDC Director Thomas Frieden has remarked.[1] HCV rates among those diagnosed with HIV are estimated to be over 90% and the projected cost of treatment for these twin outbreaks is currently $100 million.[1] Continue reading