Health Equity Matters
In this Newsletter
Summer 2013 ~ Vol.2, #3
Leandris C. Liburd, PhD, MPH, MA
Associate Director for Minority Health and Health Equity, CDC/ATSDR
Associate Director for Minority Health and Health Equity, CDC/ATSDR
This issue of Health Equity Matters is published during a time of historic achievements and celebrations. Our office – the Office of Minority Health and Health Equity is celebrating our 25th anniversary. You also may have read or heard about the 50th anniversary of the March on Washington and Dr. Martin Luther King’s “I have a dream” speech. Thousands of people will visit our nation’s capital August 24 -28, 2013 to commemorate that historic event. On October 1st, the new Health Insurance Marketplace will open for enrollment in every state in the U.S. Millions of Americans currently without health insurance will be able to apply. Read about these important events and more in this edition of Health Equity Matters.
We welcome your comments, and encourage you to continue to circulate the newsletter among your colleagues and friends.Leandris C. Liburd, PhD, MPH, MA
Associate Director for Minority Health and Health Equity, CDC/ATSDR
Office of Minority Health & Health Equity (OMHHE)
News You Can Use!
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25 Years a Champion for Health Equity
This year marks the 25th anniversary of the CDC Office of Minority Health and Health Equity (OMHHE), founded in 1988 as the Office of Minority Health. On August 8, 1988, CDC's Office of Minority Health was established by the CDC Director as a small coordination office in response to Secretary Heckler's 1985 landmark report on minority health.
OMHHE accelerates the work of CDC and our partners in improving health by eliminating health disparities; promoting social and environmental conditions conducive to health; and achieving health equity. During these 25 years, OMHHE has invested considerable effort toward advancing the science and practice of eliminating health disparities and improving minority health. OMHHE has in the past and continues to support internship opportunities for qualified undergraduate and graduate students interested in minority health. These internships provide meaningful research and practical experiences at CDC and in other public health settings around the country.
OMHHE’s anniversary celebration will involve a series of events from September through December, including the opening of a museum exhibit titled Health is a Human Right: Race and Place in America, at the David J. Sencer CDC Museum; the second annual State of Health Equity at CDC Forum; a panel discussion with Helene Gayle, MD, MPH, President and CEO of CARE USA and former Director of the National Center for HIV, STD and TB Prevention; and the release of the first “CDC Report on Strategies for Reducing Health Disparities” MMWR supplement.
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Achievements of Health Equity Offices at CDC Celebrated
OMHHE congratulates two CDC health equity offices that are also celebrating anniversaries: the National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention’s (NCHHSTP) Office of Health Equity, which is celebrating its 10th anniversary and the National Center for Emerging and Zoonotic Infectious Diseases’ (NCEZID) Office of Health Disparities, which is celebrating 20 years of service.
Established in 2003 as NCHHSTP’s Office of Health Disparities, and later as the Office of Health Equity (OHE) in 2009, OHE’s mission is to promote health equity and reduce health disparities among populations disproportionately affected by HIV, viral hepatitis, sexually transmitted diseases, tuberculosis, and other related conditions. NCHHSTP is celebrating their 10th anniversary by hosting a one day event on November 7th featuring speakers who will discuss the promotion of health equity in infectious diseases and perspectives on addressing the social determinants of health from the international, national, and local levels. Dr. Howard Koh, Assistant Secretary for Health for the Department of Health and Human Services and Professor Sir Michael Marmot, Director of the Institute of Health Equity and MRC Research Professor in Epidemiology at the University College London, will give the keynote presentations. NCHHSTP will also highlight the milestone release in September of the Public Health Reports special issue on Social Determinants of Health and Public Health Practice.
NCEZID’s Office of Health Disparities, formerly the Office of Minority and Women’s Heath, will be hosting a CDC seminar on migrant health to commemorate its 20th anniversary. The Office of Health Disparities, which has played a leading role in CDC/ATSDR work on neglected infections, has been a long-time supporter of the Ferguson Fellowship Program, the International Conference on Women and Infectious Diseases, the International Conference on Emerging Infectious Diseases Leaders Program, and the NCEZID Health Disparities Committee.
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Health is a Human Right: Race and Place in America exhibition
The David J. Sencer CDC Museum, in collaboration with OMHHE and through additional support from the California Endowment through the CDC Foundtation, will host an exhibit exploring historic issues around health disparities in the United States.
Health is a Human Right: Race and Place in America, on display from September 28, 2013 to January 17, 2014, will examine the evolution of minority health and health equity in the 20th and early 21st centuries.
Organized thematically around the social determinants of health, the exhibit includes historic photographs, documents, objects, and interactive displays that describe the many facets of communities that contribute – negatively and positively – to the health status of different populations. The influence of issues such as migration, discrimination, housing and education on health is described using historical events.
The Museum attracts 70,000 visitors a year, including CDC employees and their families, public health professionals from across the United States and the world, and members of the general public who are drawn to the work of CDC. Health is a Human Right: Race and Place in America will open on a Saturday, September 28th coinciding with Smithsonian magazine’s Museum Day Live.
This picture above, from the exhibit, depicts the Chinese language version of “Be Certain: Get Tested for Hepatitis B” bus shelter targeting New York City’s Asian community, 2012. Image courtesy of New York University-Center for Asian-American Health.
The picture with the exhibit title is an Emerson Elementary School class picture, ca. 1947, courtesy of the San Francisco Public Library.
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2013 State of Health Equity at CDC Forum
Building upon a successful 2012 event to examine CDC’s work to advance health equity, OMHHE will convene our second State of Health Equity at CDC Forum on October 29 in Atlanta.
The Forum represents an agency-wide effort to focus our broad health equity work into key areas for action - measuring health disparities; essential health equity program elements; organizational infrastructures that support health equity at CDC; and policies that support health equity.
This second in a series of Forum events, Assessing Health Equity: Moving from Models to Measures to Action, will take a closer look at key measurement issues and how they relate to health equity action. CDC staff from multiple disciplines will gather to discuss conceptual models that affect what and how we measure, and how what we measure can expand or constrain our capacity to act.
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Summer Interns Share Experience
One hundred and ninety two students with the CDC Undergraduate Public Health Scholars (CUPS) Program and 11 graduate and medical students with the Dr. James A. Ferguson Emerging Infectious Diseases Fellowship Program wrapped up their summer training program filled with a variety of learning and networking opportunities.
At the end of their projects, CUPS and Ferguson student presented their work to their mentors and other audiences at respective locations. Project IMHOTEP students presented their poster sessions at Morehouse College on August 1, 2013. The assigned projects ranged from the study of social determinants of health to public health topics, such as HIV, AIDS, TB and STD prevention programs and occupational safety and health focused on metrics and data analysis.
The Ferguson fellows presented their projects at both locations of placement, in Atlanta and Baltimore, on July 25-26, 2013. The projects included topics such as treatment outcomes for hepatitis C in federal prisons; development of an HPV (human papilloma virus) Fact Sheet for tribal policymakers and health directors, and experience with infectious outbreaks linked to compounding pharmacies in the United States.
More than 50 CDC mentors made this effort possible, and we thank the mentors for their time in making this a successful program. Some of them have been collaborating with the OMHHE for years, and continue their involvement because it is a mutually enriching experience.
The CUPS program, coordinated by the OMHHE, exposes undergraduate students interested in minority health to the field of public health research and practice by providing hands-on, project-oriented assignments. The Ferguson fellowship program administered by the Kennedy Krieger Institute (KKI), in collaboration with the National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), provides hands-on experience at KKI and CDC for graduate students of under-represented populations and those interested in addressing infectious diseases and health disparities in medical, dental, veterinary, pharmacy, and public health programs.
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Migrant Stream Forums
OMHHE supports enhanced CDC awareness of migrant health initiatives and involvement in regional Migrant Stream Health Forum Conferences held in the following regions: Eastern, Midwest, and West Coast. This support takes place through our partnership agreement with the Human Resources and Services Administration’s (HRSA) Office of Special Populations.
As a result of the enhanced awareness, OMHHE works with different centers at CDC to fund these forums, and resources are used to increase the number of scholarships available to support front line staff being able to attend these training events.
For more information on the 2013 conferences, see the below section Announcements.
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CDC/ATSDR Tribal Support Updates
CDC/ATSDR Tribal Support has announced the availability of funds to strengthen and improve the infrastructure and performance of tribal public health agencies and tribal health systems through capacity building and quality improvement.
Initiating tribal-specific programs will allow awardees to accelerate and expand the reach and health impact of tribal public health infrastructure. The Tribal Support Unit will fund
- federally recognized tribes to develop disease interventions, build public health infrastructure, and cultivate community partnerships
- a project evaluator to conduct a program evaluation project
The summer 2013 CDC/ATSDR Tribal Advisory Committee Meeting and 10th Biannual Tribal Consultation Session have been postponed. CDC anticipates rescheduling for fall 2013. The new dates will be posted on the Tribal Support website.
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New fact sheets available: state-specific information on Sickle Cell Disease – Findings from RuSH
Good data can lead to a better understanding of the health gaps that exist for people with blood disorders such as sickle cell disease.
Visit the free materials page of CDC’s Sickle Cell Disease (SCD) website to get information on sickle cell disease collected from 5 of the 7 states funded to participate in the Registry and Surveillance System for Hemoglobinopathies (RuSH) pilot project.
Currently state-specific fact sheets featuring data on sickle cell disease provided by the pilot project are available for both health care providers and the general public for five states:
- California
- Georgia
- Michigan
- North Carolina
- New York
For more information on CDC’s RuSH project, visit CDC's Hemoglobinopathies Monitoring website.
Commentary
The Affordable Care Act, Health Disparities, and Clinical Preventive Services
Frederic E. Shaw, MD, JD
Senior Advisor for Health Reform, OHSC, OADP, CDC
Senior Advisor for Health Reform, OHSC, OADP, CDC
Senior Advisor for Health Reform,
Office of Health System Collaboration, Office of the Associate Director for Policy, CDC
One of the expected effects of the Affordable Care Act will be to reduce differences in uninsurance rates by race and ethnicity in the United States. By 2019, an estimated 25 million nonelderly Americans will acquire new health coverage, according to the Congressional Budget Office. 1 This will benefit blacks and Hispanics, who have historically had lower rates of insurance coverage than whites. 2 For public health, a key effect of this is likely to be a reduction in racial and ethnic disparities in access to clinical preventive services.
The uptake of effective clinical preventive services, such as cholesterol checks and cancer screenings, is important to public health because the use of these services can reduce preventable disease and deaths. But tens of millions of people in the United States have not been using these services. For example, recent analyses show that less than half of patients with diagnosed cardiovascular disease were prescribed aspirin or other antiplatelet agents, and less than half of people with hypertension had it under control. 3 A greater uptake of preventive services could save tens of thousands of lives every year. 4
Racial and ethnic minorities have lagged behind whites in the use of some recommended clinical preventive services and treatments. For example, CDC reported in 2012 that blacks or Hispanics, or both, had lower rates than non-Hispanic whites for treatment for high blood pressure; poorer glycemic control among adults with diabetes; and lower rates of screening for tobacco use during physician visits; among others. 3
One way to reduce racial and ethnic health disparities is to increase the use of preventive services by blacks, Hispanics, and other racial/ethnic groups. The Affordable Care Act will help do this by expanding the availability of health insurance through the new Health Insurance Marketplace and the expansion of Medicaid in some states. Expanding insurance facilitates higher levels of use of preventive services. For example, after Massachusetts enacted comprehensive health reform in 2006, residents experienced gains in use of preventive services. 5
In Oregon, after residents acquired Medicaid coverage, they used certain preventive services at a higher rate than residents who did not acquire coverage. 6 The Affordable Care Act makes preventive services easier to access. For example, the law requires most private health plans to cover, at no cost to the patient, a set of recommended clinical preventive services for children, adolescents, women, or all adults. In early 2013, the US Department of Health and Human Services estimated that, because of the Affordable Care Act, 71 million additional Americans had access to preventive services without cost-sharing. 7 Millions more will receive new access to preventive services through the expansions of Medicaid. 8
CDC has a long history of promoting and monitoring the use of clinical preventive services.4 Along with the Centers for Medicare & Medicaid Services, CDC helps manage many programs aimed at increasing uptake and preventing disease. One example is the Million Hearts® initiative, which seeks to prevent 1 million heart attacks and strokes over the next five years through improvements in clinical preventive services and community prevention. 9 Through this and many other effects, the Affordable Care Act can be a force to eliminate health disparities.
People who need health insurance can visit the new Health Insurance Marketplace, a key part of the health care law that will be open for business on October 1st, 2013. At the Marketplace people can buy insurance from private health plans that cover a comprehensive set of benefits, including doctor visits, hospital stays, preventive care, and prescriptions. The best source of information about the Marketplace is healthcare.gov
.References
1. Congressional Budget Office. Table 1. CBO's May 2013 estimate of the effects of the Affordable Care Act on health insurance coverage. May 2013.2. Clemans-Cope L, et al. Coverage expansions will reduce differences in uninsurance rates by race and ethnicity. Health Affairs 2012;31:920-930. Available at http://content.healthaffairs.org/content/31/5/920.full.pdf+html.
3. CDC. Use of selected clinical preventive services among adults—United States, 2007-2010. MMWR 2012;61 (Suppl; June 15, 2012).
4. Frieden TR. Foreword. In: CDC. Use of selected clinical preventive services among adults—United States, 2007-2010. MMWR 2012;61 (Suppl; June 15, 2012):1-2.
5. The Henry J. Kaiser Family Foundation. Focus on health reform: Massachusetts health care reform: Six years later. May 2012. Available at:
http://kaiserfamilyfoundation.files.wordpress.com/2013/01/8311.pdf.6. Baicker K, et al. The Oregon experiment—Effects of Medicaid on clinical outcomes. New Engl J Med 2013;368:1713-1722.
7. Skopec L, Sommers BD. Seventy-one million additional Americans are receiving preventive services coverage without cost-sharing under the Affordable care Act. ASPE Issue Brief (US Department of Health and Human Services), March 2013.
8. Cassidy A. Health policy brief: Preventive services without cost sharing. Health Affairs, December 28, 2010.
9.
US Department of Health and Human Services. Million Hearts website.Feature
March on Washington and Collaboration with the King Center
The commemoration of the 50th anniversary of the March on Washington and Dr. Martin Luther King, Jr.’s “I Have a Dream” speech kicked off in Atlanta on August 17. The actual March is being recreated in Washington, D.C. on August 24 with a culminating ecumenical service on August 28th – the date of the march 50 years ago. Presidents Obama, Clinton, and Carter, among other dignitaries, are expected to attend. There will be many opportunities for CDC to get involved and promote public health and prevention messages during the celebration. Additional information on this event can be found on-line at MLKDREAM50.com.CDC and The King Center began a relationship in 2005 as an informal partnership with The King Center participating in the annual Black History Month Special Emphasis Program coordinated by the CDC Office of Diversity Management and Equal Employment Opportunity (ODMEEO). In January of 2008, CDC and The King Center entered into a formal partnership agreement to address areas of mutual public health interest, including youth violence prevention, health equity and health disparities, environmental justice and community health, birth defects, and chronic disease prevention. Beginning in September 2011, CDC assigned Carlton Duncan, as Special Project Advisor, to The King Center to assist in developing and implementing public health initiatives consistent with the goals of the partnership.
Over the past 5 years, CDC and The King Center have collaborated on a variety of public health events including community health programs and town hall discussions with The King Center and others interested in minority health. In 2008, then CDC Director Dr. Julie Gerberding was invited to provide remarks at the annual ecumenical service celebrating the life and legacy of Dr. Martin Luther King Jr., held at Atlanta’s Ebenezer Baptist Church. This was an unprecedented opportunity to raise the visibility of public health among those attending the service and thousands of others watching by television.
More recent accomplishments include the development of a strong working relationship between The King Center and CDC’s Office of Minority Health and Health Equity (OMHHE). During the 2013 King Holiday celebration, Dr. Bernice King, CEO of The King Center, was the keynote speaker for the annual King Lecture at Brown University. With scientific input from OMHHE, Dr. King focused many of her remarks on eliminating health disparities and pursuing health equity consistent with the work and vision of her father.
Additionally, in the spring of 2013, The King Center worked with CDC and Brown and Harvard Universities to create and implement the inaugural Millennial Health Leaders Summit held at CDC and The King Center. This event hosted more than 50 graduate level public health and public policy students, along with medical students from across the country for two days of intensive discussions about contemporary public health issues and challenges that await the next generation of health professionals. On day two of the summit, high school students from the Metropolitan Atlanta area were paired with the graduate and medical students to explore innovative responses to some of the health disparities discussed the day before. Bringing together students at the graduate school level with high school students was effective in educating the high school students about public health and other health careers and creating a space to discuss solutions from the standpoint of the millennial generation.Science Speaks
Selected publications from OMHHE authors:
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Ramal Moonesinghe, PhD, (OMHHE Senior Mathematical Statistician)
Man-Huei Chang, MPH, Heba Athar, MD, Paula W. Yoon, ScD, Epidemiology and Analysis Program Office; Michael T. Molla, PhD, National Center for Health Statistics; Benedict I. Truman, MD, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention; Ramal Moonesinghe, PhD, Office of Minority Health and Health Equity; CDC.
State-Specific Healthy Life Expectancy at Age 65 Years — United States, 2007–2009. Morbidity and Mortality Weekly Reports (MMWR), July 19, 2013, Volume 62, No. 28; 561-566.
Conversations in Equity
Our blog Conversations in Equity shares and exchanges perspectives and progress in the science and practice of health equity.
See the latest post and add your comments today!
Health Equity Champion
Dr. Scout
Director, Network for LGBT Health Equity
Director, Network for LGBT Health Equity
.” Commissioned by the National Institutes of Health, the goal of the report was to “assess current knowledge of the health status of lesbian, gay, bisexual, and transgender populations; to identify research gaps and opportunities; and to outline a research agenda to help NIH focus its research in this area.” ( Report Brief, March 31, 2011).The report goes on to say that “researchers face a number of challenges in understanding the health needs of LGBT populations, including a lack of data.” This research is also needed to inform public health actions to reduce health disparities in the lesbian, gay, bisexual, and transgender (LGBT) community. Building understanding of the unique health needs and experiences of the LGBT population characterizes the career and personal passion of Dr. Scout, OMHHE’s health equity champion for the Summer 2013 issue of Health Equity Matters. Nominated by CDC’s Sexual and Gender Minorities Workgroup, we commend Dr. Scout for his tireless leadership in working to achieve health equity for all LGBT people.
--Leandris C. Liburd
Dr. Scout is the Director of the Network for LGBT Health Equity
and an Adjunct Assistant Clinical Professor at Boston University School of Public Health. As Director of the Network, he leads a team that provides a variety of technical assistance for state and federal health policy makers and works to link local LGBT health advocates to each other ( follow their activities on their blog, lgbthealthequity.wordpress.com). “People may not understand lesbian, gay, bisexual and trans issues completely yet, or may have never even met a trans person such as myself – but there’s an army of public health professionals out there all working to really make the world better for everyone,” said Dr. Scout, after accepting OMHHE’s nomination.Dr. Scout has been doing LGBT health policy advocacy for over 10 years. It was a difficult job at the beginning. “In one of my first jobs, they fired me and every other LGBT person on the same day. In the next, the senior boss would joke about exterminating all LGBT people in front of me. I learned early that mainstream jobs weren’t open to me. Little did I know how that early discrimination would ultimately pave the way for such a rewarding career.”
He was the first recipient of the Community Service Award from the National Coalition for LGBT Health. He is a frequent public speaker and cultural competency trainer specialized in tobacco, wellness, transgender health, social determinants, health disparities, and surveillance. Dr. Scout is an openly transgender father of three teens. “What do I really want to see for LGBT health next? –he was asked. “That’s simple – that LGBT measures are routinely included in surveillance. When we’re not counted, all the health problems that stem from discrimination like what I faced are invisible.”
Announcements
- Society for Public Health Education (SOPHE) 65th Annual Meeting
March 19–21, 2014
Baltimore, Maryland
Deadline for Abstracts submission: August 27, 2013 at 11:59 PM ET
- 100 Congregations for Million Hearts®
Email for details on an upcoming Webinar August 28, 2013, 4-5pm EDT Million Hearts® Team at millionhearts@cms.hhs.gov - Call for Papers for a Special Workshop on Public Health's Wicked Problems:
Can InfoVis Save Lives?
Deadline for Submissions: September 6, 2013
Email submissions to publichealthinfoviz@gmail.com Special Workshop
October 13–18, 2013
Atlanta, Georgia
- United States Conference on AIDS
September 8–11, 2013
New Orleans, Louisiana
Original research, case studies/practice reports, systematic reviews, evaluation studies, methodology innovations, or commentary on the following topics of specific interest invited, while welcoming work on all aspects of public health and information visualization.
- 2013 Association of State and Territorial Health Officials (ASTHO) Annual Meeting
September 19, 2013
Orlando, Florida
- Tri-Regional Faith & Community Health Summit
October 3-5, 2013, Atlanta, Georgia
October 24-26, 2013, Kansas City, Missouri
- Border Binational Health Week
October 7–11, 2013
US Mexico Border Health Commission
- Binational Health Week
October 12–21, 2013
- 26th Annual East Coast Migrant Stream Forum October 17–19, 2013
San Juan, Puerto Rico
- NIH Request for Information: Inviting Comments and Suggestions on the Health and Health Research Needs, Specific Health Issues and Concerns for Lesbian, Gay, Bisexual, Transgender, and Intersex (LGBTI) Populations
Deadline: October 28, 2013
- 2013 Undergraduate Education for Public Health Summit
Faculty Development: Responding to Trends in Undergraduate Public Health Education
November 2, 2013
Boston, Massachusetts
- 23rd Annual Midwest Stream Farmworker Health Forum November 14–16, 2013
South Padre Island, Texas
For more announcements, see the Minority Health Announcements Page
Statistics Highlight
State-Specific Healthy Life Expectancy at Age 65 Years — United States, 2007–2009
Healthy life expectancy (HLE) at age 65 years was greater for whites than for blacks in most states except in Nevada and New Mexico. The largest difference in HLE between whites and blacks was 7.8 years in Iowa. (MMWR).
Data Source: CDC, MMWR Weekly, July 19, 2013 / 62(28);561-566.
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Progress on Childhood Obesity
- About 1 in 8 preschoolers is obese in the US.
- About 1 in 5 (19%) black children and 1 in 6 (16%) Hispanic children between the ages of 2 and 5 are obese.
- Obesity rates among low-income preschoolers have leveled off from 2003—2008 and now appear to be falling.
For more information, see the CDC Vital Signs web page: Progress on Childhood Obesity
For additional information, see: Childhood Overweight and Obesity
Quick Links
- Addressing Obesity Disparities Health Equity Resource Web Guide
Division of Nutrition, Physical Activity & Obesity (DNPAO)
National Center for Chronic Disease Prevention & Health Promotion (NCCDPHP)
- CDC/DNPAO Health Equity Toolkit
Resource for State Practitioners Addressing Obesity Disparities
NSPAI, NCCDPHP
- CDC’s Disability & Health Data System (DHDS) National Center on Birth Defects & Developmental Dispabilities (NCBDDD)
- Hemophilia Videos NCBDDD
- CDC Winnable Battles: Targets Trend graphs are updated with the latest data points
- CDC Stacks Free Digital Library
- Primer on Cultural Competency & Health Literacy
Maryland Department of Health & Mental Hygiene
- Cultural Competency & LGBT Health Disparities: Identifying Barriers & Tailoring Strategies
Research to Reality cyber-seminar explored several health disparities this population faces across the cancer continuum
National Cancer Institute (NCI)
- Government's Role in Protecting Health & Safety
Frieden TR. N Engl J Med. 2013, May 16; 368(20):1857-9.
- 2012 National Healthcare Quality Report (NHQR) & National Healthcare Disparities Report (NHDR)
Agency for Healthcare Research & Quality (AHRQ) - New Census Bureau Interactive Map Shows Languages Spoken in America
United States Census Bureau - Helping Consumers Understand & Use Health Insurance in 2014
Institute Of Medicine (IOM)
- Roundtable on Population Health Improvement: June 2013 Workshop
Population Health & the Affordable Care Act (ACA)
IOM
- Roots of Health Inequity
Web-based course & learning collaborative which discusses social justice in public health practice. Online Learning Collaborative
National Association of County & City Health Officials (NACCHO)
Trivia!
In what Year was the first measles vaccine liscensed?
1954 1963 1971
You can get Lyme Disease anywhere in the United States. True or False?
True False
Why was September 15th chosen as the starting point for the Hispanic Heritage Month?
It is the anniversary of independence of 5 Latin American countries:
Costa Rica, El Salvador, Guatemala, Honduras & Nicaragua
Mexico & Chile celebrate their independence days on Sept. 16 & Sept. 18, respectively
All of the Above
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