Health Status Disparities in the United States
**Please note** Presentations and conference papers are posted below.
"Americans should be forgiven for thinking that our health problems are pretty much all the result of medical care that's too expensive, too riddled with errors, and not available to those who can't pay," said Dr. M. Gregg Bloche, professor and co-director at the Georgetown-Johns Hopkins Joint Program in Law and Public Health, a nonresident senior fellow at the Brookings Institution, and an adjunct professor at the Johns Hopkins Bloomberg School of Public Health. In his opening address to this half-day conference on U.S. health status disparities, Bloche continued by stating that "health status has much more to do with how we live—with the social and economic conditions that shape our lives—than with the medical care we receive or with what public health authorities do to control contagious disease." He noted that Americans view health care—which plays a surprisingly small role in determining our health—as a matter of right, while they are generally "accepting of enormous differences in wealth and status." Health disparities, he noted, have "potentially explosive political implications" and yet, are "astonishingly absent from our discussions of health policy in our political campaigns" due to this American disconnect between health and wealth.
Providing an overview of socioeconomic inequalities in health status, George A. Kaplan, director of the Center for Social Epidemiology and Population Health and professor of public health at the University of Michigan, translated knowledge about socioeconomics and health disparities into possible health policy levers. "The relationship between socioeconomic position and health," he said, "is a widespread relationship that we see across periods of time, across places in the world, and across groups… and it is almost invariably in the same direction," as socioeconomic position increases, health improves. Kaplan stressed that although there are many different ways to examine health disparities—through the lenses of race and ethnicity, socioeconomics, gender, geography, sexual orientation—socioeconomic inequities should be central to the health policy conversation, due to the ability to use policy levers to alleviate some of the socioeconomic inequity. He outlined upstream policies, such as education and training; reducing child poverty; reducing marginalization by race, ethnicity, and nativity; and increasing access to quality health care to help reduce inequality.
Adding to this conversation, Thomas C. Ricketts, deputy director of the Cecil G. Sheps Center for Health Services Research and a professor at the University of North Carolina in Chapel Hill said, "It isn't just poverty, it's where you are when you are poor." He admitted to being a "little provocative" as he used visual interpretations of health status data to demonstrate what he believes is a more significant distinction in U.S. health status: regional disparities. Ricketts began by discussing the data on rural and urban health inequalities and used it to argue that much of the difference between metropolitan and non-metropolitan counties, a common geographic distinction used by researchers, is explained by factoring in age, gender, and ethnicity. With this in mind, he used maps to highlight the differences in larger geographical regions. Ricketts emphasized his point by using stroke mortality rates to demonstrate higher health inequality rate ratios among regional differences than among racial differences. He argued that place-specific policies that address these regional differences may be a more appropriate mechanism for policy interventions than any other being used.
Switching from a socioeconomic- and geographic-centered discussion to one of race, David Williams, professor of African and African American Studies, Public Health, and Sociology at Harvard University, presented a sweeping overview of the influence of race on health status. Williams argued that "race does matter" when looking at health disparities. The income disparities between races, exposure to social and economic adversity over the life course and experiences of discrimination and institutional racism can affect the health of minority groups in multiple ways, he noted. Williams started by emphasizing that although some Americans believe racism is a thing of the past, racial disparities do exist and have been persistent over time, and supported this assertion with research charting disparities between 1950 and 1998. He argued that bias and calculation methods in studies of health status inequalities have generally hidden racial disparities. "Race and socioeconomic status reflect two related but not interchangeable systems of inequality," he said. He underscored this point by showing that even the highest socioeconomic group of African-American women have equivalent or higher rates of infant mortality, low birth-weight, hypertension and obesity than the lowest socioeconomic group of white women. Williams emphasized the use of targeted interventions to address racial inequalities and urged redefining health policy to include all sectors of society that have health consequences.
Continuing the discussion of racial disparities, Dr. Paula Braveman, director of the Center on Social Disparities in Health and a professor at the University of California in San Francisco, focused her presentation on the likely causes of black-white differences in infant health and birth outcomes. She noted that babies born to African-American mothers are twice as likely to be born premature, have low birth weight or die in infancy. However, the widely-accepted causes of being born too small and too early—tobacco, excessive alcohol, poor nutrition, drugs, maternal height and chronic disease—do not account for racial disparities in birth outcomes. In an attempt to explain them, Dr. Braveman went beyond these factors and looked at the biologic plausibility of a "suspected" cause of poor birth outcomes: the cumulative lifetime affects of psychological stress. Through studies of major psychosocial stressors experienced during pregnancy by black and white women, the Center on Social Health Disparities has found significantly higher levels of psychosocial stress among black women in California. Dr. Braveman's policy suggestions included acting on the best available knowledge to reduce adverse risk factors before and during pregnancy, funding more research on reducing stress and increasing social support, and funding bio-medical research into the suspected causes of low birth weight—environmental toxins, infections, and gene-environment interaction. Reiterating Dr. William's sentiments, she added a word of caution about controlling for socioeconomic status in research data analysis, saying that factors such as black/white differences in wealth, quality and rewards of education, neighborhood conditions and childhood socioeconomic conditions among similar income levels make it impossible to control for all relevant socioeconomic factors.
In the final presentation, Mary Lou de Leon Siantz, assistant dean of Diversity and Cultural Affairs at the University of Pennsylvania School of Nursing, presented an overview of Hispanic health disparities, with a focus on children. She highlighted the recent and predicted future increases in the Hispanic population, and higher rates among this population of being uninsured, uneducated, and/or impoverished. She highlighted the high risk for developmental and behavioral disorders as well as obesity, and pointed out immigration, acculturization, and language as being special issues affecting the health status of Hispanics. As with many of the disparities discussed in this conference, more research into their origins is needed. Siantz stressed the need to diversify medical and nursing schools in order to increase the number of culturally sensitive health professionals available to these populations while at the same time incorporating sensitivity to culture and inequalities in health curricula. She also suggested more cooperation between the United States and Mexico so as better to manage migration and to help mitigate poor health outcomes through bi-national health insurance and improving language skills in both countries.
By Julie Doherty
- Dr. M. Gregg Bloche, Professor of Law and Co-Director, Georgetown-Johns Hopkins Joint Program in Law and Public Health, Georgetown University; Nonresident Senior Fellow, The Brookings Institution; and Adjunct Professor, Bloomberg School of Public Health, Johns Hopkins University
- Panel 1: Understanding Health Disparities: Income, Culture, and Geography
- George A. Kaplan, Director, Center for Social Epidemiology and Population Health; and Professor of Public Health, University of Michigan
- Thomas C. Ricketts, Deputy Director, Cecil G. Sheps Center for Health Services Research; and Professor of Health Policy and Administration and Social Medicine, The University of North Carolina, Chapel Hill
- Panel 2: Understanding Health Disparities: Race and Ethnicity
- David Williams, Professor of African and African American Studies, of Public Health, and of Sociology, Harvard University
- Dr. Paula Braveman, Director, Center on Social Disparities in Health; and Professor of Family and Community Medicine, University of California, San Francisco
- Mary Lou de Leon Siantz, Assistant Dean of Diversity and Cultural Affairs, University of Pennsylvania School of Nursing
- <b>Dr. M. Gregg Bloche - <i>edited transcript</i> -</b> Opening Presentation
- <b>George Kaplan-</b> <b><i>edited transcript</i></b> - Socioeconomic Inequalities in Health: What They Look Like and What Can be Done About Them
- <b>Thomas C. Ricketts</b> - <b><i>original submission</i></b> - <b>Geography and Health Disparity</b>
- <b>Dr. Paula Braveman</b> - <b><i>edited transcript</i></b> - The Unsolved Mystery of Racial Disparities in Infant Health: Do We Know Enough to Act?
- <b>George Kaplan-</b> Socioeconomic Inequalities in Health: What They Look Like and What Can be Done About Them
- <b>Thomas C. Ricketts-</b> Disparity and Geography
- <b>David Williams-</b> Racial Inequalities in Health: The Social Determinants of Disease
- <b>Dr. Paula Braveman-</b> The Unsolved Mystery of Racial Disparities in Infant Health: Do We Know Enough to Act?
- <b>Mary Lou de Leon Siantz-</b> Understanding Health Disparities: The Hispanic Experience