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Origins Of Disparities

PERSPECTIVE

Policy Challenges In Addressing Racial Disparities And Improving Population Health

Abstract

 
Socioeconomic status fundamentally affects most health and disease outcomes, but black Americans are doubly disadvantaged by low status, discrimination, and residential segregation. Improving health and removing disparities are essential goals, but some efforts that improve the health of blacks in important ways also increase black-white disparity ratios. People with more information, influence, resources, and social networks may be better able to take advantage of new technologies and scientific developments, initially increasing disparities. Better health and reduced mortality should be the key policy criteria, but these criteria should be linked with consideration of careful targeting to level the playing field and close disparities.

Most Americans believe in equal opportunities and in the idea that everyone should have an equal start to be healthy and to acquire the education and developmental resources needed for successful living. Evidence of racial disparities in access to health care resources and educational opportunity are disturbing, and national health priorities seek to reduce and ultimately eliminate these disparities. The sources of many racial disparities are deeply embedded in our history of slavery and segregation, the hierarchical structure of our society, and the social ideologies that inform our thinking and social policies. Although people can agree that disparities are undesirable and should be eliminated, the political will to take necessary action often conflicts with other goals, economic interests, and ideologies about personal agency and responsibility. Much progress has been made over the decades in attaining greater equality and fairness in social intercourse between black and white Americans, but the gap between aspirations and reality remains very large and resistant to change, as attested to by our persistent inability to make health insurance universal or to ensure that all children receive child care and schooling of good quality.

It is common in the literature to view the sources of inequality as inherent in our capitalist economy and the resulting hierarchies of resources, knowledge, and interests. Hierarchy, of course, exists everywhere, but growing inequalities of income are a cause of much concern. Many proposals call for social policies that would redistribute income to the most disadvantaged through the tax structure and an improved safety net or massive interventions to rebuild infrastructures in ways that improve the lives and opportunities of our poorest citizens. But it is also evident that these proposals are contested and difficult to implement. Many aspire for large social changes in priorities and commitments, but we also have to think carefully about promoting the health and welfare of our most disadvantaged citizens within the economic and political realities of the present.

Numbers can be deceptive.

Top Numbers can be deceptive. New technology can lead... Initiatives aimed at groups... A focus on health... Schooling is an important... NOTES

 
Racial disparities are undesirable, and every effort must be made to reduce them. However, it is important to think carefully about interventions and not assume that initiatives directed at reducing such disparities bring the largest gains in advancing the health of black citizens.³ Increasingly, much of the policy discussion is focused on whether disparities are increasing or decreasing and less so on which interventions can bring the largest health gains for all. Williams and Jackson note, for example, the increase in the infant mortality disparity ratio between 1980 and 1991. Indeed, the black-white infant mortality ratio did increase during this period from 2.0 in 1980 to 2.4 in 1991. By 1999 and 2000 the ratio increased to 2.5.⁴ Ratios are often misleading, though, in that small changes in small numbers can produce large ratios. Differences between groups that have two and one deaths per 1,000 live births result in a ratio of 2.0; rates of 500 versus 250 deaths per 1,000 yield the same ratio.

There is another way of looking at infant mortality rates, and other disease and mortality rates as well, that are more focused on improving overall population health. Between 1980 and 2000 the white infant mortality rate fell from 10.9 deaths per 1,000 live births to 5.7 deaths, a reduction of 5.2 deaths per 1,000. During the same period, black deaths per 1,000 live births fell from 22.2 to 14.0, a decrease of 8.2 deaths per 1,000. But the black-white infant mortality ratio increased 25 percent.⁵ Simply focusing on the ratio misses the important advances made in black infant health with improvements in technology and care and may confuse us as to what is and is not worth undertaking.

Similar observations come from research on health services. Katherine Baicker and colleagues studied racial disparities using Medicare claims data for 1998–2001.⁶ They found a clear distinction between the best quality of care for black patients and the size of racial disparities. For example, only 53 percent of blacks with diabetes in the Bronx, which had only a 4 percent disparity between blacks and whites, had hemoglobin (HbA1c) testing, but in Washington, D.C., which had a 14 percent disparity, 59 percent of blacks with diabetes had appropriate testing. Baicker and colleagues note that addressing utilization may help more blacks than focusing on disparities.

New technology can lead to greater inequality.

Top Numbers can be deceptive. New technology can lead... Initiatives aimed at groups... A focus on health... Schooling is an important... NOTES

 
Underlying these statistical observations is a phenomenon that Bruce Link and Jo Phelan conceptualize as "fundamental cause."⁷ When new opportunities for improving health arise involving new knowledge or new technologies and requiring an individual response, those with better resources, knowledge, influence, and social networks are those who benefit most quickly. Thus, most new opportunities to promote population health inevitably favor the most advantaged. Everyone ultimately benefits from knowledge and technological innovations, but at least for some in increased rather than reduced disparities. A crucial question is how cost-effective alternative interventions are in promoting overall population health, involving the health of both disadvantaged and advantaged people.

Initiatives aimed at groups are the most effective.

Top Numbers can be deceptive. New technology can lead... Initiatives aimed at groups... A focus on health... Schooling is an important... NOTES

 
To the extent that health initiatives are not tied to individual action, all social groups are more likely to benefit in comparable ways. Thus, fluoridation of water supply, fortified foods, or environmental controls that reduce toxic pollution, such as the elimination of lead from gasoline and paints, are less likely to result in disparities than initiatives encouraging voluntary efforts such as educational campaigns to promote careful tooth brushing, preventive fluoride treatment, increased exercise, or improved nutrition. The range of possible initiatives affecting entire populations and their health are extensive, including ensuring drug safety, proper regulation of the food supply, vehicle requirements and highway safety infrastructures, recreational space for safe exercise, adequate and safe transportation, environments free of cigarette smoke and other toxic pollutants, and many more. Many efforts aimed at populations rather than individuals provide opportunities to promote health in cost-effective ways while decreasing the likelihood of disparities resulting from advantages of status.

A focus on health interconnections rather than single diseases is most useful.

Top Numbers can be deceptive. New technology can lead... Initiatives aimed at groups... A focus on health... Schooling is an important... NOTES

 
In addressing population health, it is useful to think broadly about health interconnections and not simply about diseases one at a time. Although much about treatment is disease-specific, influences such as income, education, physical environment, neighborhood, nutrition, stress, and more affect a range of diseases across etiologies and bodily systems.

Williams and Jackson note the relatively low rate of suicide among blacks, which they view as something of a success story, and the high homicide rate.⁸ Such patterns may not be independent. In his classic study of suicide in 1897, Emile Durkheim observed that social conditions involving a breakdown in norms or religious encouragement of introspective exploration increased rates of suicide.⁹ Studies also commonly noted that groups that had high rates of suicide had low homicide rates. Such has been the case with black Americans, who have consistently had high rates of death from homicide, often involving acquaintances and intimates, and low rates of suicide.

It has been hypothesized that both suicide and homicide are related to social constraints and are aggressive responses to objective frustrations.¹⁰ Repressed groups, it is suggested, are more likely to express tension and distress outwardly, while those experiencing fewer outer constraints are more likely to act aggressively against themselves. This remains more a hypothesis than an established conclusion, but it suggests the value of broader perspectives.

Looking at these sources of mortality in the aggregate shows the clear black disadvantage. It is arguable that interventions to address the underlying economic and social tensions through employment, improved housing, or other means would yield more health gain than those seeking to prevent either suicide or homicide directly, which is extremely difficult.

Schooling is an important vehicle for upward mobility.

Top Numbers can be deceptive. New technology can lead... Initiatives aimed at groups... A focus on health... Schooling is an important... NOTES

 
Reducing disparities requires special efforts to target groups that lack the knowledge, resources, or networks to readily take advantage of health opportunities. This includes programs focused on the most disadvantaged that provide immunizations, prenatal and child care, more ready access to medical care, nutrition supplementation, and related interventions. Since schooling is a particularly powerful vehicle for upward mobility and economic security, as well as personal empowerment, programs that prepare children early in life for school success and that continue to support academic engagement are particularly important for future health and a valued resource on its own terms. Schools are also gateways for providing children with important health resources and in some cases access to needed medical care. Closing inequalities in preparation for and engagement with schooling, and in school quality, offers important opportunities for greater social equality and health improvement.¹¹ An additional advantage is that support for schooling crosses most political alignments.

The United States is committed over the long run to eliminating racial inequalities in health. Doing so will require concerted efforts in many areas, including access to high-quality medical care, support for healthy social and educational development, and enhancement of environmental and neighborhood infrastructures. Enhancement of aggregate population health, linked with thoughtful targeting to encourage access to resources and uptake of health opportunities, will bring us closer to achieving our national aspirations for equality in health.

Editor's Notes

 
David Mechanic (mechanic{at}rci.rutgers.edu) is director of the Institute for Health, Health Care Policy, and Aging Research; University Professor; and René Dubos Professor of Behavioral Science at Rutgers, the State University of New Jersey, in New Brunswick.

NOTES

Top Numbers can be deceptive. New technology can lead... Initiatives aimed at groups... A focus on health... Schooling is an important... NOTES

 

1. D.R. Williams and P.B. Jackson, "Social Sources of Racial Disparities in Health," Health Affairs 24, no. 2 (2005): 325–334.[Abstract/Free Full Text]
2. For an excellent exposition on some of these processes, see G. Davey Smith, ed., Health Inequalities: Lifecourse Approaches (Bristol: Policy Press, 2003).
3. A more detailed discussion is in D. Mechanic, "Disadvantage, Inequality, and Social Policy," Health Affairs 21, no. 2 (2002): 48–59. See also D. Mechanic, "Rediscovering the Social Determinants of Health," Health Affairs 19, no. 3 (2000): 269–276.
4. U.S. Centers for Disease Control and Prevention, "Infant Mortality and Low Birth Weight among Black and White Infants—United States, 1980–2000," Morbidity and Mortality Weekly Report 51, no. 27 (2002): 589–592.
5. Ibid. Used as a source for calculations.
6. K. Baicker et al., "Who You Are and Where You Live: How Race and Geography Affect the Treatment of Medicare Beneficiaries," Health Affairs, 7 October 2004, content.healthaffairs.org/cgi/content/abstract/hlthaff.var.33 (16 December 2004).
7. B.G. Link and J.C. Phelan, "Fundamental Sources of Health Inequalities," in Policy Challenges in Modern Health Care, ed. D. Mechanic et al. (New Brunswick, N.J.: Rutgers University Press, 2005), 71–84.
8. Williams and Jackson, "Social Sources of Racial Disparities."
9. E. Durkheim, Suicide: A Study in Sociology (1897), trans. J.A. Spaulding and G. Simpson (New York: Free Press, 1951).
10. A.F. Henry and J.F. Short Jr., Suicide and Homicide: Some Economic, Sociological, and Psychological Aspects of Aggression (New York: Free Press, 1954).
11. D. Mechanic, "Socioeconomic Status and Health: An Examination of Underlying Processes," in Pathways to Health: The Role of Social Factors, ed. J.P. Bunker, D.S. Gomby, and B.H. Kehrer (Menlo Park, Calif.: Henry J. Kaiser Family Foundation, 1989), 9–26.

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