rwjf laveist state of racial inequities in health

8/20/2019 RWJF LaVeist State of Racial Inequities in Health

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The State of

Racial Inequalitiesin Health


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“As this generation comes

of age, the health status of

the nation will be areection of the health

of the people whom we

currently refer to as racial

and ethnic minorities.”

THE STATE OF RACIAL INEQUALITIES

IN HEALTH

Thomas A. LaVeist, PhD

William C. and Nancy F. Richardson Professor in Health Policy

Director, Hopkins Center for Health Disparities Solutions

Johns Hopkins Bloomberg School of Public Health

INTRODUCTION

The 20th century witnessed a literal change in the “face of America.” At the dawn of

the century, the racial “color-line” described by W.E.B. DuBois1 was mainly drawn

between black and white Americans. The 19th century’s Manifest Destiny policies

had rendered Mexicans as immigrants in their native land, and left what remained

of the American Indian nations defeated and living on reservations. The countrywas only a few decades removed from slavery, but former slaves lived among whites

as constant reminders of an ignoble history at odds with the noble principles of the

nation’s founding declaration that all men are created equal.

As the 20th century approached its nal decades, there was increasing recognition

that the nation’s demographic prole was experiencing a transition. In 1950 non-

Hispanic whites comprised about 90 percent of the population. By 2010 the per-

centage had declined to about 69 percent. The Census Bureau projects that by the

middle of the 21st century, non-Hispanic whites will comprise a numerical minority

of the population. Already, more than 50 percent of the population younger than age

5 are minorities. And, according to the U.S. Department of Education, the majority

of public school students in the United States are racial or ethnic minorities. As this

generation comes of age, the health status of the nation will be a reection of the

health of the people whom we currently refer to as racial and ethnic minorities. This

portends a signicant decline in the overall health of the nation if we do not make

progress in improving minority health.

This paper presents an overview of the state of health inequalities in the United

States. The rst section provides a brief history of the major developments in the

national effort to address health inequalities, from publication of The Report of the

Secretary’s Task Force on Black and Minority Health, also known as the Heckler

Report , to the present. Part Two focuses on alternative methods for quantifying

disparities, the impact on individual health, broader economic effects, and the role

of social determinants. The nal section outlines directions for future efforts to

eliminate health inequalities.

PART 1: A BRIEF RECENT HISTORY OF EFFORTS TO

ADDRESS HEALTH INEQUALITIES

The year 1985 marked the emergence of minority health and health disparities into

the nation’s consciousness2. That year the U.S. Department of Health and Human

Services (DHHS) issued the Heckler Report , in honor of Margaret M. Heckler, the

department’s secretary. Based mainly on data from 1980, the 10-volume report

documented the dire state of the health of racial and ethnic minorities across key


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health indicators. In response to that report, DHHS received congressional authori -

zation to establish the Ofce of Minority Health (OMH) in 1986 and the Ofce of

Minority Health Resource Center in 1987.

Other developments followed: In 1990, DHHS Secretary Louis Sullivan appointed John Rufn as associate

director of Minority Programs and director of the newly established Ofce of

Minority Programs (OMP) at the National Institutes of Health.

Also in 1990, the Ofce of Disease Prevention and Health Promotion coor -

dinated federal agencies, businesses, and community organizations to establish

Healthy People 1990, a comprehensive, nationwide health promotion and dis-

ease-prevention agenda that included a set of goals to “increase quality and years

of life” and “eliminate health disparities.”

In 1993, Congress replaced OMP by establishing the Ofce of Research on

Minority Health (ORMH).

In 2010 DHHS released Healthy People 2020 with a new set of 10-year goalsand objectives for health promotion and disease prevention.

The rst decade of the 21st century brought renewed attention to minority health and

health inequalities. President Clinton signed the Minority Health and Health Dispar-

ities Research and Education Act of 2000, which enhanced support for biomedical

and behavioral research on minority health, supported training, and established

the National Center on Minority Health and Health Disparities to replace ORMH.

The center was elevated to institute status at NIH when the Patient Protection

and Affordable Care Act renamed it the National Institute on Minority Health and

Health Disparities.

Reports from such venerable sources as the National Research Council, the sur -

geon general, and the Institute of Medicine brought much needed gravitas to the

health-disparities issue, which was still ghting to gain credibility in the face of

some who argued, in spite of the overwhelming evidence, that health disparities did

not exist (Klick and Satel 2006).

Between 1998 and 2002, Surgeon General David Satcher issued a series of reports

documenting dramatic disparities across a variety of health-related topics, includ-

ing tobacco (DHHS 1998, DHHS 2000, and DHHS 2001), mental health (DHHS

1999 and DHHS 2001), oral health (DHHS 2000), and youth violence (DHHS 2001).

The Institute of Medicine (IOM) of the National Academies also published several

relevant reports. These included Crossing the Quality Chasm: A New Health System

for the 21st Century (IOM 2001), which highlighted the importance of attending to

health care quality and not just expanding access to care, and Unequal Treatment:

Confronting Racial and Ethnic Disparities in Health Care (IOM 2002), comprehen-

sive documentation that racial and ethnic minorities have less access to health careand that the care they get is often of poor quality. The National Research Council

(NRC) of the National Academies conducted a series of assessments and analyses

of the NIH minority research and training programs that had been initiated by the

ORMH. This resulted in the 2005 report Assessment of NIH Minority Research and

Training Programs: Phase 3 (NRC 2005), which examined the effectiveness of the

programs and provided recommendations for improvement. And in 2006, the IOM

issued the report Examining the Health Disparities Research Plan of the National

Institutes of Health: Unnished Business (IOM 2006).


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Perhaps more than any other report, IOM’s Unequal Treatment presented a com-

pelling case supporting the existence of health care disparities and placed the issue

rmly on the national health policy agenda. This report was so successful because

it limited its scope in two fundamental ways: (1) the report was not about disparities

in health status, and (2) the report was not about health care access. With some past

reports on disparities, opponents of devoting resources to addressing race inequal-

ities in health pointed out that limitations in access to care resulted from multiple

complex societal factors, including employment status, and geography. Some would

even argue that there were racial/ethnic differences in patient behavior, with minori-

ties more likely to delay seeking care and/or refusing to consent to some procedures.

This line of reasoning offered the position that these were broad societal problems

not easily addressed through medical intervention, health policy, or reallocation of

health care resources. Unequal Treatment brilliantly avoided this pitfall by exclud-

ing these topics. Instead, the report compiled the results of well-designed studies of

racial and ethnic differences in quality of health care among patients who were both

insured and sought care. The mountain of evidence the IOM committee uncovered

was impossible to ignore.While the issue of health disparities became common knowledge among policymak-

ers and health researchers, it was not as widespread among the general public. A

2010 poll surveyed 3,159 American adults of diverse racial/ethnic backgrounds, rep-

licating a similar poll conducted in 1999 (Benz et al. 2011). Results of the poll are

summarized in Table 4. The study found that 59 percent of Americans in 2010 were

aware of racial and ethnic disparities among African-Americans and Hispanics, a

modest increase over the 55 percent recorded in 1999. Also, while 89 percent of

African-American respondents were aware of the disparities compared with whites,

only 55 percent of whites were aware. While the African-American awareness rate

was strong, there was relatively little awareness among racial and ethnic minority

groups about disparities that disproportionately affected their own communities.

For example, only 54 percent of African-Americans were aware of disparities in the

rate of HIV/AIDS between African-Americans and whites, and only 21 percent of

Hispanics were aware of those disparities between their group and whites.

Table 4.

Changes in public awareness of racial and ethnic disparities, 1999–2010

Percent of respondents aware

Disparities between whites and: 1999 2010

African-Americans and Hispanics or Latinos and

Asian-Americans or Pacific Islanders–a 52

African-Americans and Hispanics or Latinos 55 59

African-Americans 57 59

Hispanics or Latinos 53 61*

Asian-Americans or Pacific Islanders –a 18

a = data not collected

Note: Significance is between 1999 and 2010.

*=p


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PART 2: HEALTH COST OF THE COLOR LINE

The most commonly used method for summarizing racial and ethnic inequalities

in health is to report age-adjusted mortality rates, as in Figure 1. The chart

shows substantial variation in mortality rates by race/ethnicity and gender, withAfrican-American males having the highest mortality rate and Asian/Pacic

Islander females

having the lowest rate.

Regardless of race/

ethnicity, females have

a lower age-adjusted

mortality rate com-

pared with men, and

African-American

females have a higher

mortality rate than all

men with the exception

of African-American

and non-Hispanic

whites.

Age-adjustment is

done to account for

the differences in

the age distributions

of the various racial/

ethnic groups. As age

is strongly associated

with every major cause

of death, failing to

adjust for age when making racial or ethnic comparisons could lead to misleadingstatistics. As Table 1 displays, non-Hispanic whites have the highest median age

(41.2) compared with Hispanics, whose median age is nearly 14 years younger (27.4).

The oldest of the racial minority groups, Asians, have a median age nearly six years

younger than non-Hispanic whites.

However, while age-

adjustment can be useful

for making broad com-

parisons, it is important

to be cautious when using

only age-adjusted mor-

tality rates for comparing

racial/ethnic groups as thiscan also be misleading.

Age-adjustment alone does

not account for two other

sources of complication

when making statistical

comparisons between

the racial/ethnic groups.

Specically, some ma-

jor causes of death tend

Figure 1.

Deaths per 100,000 Persons

Age-adjusted mortality rates by

race/ethnicity and gender, 2011

0

200

400

600

800

1000Female

Male

Hispanic API Am IndianBlackWhite

Source: U.S. National Center for Health Statistics, National

Vital Statistics Reports, Volume 63, Number 3, Table 1

Table 1.

Median age of U.S. resident population byrace and Hispanic origin, 2009

Race/Ethnic Group Median Age

Non-Hispanic White 41.2

Non-Hispanic Black 31.3

American Indian, Alaska Native 29.5

Asian 35.3

Native Hawaiian, Other Pacific Islander 29.9

Hispanic 27.4


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to occur at younger ages than others. For example, homicide deaths tend to occur

among persons under age 35, while cancers deaths are more likely to occur among

persons over 60. Also, racial/ethnic minorities tend to acquire chronic diseases

(such as cardiovascular disease and cancer) at younger ages and also die of these

diseases at younger ages compared with non-Hispanic whites and Asians/Pacic

Islanders (APIs). As a result, the impact of some causes of death can be greater than

others with respect to lost human potential. The statistic “years of potential life lost”

(YPLL) accounts for this. YPLL computes the years of potential life lost, assuming

the person would have lived to age 75 if not for the untimely death. YPLL expresses

not only the fact that the deaths have occurred, but also that these premature deaths

take a heavy toll on a community by way of lost potential productivity within the

economy as well as the loss of the contributions of individuals to their families and

communities.

Table 2 displays YPLL by race and ethnicity for 2010. The table shows substantial

differences across the groups, with APIs having the lowest number of years of

potential life lost and African-Americans with the highest. The table also computes

the disparity in age-adjusted mortality rates and YPLL by comparing each groupto Asians/Pacic Islanders. The table shows that estimates of the racial/ethnic

disparities as measured by years of potential life lost reveal greater inequalities

compared with age-adjusted mortality. For example, the age-adjusted mortality rate

ratio for African-Americans compared with Asians/Pacic Islanders is 2.1, indicat-

ing that African-Americans’ deaths occur at about double the rate of deaths among

APIs. However, the rate ratio for YPLL of 3.2 indicates that the impact of wasted

potential that health disparities represent is even greater. The rate of YPLL among

African-Americans is more than triple the YPLL among Asians/Pacic Islanders.

Table 2.

Years of potential life lost by race and ethnicity, 2010

YPLLYPLL rate ratio

compared with API

Age-adjusted rate

ratio compared

with API

Total 6642.9

White 8329.5 2.7 1.7

African-Americans 9832.5 3.2 2.1

AIAN 6771.3 2.2 1.5

API 3061.2 1.0 1.0

Hispanic 4795.1 2.6 1.3

Comparisons of disparities in total mortality can also obscure the magnitude of

health inequalities, because there are differences by race/ethnicity in the proportions

of deaths from specic causes. Table 3 displays YPLL for leading causes of death

by race and ethnicity. The table also shows the percentage that each cause of death

contributes to total YPLL. While heart disease is the leading cause of death for all

American racial/ethnic groups, it is instructive to observe that cancer contributes the

greatest number of years of potential life lost for each group.


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Stroke accounts for more than 8 percent of all YPLL for Asians/Pacic Islanders.

This is more than double the percentage for all other racial/ethnic groups. Chronic

liver disease and cirrhosis accounts for 7.5 percent of YPLL for American Indians

and Alaska Natives, while Hispanics are the only other group with a YPLL per -

centage over 4. These two groups also have higher numbers of YPLL due to motor

vehicle injuries compared with all other groups. For African-Americans, both HIV

and homicide stand out as large contributors to YPLL. HIV accounts for 3.4 percent,more than double any other group, and homicide accounts for 8.4 percent. Together,

HIV and homicide account for nearly 12 percent of all years of potential life lost for

African-Americans. On the other hand, suicide only accounts for 2 percent of YPLL

for African-Americans, which is the lowest of all racial/ethnic groups. For whites

and Asians/Pacic Islanders, suicide accounts for more than three times as many

YPLL compared with African-Americans.

In addition to the complication of racial/ethnic differences in age distributions and

causes of death, another consideration for producing group comparisons of health

Table 3.

Years of potential life lost by selected leading causes of death by race and ethnicity, 2010

White African American AIAN API Hispanic/Latino

YPLL % of

total

YPLL % of

total

YPLL % of

total

YPLL % of

total

YPLL % of

total

All 6342.8 9832.5 6771.3 3061.2 4795.1

Heart disease 900.9 14.2 1691.1 17.2 820.6 12.1 400.1 13.1 598.1 12.5

Stroke 142.7 2.3 358.1 3.6 129.7 1.9 250.6 8.2 150.4 3.1

Cancer 1375.8 21.6 1796.7 18.2 929.5 13.7 874.7 28.6 951.2 19.8

Chronic lower respiratory

diseases

176.1 2.8 187.7 1.9 154.5 2.3 33.2 1.1 59.6 1.2

Influenza and pneumonia 66.7 1.0 109.8 1.1 99.3 1.5 38.4 1.3 57.5 1.2

Chronic liver disease and

cirrhosis

173.5 2.7 120.2 1.2 510.8 7.5 41.7 1.4 201.6 4.2

Diabetes mellitus 139.0 2.2 316.4 3.2 267.6 4.0 69.5 2.3 158.5 3.3

Alzheimer’s disease 12.4 0.2 10.0 0.1 8.8 0.1 3.2 0.1 8.4 0.2

HIV 39.9 0.6 329.5 3.4 46.1 0.7 10.7 0.4 74.9 1.6

Motor vehicle injuries 419.0 6.6 393.4 4.0 570.6 8.4 147.9 4.8 340.3 7.1

Other unintended injuries 435.0 6.9 218.9 2.2 449.6 6.6 46.5 1.5 191.2 4.0

Suicide 430.8 6.8 196.4 2.0 256.4 3.8 199.7 6.5 193.6 4.0

Homicide 138.7 2.2 821.2 8.4 256.4 3.8 68.8 2.3 238.0 5.0

All other causes 1892.3 29.8 3283.1 33.4 2271.4 33.5 876.2 28.6 1571.8 32.8


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inequalities is the substantial variation within groups. For example, age-adjust-

ed mortality rates and years of potential life lost both show that Hispanics have

a relatively good health prole compared with non-Hispanic whites. However, a

closer look at within-group variation among Hispanics reveals a more complex

story. Figure 2 displays age-adjusted mortality rates for specic Hispanic subgroups.

The gure shows substantial variation, whereby the age-adjusted mortality rate for

Central Americans is similar to the Asians/Pacic Islander population. However, the

Puerto Rican rate is comparable to non-Hispanic whites. Data similar to what is pre-

sented in Figure 2 is not readily available for other racial groups. However, several

studies suggest that nativity, where you are born, is an important source of variation

in health for other groups as well, including Asians/Pacic Islanders (Kandula et

al. 2007; Yu et al. 2004; Cho and Hummer 2001), and blacks or African-Americans

(Elo and Culhane 2010; Grifth et al. 2011).

In addition to variations in nativity, immigration status has also been identied

as an important source of variation. The “Hispanic paradox” has been well docu-

mented (see Medina-Inojosa et al. 2014 or Franzini et al. 2001 for reviews of this

literature). The Hispanic paradox refers to the phenomenon that Hispanics arecharacterized by low

socioeconomic status,

but have better than

expected health and

mortality outcomes.

There is robust litera-

ture in this area, and

some recent studies

have added nuance

to this pattern. For

example, a recent

study by Hayward et

al. (2014) supported

the Hispanic paradox

for mortality, but did

not nd the same

pattern for disability.

Instead they docu-

mented a substantially

higher rate of disabil-

ity compared with

non-Hispanic whites.

Additionally, a study

led by LaVeist-Ramos

(2012) compared health status, health behavior, and health services utilization of black Hispanics (people who are both black and Hispanic, such as from the Domin-

ican Republic, Cuba, or Puerto Rico) against non-Hispanic blacks (African-Amer -

icans who do not have Hispanic heritage) and non-black Hispanics (Hispanics who

do not have black heritage). Black Hispanics’ health behaviors resembled those of

non-black Hispanics or were similar to both non-black Hispanics and non-Hispanic

blacks. For health services outcomes, they resembled non-Hispanic blacks. However,

their health status was inuenced by both race and ethnicity, with black Hispanics

resembling both non-black Hispanic and non-Hispanic black people.

Figure 2.

Deaths per 100,000 persons

Age-adjusted mortality rates by

specific Hispanic origin and gender, 2011

Source: U.S. National Center for Health Statistics, NationalVital Statistics Reports, Volume 63, Number 3, Table 5

Other

Hispanic

Central

American

CubanPuerto

Rican

Mexican0

200

400

600

800

1000Female

Male


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PART 3: THE ECONOMIC COSTS OF UNEQUAL HEALTH

Since the publication of Unequal Treatment , health care advocates have relied on a

compelling social justice argument to press policymakers to direct resources toward

efforts to address racial and ethnic inequities in health, with the premise that doingso is in keeping with American values. LaVeist and colleagues (2011) tested whether

there was more to racial health inequities than the moral argument, given the enor-

mous social and psychic costs premature deaths impose on families and commu-

nities. The premature death of a working mother or father has negative impacts on

families that ripple throughout the economy in the form of lost income and wages,

forgone taxes, increased need for social and community services, and increased

need for Social Security survivors’ benets.

Three sets of analyses were conducted to estimate the economic burden of health

disparities in the United States: (1) direct medical costs of health inequalities, (2)

indirect costs of health inequalities, and (3) costs of premature death. The analyses

found:

1. In the four-year period between 2003 and 2006, 30.6 percent of medical care

expenditures for African-Americans, Asians, and Latinos were excess costs

that were the result of inequities in the health status of these groups.

2. Between 2003 and 2006, the combined direct and indirect cost of health

disparities in the United States was $1.24 trillion (in 2008 ination-adjusted

dollars). This is more than the gross domestic product of India, the world’s

12th-largest economy in 2008, and equates to $309.3 billion annually lost to

the economy.

3. Eliminating health disparities for minorities would have reduced direct medi-

cal care expenditures by $229.4 billion for the years 2003–2006.

4. Eliminating health inequalities for minorities would have reduced indirect

costs associated with illness and premature death by more than a trilliondollars between 2003 and 2006.

The large number of premature deaths among American racial and ethnic minority

groups represents a substantial loss of human potential, a loss of talent and pro-

ductivity that might otherwise have contributed to the betterment of society. By

imposing a substantial burden on the economy, health disparities cause suffering for

the entire society. While the scope of the challenge in addressing these inequities is

large, these ndings indicate that the same is true for the potential savings.

PART 4: SOCIAL DETERMINANTS AND HEALTH

INEQUALITIES

Social determinants of health refer to conditions in the environments in which

people live, work, learn, and play that affect a wide range of health, physical func-

tioning, and quality-of-life outcomes and risks. The social-determinants perspective

observes that conditions (e.g., social, economic, and physical) in these settings (e.g.,

school, church, workplace, and neighborhood) can affect health by placing persons

at increased exposure to health risks as well as limiting access to resources needed

to live a healthy lifestyle. In addition to the more material attributes of “place,” the

patterns of social engagement and sense of security and well-being are also affected

“The large number of

premature deaths among

American racial and eth-nic minority groups rep-

resents a substantial loss

of human potential, a loss

of talent and productivity

that might otherwise have

contributed to the better-

ment of society.”


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by where people live. Resources that enhance quality of life can have a signicant

inuence on population health outcomes. Examples of these resources include safe

and affordable housing, access to education, public safety, availability of healthy

foods, local emergency/health services, and environments free of life-threatening

toxins.

The World Health Organization’s Commission on Social Determinants of Health

published a comprehensive conceptual framework for understanding how social de-

terminants produce ill health, summarized in Figure 3. The framework recognizes

that the socioeconomic and political context of a society (both through formal policy

and through social norms and customs) interacts with characteristics of individuals

that are used to assign social status, such as income status, race, gender, and social

position. The society’s cultural norms determine the degree to which policies are set

that may benet or harm powerless individuals. Some possible examples to consider

are policies that produce income inequality, limit voting rights, or allocate insuf-

cient educational resources to low-income communities. Social norms can also im-

pact health through informal processes that create hierarchy from characteristics of

individuals, such as race, gender, or income status. For example, exposure to racismis an example of a social norm that has been well documented to affect health3.

Racism can affect health and produce health inequalities through three related

pathways: (1) structural factors such as the organization of society, (2) interpersonal

interactions such as discrimination, and (3) internalized racism. Perhaps the best-

documented example of structural racism and health is through racial residential

segregation (Williams and Collins 2001). Segregation has been documented to result

Social cohesion &

social capital

Material circumstances(living and working

conditions, food

availability, etc.)

Psychosocial factors

Behaviors and

biological factors

Health system

Socioeconomic

position

Social class

Gender

Ethnicity (racism)

Education

Occupation

Income

Socioeconiomic

and political

contest

Macroeconomicpolicies

Public policieseducation, health,

social protection

Culture andsocietal values

Social policies labour market,

housing, land

Governance

Impact on

equity in

health and

well-being

Structural determinants social determinants of

health inequities

intermediary determinants social determinants

of health

Figure 3.

The Commission on Social Determinants of

Health, Social Determinants Framework

Source: Solar O, et al. A Conceptual Framework for Action on the Social

Determinants of Health: Social Determinants of Health Discussion Paper 2.Geneva: World Health Organization; 2010.


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in race differences in health risks (LaVeist and Wallace 2000; Kwate 2008) and less

availability of resources needed to live a healthy lifestyle (Morland and Filomena

2007; Smith et al. 2007).

The effects of interpersonal racism stress have also been well documented. Forexample, racial discrimination has been associated with blood pressure (Dolezsar

et al. 2014; Krieger and Sidney 1996), substance use and abuse (Sanders-Phillips

et al. 2014), mental health (Hurd et al. 2014), and physical health (De Vogli et al.

2007). There is also large research literature on the effects of internalized racism

on health. Studies have demonstrated associations between internalized racism and

obesity and blood pressure (Tull et al. 1999), as well as mental health (Williams and

Williams-Morris 2000).

Since the 1990s several studies have examined the role of implicit bias in health

inequalities. Implicit bias is a positive or negative attitude toward a person, thing, or

group. Implicit bias is unconscious, and it sometimes is referred to as unconscious

bias (Greenwald and Banaji 1995). This differs from explicit bias, which is an at ti-

tude that somebody is consciously aware of having. Implicit bias has aspects of bothinterpersonal and internalized racism. It can be the underlying cause of interper-

sonal racism, for example, health care providers offering differential levels of care

to patients based on race/ethnicity (Green et al. 2007; Cooper et al. 2012; Sabin and

Greenwald 2014; Moskowitz et al. 2012 ). Individuals can also harbor implicit nega-

tive bias against their own racial/ethnic group (Ashburn-Nardo et al. 2003). This can

be a cause or consequence of internalized racism.

PART 5: SUGGESTED WAYS FOR MAKING PROGRESS IN

ADDRESSING DISPARITIES

The World Health Organization’s Commission on Social Determinants of Health

(WHO 2011) suggested four strategies in which policy can be deployed to addresshealth inequalities: (1) decreasing social stratication (e.g., power, prestige, wealth,

human capital, etc.); (2) decreasing exposure to risk; (3) lessening the vulnerability

or improving the ability of disadvantaged persons to cope with risk; or (4) interven -

ing through health care to reduce the unequal consequences of social determinants.

Decreasing social stratifcation would likely be the most impactful of these strat-

egies, yet seems the least likely remedy to be adopted. Several studies have docu -

mented better health in countries with less income inequality (Torre and Myrskyla

2014; Hiilamo 2014; Harling et al. 2014).

There is also evidence that decreasing exposure to health risks can eliminate

disparities. A study of black and white persons living together in an integrated

community found no race disparities in diabetes (LaVeist et al. 2009) or obesity

among women (Bleich et al. 2010), and a greatly reduced disparity in blood pressure(Thorpe et al. 2008). In this study, race differences in health risks exposures were

controlled because both race groups lived in similar social conditions. That dispar-

ities were mostly not present in this community indicates that racial/ethnic dispari-

ties are not immutable, and that when people are exposed to similar health risks they

have similar health outcomes.

Adopting a “Health in All Policies” (HiAP) approach can lessen the vulnerability

of disadvantaged populations. HiAP is based on the realization that policies in


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virtually every sector, e.g., education, housing, and criminal justice, can have an

impact on health. The HiAP approach is to conduct an assessment of all proposed

policies for their potential health impact (Collins et al. 2009). By conducting a

health impact assessment, the differential health impacts of a potential policy de-

cision are understood, public health is included in the policy discourse, and policy-

makers are able to see how their decisions can maximize positive health impacts,

minimize negative health impacts, and ensure that health impacts are distributed in

an equitable manner.

The Centers for Disease Control and Prevention (CDC) established Racial and

Ethnic Approaches to Community Health (REACH) in 1999 to address its Healthy

People 2010 goals of improving minority health and eliminating health disparities

(Jenkins et al. 2011; Liao et al. 2010). The REACH program empowers community

based-organizations to mitigate health risks in their communities. Evaluations

of REACH found that it was effective in addressing cholesterol screening and

diabetes-related amputations (Jenkins, et al. 2011; Liao et al. 2010), suggesting that

community-based approaches can be effective for improving the health of minority

populations.

Perhaps the most common (and likely least effective) approach to addressing racial/

ethnic disparities is to intervene through health care. The expansion of Medicaid

as part of the Patient Protection and Affordable Care Act attempts to address health

inequalities by increasing access to care to millions of uninsured Americans. This

is a necessary and appropriate step. However, there is overwhelming evidence that

expanding access to health care alone will not solve the health inequalities problem.

For example, this is precisely what the Institute of Medicine’s report Unequal Treat-

ment documented.

The elimination of health disparities, it seems, will likely be achieved through

multi-sectored approaches, bringing together stakeholders from various sectors

(including health care) and community members empowered with the resources

to nd solutions. Broad partnerships and collaboration are essential to eliminating

risks, transforming communities, and ending health inequality for all.


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NOTES

[1] In his seminal book The Souls of Black Folk (1903), W.E.B. Du Bois proposed

that “the problem of the Twentieth Century is the problem of the color-line.”

[2] There certainly were efforts to address health disparities before 1985, for exam-

ple, the creation of the Indian Health Service in 1955, and Medicare and Medicaid a

decade later. There were other efforts in the earlier part of the century as well. How-

ever, I focus on 1985 as the beginning of the modern national governmental effort

in policy and public health programming targeted to health inequalities by race

and ethnicity across the various groups. The post-1985 era is also distinct in that it

went beyond improving health care access, but also attempted to address population

health issues.

[3] See Feagin and Benneeld (2014); Dolezsar et al. (2014); and Paradies et al.

(2014) for recent reviews of the literature. Also see Paradies (2006) and Williams et

al. (2003), and Williams and Mohammed (2009).


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