Which Health Disparities Do We Want to Reduce?

By David A. Kindig, MD, PhD

Over the past few weeks, I have been blogging on population health measurement, under the headline that you can’t manage what you can’t measure. While I’ve given quite a bit of attention to overall outcomes, I haven’t directly addressed disparities.

Improving the length and/or quality of life overall doesn’t necessarily translate to improved health for all population groups. Policies and programs can have a differential affect on subpopulations that exacerbate rather than diminish disparities.

Deciding which outcomes to target to improve overall health involves value judgments – whether the goal is improving overall health or reducing disparities. There is not a “correct” formula for simultaneously improving overall health and reducing disparities. The 50:50 weighting suggested by the figure below represents just one possible approach but the ethical dimensions of such choices cannot be ignored; in a resource limited world, should we focus on raising the bar overall or narrowing the gaps?

This is a value choice to be made by individuals and groups in light of their local, state or national situations and perspectives.

As the figure shows, disparities in outcomes exist across a spectrum of categories. These include race and ethnicity but also social and economic status, gender, and geography (and other dimensions as well). However, people often focus on disparities primarily in the race/ethnicity dimension. Last month the CDC released its first ever report on disparities and inequalities. Despite the report’s emphasis on the social determinants of health (the first section focuses on income and education), media coverage focused on the findings about racial disparities.

Here in Wisconsin, our ethnic minority populations are relatively small and geographically concentrated, but every county in the state has substantial health disparities by education level and income. In fact, the state earned a “C-” overall for health disparities in its 2010 Health of Wisconsin Report Card (which employs an innovative multidomain disparity index). The figure below from this report shows the distribution of death rates for various population segments both above and below the state average. It illustrates the point that racial disparities are significant but that there are also other critical differences across other population segments, such as those with different levels of education.

Chronic racism has been shown to have a biologic effect on health through stress pathways, and institutional racism has created many of the disparities in income, education, and health services that influence health outcomes. We clearly need to develop and support policies to address and eliminate racism on every level in our communities.

But focusing our attention too narrowly may make us think of obstacles instead of opportunities. To improve population health, we need to think beyond race to recognize the many factors that affect health differentially. In a country still battling racial stereotypes and prejudice, this broader perspective on disparities may help create a unified and constructive approach to addressing our collective health challenges.

David A. Kindig, MD, PhD, is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.

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For further reading:

Jones CP. (2000). Levels of racism: A theoretical framework and a gardener’s tale. American Journal of Public Health, 90, 1212-1215.

Webb BC, Hairston KG, Simpson SL. (2011). From politics to parity: Using a health disparities index to guide legislative efforts for health equity. American Journal of Public Health, Published online ahead of print January 13, 2011: e1-e7. doi:10.2105/AJPH.2009.171157.

Schoeni RF, Dow WH, Miller WD, Pamuck ER. (2011). The economic value of improving the health of disadvantaged Americans. American Journal of Preventive Medicine, 40(1S1), S67-S72.

Comments

[Ed Donovan, James M. Anderson Center for Health Systems Excellence]

I agree that focusing directly on racial disparities in health often helps identify obstacles rather solutions. Focusing rather on the social and physical environmental determinants of health may help directly answer the "what's in it for me" question and indirectly address racial/ethnic disparities.
Few who practice racism, even unconsciously, seem able to articulate the personal benefits of working to eliminate racism. Plus there's no convincing evidence base for treating racism. However, the population-level benefits of improving the physical and social environments are more apparent.
Because I am able to compensate, I am less likely to suffer from the lack of fresh fruits and vegetables in my neighborhood or the industrial haze visible in the distance from my window. Nevertheless I would love it if I were able to walk to the grocery store or see the mountains beyond the haze.
Improving the social and physical environments is likely to have a greater impact on those who suffer most from current conditions. Still, we can all see and feel the benefits. This approach may do little to mitigate the effects of racism, but a portion of the racial gap may diminish.

[Jared]

This article is featured in the March 3rd edition of the Health Wonk Review. Thanks for your submission!

http://lucidicus.org/editorials.php?nav=20110303a

[Bill Rock]

David, I found the blog site in On Wisconsin. Interesting as usual.And of course veri different view from mi professional life.Thanks. I will be an avid follower. Bill Rock