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Appendix 10.
Clarification and Examples of Health
Disparities and Health Equity
The following discussion clarifies the types of population-based
differences in health status that should be given high priority in Healthy
People 2020. The concepts of health equity and eliminating health disparities
are rooted in deeply held American social values. Key values underlying the
concepts of eliminating health disparities and achieving health equity are:
- All people are valued equally, the basis for the concept of
fairness.
- Health is valued highly for everyone because it is essential to
personal well-being and ability to participate fully in a democratic society.
Furthermore, our prosperity as a society depends on the health of our entire
population.
- Every person should be able to achieve the highest level of health
possible, without distinction based on race, ethnic group, religion,
socioeconomic status, gender, physical or mental disability, sexual
orientation, rural/urban residence, or other characteristics that have
historically been linked to discrimination or having less influence or
acceptance in society.
- The resources needed for health should be distributed fairly; these
include not only access to quality medical care, but also the living and
working conditions that are necessary for health.
Examples of Disparities in Health Status
- Black infants have higher mortality rates than white infants.
- Maternal mortality is higher among Black women.
- Among the elderly, women's health and functional status are worse
than men's.
- Black women are more likely than white women to die from breast
cancer.
- Life expectancy at age 26 is shorter and rates of heart disease and
diabetes are higher among people of lower incomes or educational levels and
among Blacks, Hispanics, and Native Americans.
- Poor or fair (contrasted with good, very good, or excellent) health
is more prevalent among children in low-income families.
- In elderly adults, disability rates are inversely related to income.
[Minkler M, NEJM 2007]
- Obesity appears to be more prevalent in adults with sensory,
physical, and mental health conditions. [Weil, Wachtman, Iezzoni et al, JAMA
2002.]
Examples of Health Differences that are not Health Disparities
These differences are of interest in trying to improve the health of
everyone in the population, but they are not linked to systematic disadvantage
or injustice. Such differences include situations in which a particular racial,
ethnic, or gender group known to be disadvantaged socially or economically
happens to have better health.
- Despite lower income levels, Hispanic immigrants have the most
favorable birth outcomes (birth weight and prematurity rates) of all the large
U.S. racial or ethnic groups. This difference is not a health disparity.xv
- Younger adults generally have better health than others.
- Women have higher rates of breast cancer than men.
- Jewish persons with ancestral origins in Northern Europe have higher
rates of Tay-Sachs disease, a genetic condition, than do others.
- African Americans (blacks) have higher rates of sickle cell disease,
a genetic condition, than do other racial groups.
- Male infants have higher rates of mortality than female infants.
Examples of Disparities in Health care
Disparities in health care arise not only from disparities in financial
access, but also from deficiencies in the organization and delivery of
services, and from lack of cultural competence among providers and staff, among
other factors.
- Older immigrants with limited English proficiency had significantly
worse access to health care than did their otherwise similar English-speaking
counterparts. [Ponce et al., J Gen Intern Med 2006]
- Latinos (Hispanics) were less likely than whites to receive pain
medication for major fractures in a large emergency room, and the difference
was not due to language barriers. [Todd, JAMA 1993 & 1994 ]
- African Americans and women receive less appropriate care for
cardiovascular disease than white men with comparable clinical presentations.
[IOM 2003]
- Pregnant African American women were less likely to receive
appropriate health advice from their health care providers.[Kogan, M, AJPH
1994]
- Examples of disparities in living and working conditions that
strongly influence health.
- Black and Hispanic children are more likely to grow up in poverty
than white children; poverty – particularly during childhood—has been
repeatedly and strongly linked to ill health.
- Black and Latino youth are more likely than white youth to live in
neighborhoods with characteristics known to have adverse effects on health,
e.g., few or no grocery stores selling fresh produce or safe places to play;
high concentration of liquor stores, fast-food restaurants, and advertisements
for tobacco and alcohol; and exposure to pollution and other hazards in the
physical environment, crime, violence, and negative role models. Health-related
neighborhood conditions also vary according to income, but racial disparities
occur even when comparing youths in families with similar income levels.
- Black, Hispanic and poor white children are less likely than children
in affluent white families to become college graduates; education influences
health through multiple pathways, including access to good jobs and good
incomes, and therefore healthier living conditions.
- Blacks are more likely than whites to be incarcerated for nonviolent
crimes; incarceration poses great risks to health, including HIV infection,
violence, and difficulty obtaining good employment following release.
- Children in poor families are less likely to have their
parents/guardians read to them, encourage them to read, and stimulate their
mental development. This can have deleterious consequences for brain
development and behavior, which determine later educational attainment and
hence affect health in adulthood.
Examples of Health Equity
Complete health equity would be the absence of all disparities in
health, health care, and the living and working conditions that influence
health. No society has achieved this, but some have come closer to the ideal.
Policies that promote health equity are those that exemplify fairness, i.e.,
that strive progressively over time to move toward that goal. Examples of
policies that promote health equity and thus exemplify fairness include:
- Medicaid and Medicare reduce disparities in access to health care by
income and consequently by race.
- The Head Start program reduces socioeconomic and racial disparities
in early childhood development, the foundation for adult health.
- The Civil Rights Act of 1965 diminished overt discriminatory
practices in all areas of society and reduced racial disparities in health
through diverse pathways [Kaplan GA et al in House, Schoeni et al, 2008].
An example of fairness or pursuing health equity in the realm of data
would be ensuring that adequate numbers of American Indians were included in
key federal health surveys to obtain information on the health needs of this
highly disadvantaged group.
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Continue to Appendix 11. Measuring Health
Disparities and Health Equity
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9. Questions that May Motivate Users to Seek Healthy People 2020
Information
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