Chapter 2- difference, disparity, and health: achieving health equity

quotation from the director of the CDC can only begin to encompass the human costs of health disparities in the United States

"Every person who dies young, is avoidably disabled, or is unable to function at their optimal level not only represents a personal and family tragedy but also impoverishes our communities and our country. We are all deprived of the creativity, contributions, and participation that result from disparities in health status."

Healthy People 2020 Identifies the people who are especially vulnerable to health disparities

"who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion."

Education enhances health in multiple ways

- It directly increases access to information about nutrition, physical activity, alcohol use, and other lifestyle choices that influence health. - It also leads to better job opportunities and, in turn, better working conditions, sick leave, paid vacation, health insurance coverage, and other benefits, including the ability to afford good-quality housing, food, and other essentials -

One of the most striking poverty-related health disparities is in life expectancy

- Males in the lowest 10 percent of income have an average life expectancy 14 years below that of males with income in the top 10 percent - for females, the gap is 13 years

Learn to Communicate across Differences

A first step is to establish some rules for the dialogue, creating a shared agreement about the values and goals of your communication. For example, do you both commit to civility, honesty, and mutual respect? What do you hope to gain from your dialogue?

how they influence health and health disparities both directly and indirectly

A low-income individual, for example, may be unable to afford a prescription for a drug to treat his asthma. Less directly, the individual's housing options may be limited to neighborhoods with high levels of air pollution that exacerbate the asthma

Among these factors, discrimination has emerged as a key contributor to stress and stress-related symptoms and poor health.

A recent report from the American Psychological Association identified an increased risk for discrimination among members of the following five groups: the poor, the disabled, racial/ethnic minorities, LGBT Americans, and older Americans

built environment that can contribute to health disparities is the level of industrial and traffic pollution in air, water, and soil

After the Environmental Protection Agency's discovery in 2015 of lead contamination in the public water supply in Flint, Michigan—where over 40 percent of the population lives below the poverty line—municipal water systems in other low-income communities across the United States also were found to be contaminated with lead

Other initiatives have followed, including the creation in 1985 of the U.S. Department of Health and Human Services Task Force on Black and Minority Health75 and new reports on health disparities from the Surgeon General, the Institute of Medicine, and the CDC

Although these reports set goals and objectives for reducing health disparities, only minimal progress has been made toward meeting those goals because accountability and funding have been inadequate

Disparities occur not only between populations, but also between subgroups within a population

Consider the LGBT population, for example. Smoking rates are higher among lesbian, gay, and bisexual Americans (20.6 percent) than among heterosexuals (14.9 percent), but rates are highest among transgender Americans (35.5 percent), possibly because of higher levels of stress in the transgender population

The SDOH are interconnected

Discrimination, for example, can influence educational attainment, housing, employment options and thus income, and other SDOH

Because our assumptions about different populations are typically based on limited exposure to individuals from those populations, they are likely be inaccurate

Even health statistics from government agencies such as the Centers for Disease Control and Prevention (CDC) are only averages and, as such, do not reflect the vast differences between the people those statistics represent

our individual and collective responses to difference can reduce opportunities, lead to injustices, and create a society characterized by health disparities.

For example, how might they influence whether to rent an apartment to a lesbian couple, hire an older adult, or even converse with a classmate wearing a headscarf? They also inform the actions we take as a society; for example, community members may oppose a measure to invest in high-quality low-income housing in their neighborhood because of unrecognized biases against people they consider "others."

certain populations tend to have higher levels of disease, disability, and death

For example, non-Hispanic blacks tend to experience greater health disparities than non-Hispanic whites overall

Notice that our society tells us who and what is different

For example, the Nigerian American author Chimamanda Ngozi Adichie observes that Africans living in many African countries do not distinguish one another by skin color

Language barriers and illiteracy can also affect health

Health literacy is the ability to obtain, process, and understand health information and services needed to make appropriate health decisions

In the decades after World War II, income gains were broadly shared throughout American society

However, between 1980 and 2013, the gap between the rich and the poor widened dramatically, contributing to what has been called "the disappearance of the middle class."

health disparities—and their accompanying costs—are avoidable

If as a society we are to reduce them, we need to understand the social, economic, and environmental disadvantages to which they are closely linked

During the same period, the Hispanic population will more than double, and the non-Hispanic black, Asian American, and mixed-race populations will increase modestly

In 2044, a "majority-minority crossover" will occur, and non-Hispanic white Americans will make up less than 50 percent of the U.S. population

The population of Americans under age 18, for example, is expected to increase only slightly between 2014 and 2060, from 74 million to 82 million

In contrast, the population of Americans age 65 or older is expected to more than double, from 46 million to 98 million

Public health experts have proposed the following initiatives to achieve a more equitable distribution of health care:

Increase minority providers. Members of minorities are more likely to seek care from health care providers of their own race or ethnicity.68 Educational programs and policies should encourage minority Americans (racial or ethnic minorities, LGBT Americans, and disabled Americans) to pursue careers in the health professions.69 Increase diversity training. All health care providers should be required to undergo diversity training to improve their ability to communicate health information in the language and at the appropriate literacy level of the client they are serving.70 Whether a person is young or old, thin or overweight, gay or straight, able or disabled—regardless of differences—high-quality care delivered promptly and with respect should be the goal. Increase preventive services. Municipalities, employers, school districts, and health care organizations should partner to offer preventive services such as mental health services, dental exams and cleanings, vision care, vaccinations, blood pressure screenings, and other services for underserved populations. Expand access to health insurance. The national initiative that has had perhaps the greatest effect on increasing access to health care for all population groups is the Affordable Care Act (ACA), which was signed into law in 2010 and implemented in stages. Under the ACA, the percentage of poor and near-poor Americans who are uninsured dropped from 27 percent and 29 percent, respectively, in 2013 to 17 percent and 18 percent, respectively, in 2015.71 Currently, provisions of the ACA are being questioned, as some members of Congress say it goes too far and others say it doesn't go far enough.

"Health for all" means living in communities that offer opportunities to thrive, physically, mentally, economically, and socially.

It means access to healthy nutrition, physical activity, safe and affordable housing, education from early childhood through adulthood, jobs that pay living wages, career opportunities, social support, community resources, freedom from discrimination, high-quality health care, and other social resources

In addition, poor Americans are more likely to reside in food deserts, communities with low or no access to food stores that sell fresh fruits and vegetables, whole-grain breads, fish, and other nutritious foods

Living in a food desert increases the risk for health problems such as obesity and obesity-related diseases

Neighborhood characteristics, such as walkability, the presence of food stores that offer plenty of healthy choices, and density of recreational facilities, also influence health

Multiple studies have linked rural environments with reduced opportunities for physical activity and increased levels of obesity

However, many exceptions to this general tendency exist

Non-Hispanic whites, for example, experience more suicides and drug overdose deaths than non-Hispanic blacks; in fact, largely because of these deaths, the mortality rate among middle-age non-Hispanic whites increased between 1999 and 2013 while it declined among all other racial and ethnic groups

In 2014, the U.S. Surgeon General published a National Prevention Strategy on the elimination of health disparitie

One of its key recommendations was to increase access to health care, especially among the communities at greatest health risk

Disparities in health also have significant financial costs

Racial and ethnic health disparities alone are estimated to cost the U.S. economy an estimated $35 billion in direct medical expenditures, $10 billion in lost productivity, and nearly $200 billion in premature deaths

Our social interactions and community environment strongly influence our health

Such factors include our level of social support, social norms and attitudes (including prejudice, discrimination, racism, and bullying), cultural influences, language barriers and levels of literacy, incarceration rates, and availability of community-based resources

immigration is expected to continue to diversify the U.S. population throughout the 21st century

The U.S. Census Bureau projects that between 2014 and 2060, as the population grows by about 98 million, the percentage of non-Hispanic whites will decline by more than a quarter

health disparities are differences in health that are "closely linked with social, economic, and/or environmental disadvantages."

These differences result from an unequal distribution of social resources, from education to housing to jobs that provide adequate health insurance and a living wage

City, county, and state governments can employ a variety of approaches to improve health equity

These efforts include improvements in standards for construction of public housing and businesses; changes to zoning ordinances to avoid the release of pesticides and other pollutants within a reasonable distance of residential neighborhoods; support for public transportation to increase accessibility to supermarkets, health care facilities, and schools and colleges; and policies or legislation to increase the minimum wage, ban environmental tobacco smoke in public spaces; build and staff community health care facilities; improve neighborhood walkability; or support famers markets or community gardens

There are also innumerable differences between people within groups

We may speak of "the Jewish experience" or "the experience of poverty," but the lives of individuals within any population group are unique and can vary dramatically

These increasing numbers of older adults will challenge us to expand age-appropriate health care and other social and community services from transportation to nutritious meals to programs that encourage social interaction and reduce isolation

Without these supports, many older people will move farther away from health equity

health equity

a condition characterized by an absence of avoidable or remediable differences in health and the attainment of optimal health for all

diversity

a condition characterized by varied compostion, espically under terms of culture, race/ethnicity, religion, sexual orientation, and the like

stereotyping

a generalized and typically negative attribute is assigned to an individual of a different population group

privilege

advantages and rights, often unearned, that are available to only some members of a society

disparities often cross populations

both black and white Americans who live in the Southeast have a much lower life expectancy than those who live in other parts of the country

Even the anticipation of discrimination increases stress

for example, an older worker who is accustomed to being honest might feel the need to lie about age on a job application to get hired

othering

interacting with people who are different as if they were intrinsically inferior to us in ways that make them less deserving of our respect and care

social determinants of health (SDOH)

social, economic, and physical conditions in the environments in which people live that affect a range of health, functioning, and quality-of-life outcomes and risks

Culture

the attitudes, beliefs, values, and behaviors characteristic of a group of people

difference

the recognition of another person as being unlike us in some important way

Reduce the Social Determinants That Contribute to Health Disparities

we must reduce the SDOH that significantly contribute to health disparities. Because these determinants are intertwined, they must be counteracted by systemic measures such as social programs, economic investment, reform of public education, improvements in mental health programs, reform of our criminal justice system, decreased segregation in our communities and institutions, and more funding for inclusive research into health care disparities.

Advocate for Yourself and Others

you can contribute to health equity by advocating for yourself and others. To do that, it helps to be able to recognize othering and discrimination when it happens to you and to take action to protect your health and change your interactions in the future