You can get garden variety health advice from the daily newspaper, the "health" section of most book stores, and of course thousands of web sites. I'm hoping to present thought provoking and maybe change provoking thoughts about individual and community health. This blog is not just what to do about health, but how to think about it. I'm looking forward to an exchange of ideas with readers. July, 2010


Tuesday, August 16, 2011

Health Policy and Health Equity

For a few decades it has been recognized that health status is not evenly distributed across the community, and that this inequality is only partially based on individual lifestyle choices.  More often health disparities are greatly determined by social factors that establish patterns of poverty, housing, educational attainment, employment opportunities, neighborhood quality, community safety, and so forth. The unequal access to resources, opportunity and security is not always a function of racism and ethnic discrimination, but the effects tend to fall along racial lines.  It is not just that greater affluence almost always is associated with better health, though that is true.  It is also a function of the gap between rich and poor, the unequal distribution of resources. 

Here are some explicit examples of health disparities.  In the U.S., the infant mortality rate (in 2006) for white infants was 5.58, while the rate for black infants was 13.35, more than double.  About 8.2% of white children have asthma, while asthma is found in 18.4% of Hispanic children. In the 15-19 age group, white males have a homicide rate of 3.4, while the rate in Black males is 69.1.  Blacks have a coronary heart disease death rate of 162 while the rate in Asian/Pacific Islanders is 77.  About 12% of those with less than a high school education have diabetes; only 6% of those with more than a high school education have diabetes.  The rate of HIV infection is 7.2 for Asians, 8.2 for whites, 25 for Hispanics, and 74 for blacks.  While there are undoubtedly lifestyle choices involved in some of these examples, it is apparent that social factors are huge determinants.  Many times choice is limited by access to resources, which is socially determined.

Consider the following chart.  The legend and labels are too small, limited by the functionality of this blog space.  Nevertheless, it is still illustrative.  Each vertical line represents a U.S. state: Utah is the top line while West Virginia is the bottom line.  The dark portion of each line represents the number of healthy days per month reported by residents of that state.  States toward the top have the most healthy days; those near the bottom have the least.  The total length of each vertical bar represents income inequality, using a measure called GINI.  The higher the GINI score, the wider is the gap between rich and poor.  States near the top of the chart have the most equally distributed wealth; those at the bottom with the largest GINI scores have the most unequally distributed wealth.  The main point is that there is almost a perfect inverse relationship: the lower the income inequality the larger the number of monthly healthy days; the higher the income inequality, the lower the healthy days.

State-specific Gini index of inequality in number of healthy days and average number of healthy days --- United States, 2007. Source: Behavioral Risk Factor Surveillance System, 2007.

As it turns out, the U.S. stacks up poorly compared to most modern, developed nations in average life expectancy.  In many nations, men and women, on average, live longer than we do in the U.S.  However, our GINI score is also higher than that found in most modern nations: the gap between rich and poor is wider here than most other developed countries. Social and economic inequality makes us sick.  For this reason, many professionals believe that inequality must be one of the targets of health promotion if the public's health is ever to reach its genetic potential.

This brings us to the great ideological debate going on in our nation at the current time.  One side says that our society should reward hard work, ingenuity and risk-taking, that we should encourage independent initiative and avoid making people dependent on government benefits.  This school of thought puts its trust in the free enterprise system, and that if government do-gooders (like most health promoters) would get out of the way, people would naturally do what was in the best interest of them, and by extension, society as a whole.  The other side says that society and markets are inherently unfair, that people are not dealt equal cards.  Social and health inequalities will not correct themselves without organized community efforts, including public health and health promotion programs and policies.  Unless we intervene and regulate, wealth will be concentrated in fewer and fewer people, creating a rarefied oligarchy and a permanent underclass.  This is not only detrimental for the disadvantaged, but over time, is not good for society as a whole. 

What do you think is the right road?

1 comment:

health quotes said...

The unequal access to resources, opportunity and security is not always a function of racism and ethnic discrimination, but the effects tend to fall along racial lines.