Health Inequality, continued

One of our national health goals, as articulated by the Healthy People project, is to decrease health disparities, to make it possible for all groups to enjoy the rates of health and freedom from disease enjoyed by those groups with the best health. This is a tall order, and won't be achieved any time soon, but in recent years we have finally come to grips with the social justice dimensions of health status.

So here is a case study. Since the early to mid 1960s, the nation has been conducting an anti-tobacco campaign. Of course that campaign has been blocked by Big Tobacco, farmers in traditional tobacco states, cigarette retailers, and the hospitality industry. Nevertheless, there has been a continuous parade of small health promotion victories as we have learned more effective ways to discourage smoking by youth, developed better smoking cessation techniques, and put in place more public policies to block the promotion of tobacco products and reduce the presence of public smoking in workplaces and communities.

While these victories can and should be celebrated, we still have 45 million smokers in the U.S. The smoker proportion of the population has dramatically shrunk, from about 55% of adult men to now around 22%, and the absolute number of smokers is smaller than in years past, but 45 million still presents a huge challenge to the public's health. It represents an unacceptable drain on our health care system. What has happened over the years is that the profile of smokers has changed. Whereas in the past, smoking was more evenly distributed among all segments, predominantly males, but now it is increasingly clustered among low income groups with minimal education. Twenty years ago, the stereotype smoker was a white, middle class sales representative. Now, the typical smoker is a low income minority person in a blue collar job.

The reasons for this shift are many. Poorly educated persons are less likely to be aware of the overwhelming case against smoking and the benefits of quitting. People on the lower rungs of socioeconomic status often have less of a future orientation, and tend to feel powerless, even when it comes to managing their own health. They are less connected to national media, in which the dangers of smoking are widely accepted with no reservations. Because they are less likely to be getting regular health care, and in the setting where they get health care (e.g. an emergency room) they are unlikely to form a long term therapeutic relationship with the same provider, and therefore are less likely to have a physician who is mentoring them over time to quit. In addition, low income minority neighborhoods and groups are special targets of tobacco marketing. There are even brands of cigarettes designed to appeal to those segments of the market. Finally, to the extent that cessation can be aided by access to resources like Chantix, these groups have a more difficult time quitting.

The above description should illustrate that solving health inequities is more than giving people access to medical services and telling them health information. It requires a comprehensive approach that reaches even into the basic structures of society. Jesse Jackson is quoted with saying (I'm paraphrasing) "Rather than promoting school choice, how about working for a society in which every school is choice and every child is chosen." That is not our world, and until it is, health inequity will continue to diminish the potential of our nation.