Title: Social Inequalities in Health: Patterns, Causes, Interventions
1Social Inequalities in Health Patterns, Causes,
Interventions
- David R. Williams, Ph.D., MPH
- Harold W. Cruse Collegiate Professor of
Sociology, Professor of Epidemiology, - Research Professor
- Institute for Social Research
- University of Michigan
2Racial Disparities in Health
- In 2001, African Americans had higher death rates
than Whites for 12 of the 15 leading causes of
death. - Blacks and American Indians have higher
age-specific mortality rates than Whites from
birth through the retirement years. - The death rate for Blacks today is equivalent to
that of Whites some 30 years ago. - Hispanics have higher death rates than whites for
diabetes, hypertension, liver cirrhosis homicide
3There Is a Racial Gap in Health in Mid
LifeMinority/White Mortality Ratios, 2000
4Immigration and Health
- Immigrants of all racial/ethnic groups enjoy
better health (adult infant mortality) than
their native-born counterparts. - As length of residence in the U.S. increases, the
health of immigrants declines. - For example, infant and adult mortality, low
birth weight, poor health practices, multiple
indicators of morbidity increase for Latinos with
length of stay in the U.S.
Vega Amaro 1994 Finch et al. 2002
5Major Challenge
-
- What interventions, if any, can reverse the
downward health trajectory of immigrants with
length of stay in the U.S.? -
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8Diabetes Death Rates 1955-1995
Source Indian Health Service Trends in Indian
Health 1998-99
9Life Expectancy at Birth, 1900-2000
76.1
77.6
71.7
71.9
69.1
69.1
64.1
60.8
47.6
Age
33.0
Year
10Infant Mortality Rates, 1950-2000
11Infant Mortality
Health, United States, 2005
12Excess Deaths for Black Population
Levine et al. 2001
13The Persistence of Racial Disparities
- We have FAILED!
- In spite of a War on Poverty, a Civil Rights
revolution, Medicare, Medicaid, the Hill-Burton
Act, dramatic advances in medical research and
technology, we have made little progress in
reducing the elevated death rates of blacks
relative to whites.
Source NCHS 2000 Deaths per 1,000 population
14Why Disparities Exist?
- Racial differences in health are not primarily
caused by genetic factors
15What is Race?
- Pure races in the sense of genetically
homogenous populations do not exist in the human
species today, nor is there any evidence that
they have ever existed in the past Biological
differences between human beings reflect both
hereditary factors and the influence of natural
and social environments. In most cases, these
differences are due to the interaction of both.
American Association of Physical Anthropology,
1996
16Why Disparities Exist?
- Socioeconomic Status (SES) is a central but
incomplete explanation of racial differences in
health.
17SAT Scores by Income
Source (ETS) Mantsios N898,596
18SES and Race
- African Americans and multiple other minorities
have lower levels of education, income,
professional status, and wealth than whites.
These racial differences in SES are the major
reason for racial differences in health. - Education and income are generally more strongly
associated with health status than race. - Racial differences in health status decrease
substantially when racial groups are compared at
similar levels of SES.
19Determinants of Health of the Population
Source Candian Institute for Advanced Research,
AB/NWT 2002.
20Determinants of Health in the U.S.
U.S. Surgeon General, 1979
21Determinants of Health in the U.S.
McGinnis et al. 2002
22SES and Health Risks
SES is linked to Exposures to health
enhancing resources Exposures to health
damaging factors Exposure to particular
stressors Availability of resources to cope
with stress Health practices (smoking, poor
nutrition, drinking, exercise, etc.) are all
socially patterned
23Percent of persons with Fair or Poor Health by
Race, 1995
PoorBelow poverty Near poorlt2x poverty Middle
Income gt2x poverty but lt50,000 Source Parmuk
et al. 1998
24Percent of Men with Fair or Poor Health by Race
and Income, 1995
25Percent of Women with Fair or Poor Health by
Race and Income, 1995
26Race/Ethnicity and SES
- Race and SES reflect two related but not
interchangeable systems of inequality - In national data, the highest SES group of
African American women have equivalent or higher
rates of infant mortality, low birth-weight,
hypertension and overweight than the lowest SES
group of white women
27Infant Death Rates by Mothers Education, 1995
28Infant Mortality by Mothers Education, 1995
29Why Race Still Matters
- All indicators of SES are non-equivalent across
race. Compared to whites, blacks receive less
income at the same levels of education, have less
wealth at the equivalent income levels, and have
less purchasing power (at a given level of
income) because of higher costs of goods and
services. - Health is affected not only by current SES but by
exposure to social and economic adversity over
the life course. - Personal experiences of discrimination and
institutional racism are added pathogenic factors
that can affect the health of minority group
members in multiple ways.
30Why Disparities Exist?
- All indicators of SES are not the same across
racial/ethnic groups.
31Race/Ethnicity and Wealth, 2000Median Net Worth
Source Orzechowski Sepielli 2003, U.S. Census
32Wealth of Whites and of Minorities per 1 of
Whites, 2000
Source Orzechowski Sepielli 2003, U.S. Census
33Why Disparities Exist?
- In addition to SES, racism is an added burden.
34Racism Mechanisms
- Institutional discrimination can restrict
socioeconomic attainment a group differences in
SES a health. - Segregation can create pathogenic residential
conditions. - Discrimination can lead to reduced access to
desirable goods and services. - Internalized racism (acceptance of societys
negative characterization) can adversely affect
health. - Racism can create conditions that increase
exposure to traditional stressors (e.g.
unemployment). - Experiences of discrimination may be a neglected
psychosocial stressor.
35MLK Quote
...Discrimination is a hellhound that gnaws at
Negroes in every waking moment of their lives
declaring that the lie of their inferiority is
accepted as the truth in the society dominating
them. Martin Luther King, Jr. 1967
36Discrimination Persists
- Pairs of young, well-groomed, well-spoken college
men with identical resumes apply for 350
advertised entry-level jobs in Milwaukee,
Wisconsin. Two teams were black and two were
white. In each team, one said that he had served
an 18-month prison sentence for cocaine
possession. - The study found that it was easier for a white
male with a felony conviction to get a job than a
black male whose record was clean.
Source Devan Pager NYT March 20, 2004
37Percent of Job Applicants Receiving a Callback
Source Devan Pager NYT March 20, 2004
38Every Day Discrimination
- In your day-to-day life how often do the
following things happen to you? - You are treated with less courtesy than other
people. - You are treated with less respect than other
people. - You receive poorer service than other people at
restaurants or stores. - People act as if they think you are not smart.
- People act as if they are afraid of you.
- People act as if they think you are dishonest.
- People act as if theyre better than you are.
- You are called names or insulted.
- You are threatened or harassed.
39Everyday Discrimination and Subclinical Disease
- Everyday discrimination was positively related
with subclinical carotid artery disease
(intima-media thickness) for black but not white
women. - Everyday discrimination was positively related to
coronary artery calcification in the study of
Womens Health Across the Nation (SWAN)
Troxel et al. 2003 Lewis et al. 2005
40Arab American Birth Outcomes
- Well-documented increase in discrimination and
harassment of Arab Americans after 9/11/2001 - Arab American women in California had an
increased risk of low birthweight and preterm
birth in the 6 months after Sept. 11 compared to
pre-Sept. 11 - Other women in California had no change in birth
outcome risk pre-and post-September 11
Lauderdale, 2006
41Why Disparities Really Exist?
- Has anyone seen the SPIDER that is spinning this
complex web of causation?
Krieger, 1994
42Racial Segregation Is
- 1. Myrdal (1944) "basic" to understanding
racial inequality in America. - 2. Kenneth Clark (1965) key to understanding
racial inequality. - 3. Kerner Commission (1968) the "linchpin" of
U.S. race relations and the source of the large
and growing racial inequality in SES. - 4. John Cell (1982) "one of the most
successful political ideologies" of the last
century and "the dominant system of racial
regulation and control" in the U.S. - 5. Massey and Denton (1993) "the key
structural factor for the perpetuation of Black
poverty in the U.S." and the "missing link" in
efforts to understand urban poverty.
43How Segregation Can Affect Health
- Segregation determines quality of education and
employment opportunities. - Segregation can create pathogenic neighborhood
and housing conditions. - Conditions linked to segregation can constrain
the practice of health behaviors and encourage
unhealthy ones. - Segregation can adversely affect access to
high-quality medical care.
Source Williams Collins , 2001
44Racial Differences in Residential Environment
- The sources of violent crimeare remarkably
invariant across race and rooted instead in the
structural differences among communities, cities,
and states in economic and family
organization,p. 41 - In the 171 largest cities in the U.S., there is
not even one city where whites live in ecological
equality to blacks in terms of poverty rates or
rates of single-parent households. - The worst urban context in which whites reside
is considerably better than the average context
of black communities. p.41 - Source Sampson Wilson 1995
45Residential Segregation and SES
- A study of the effects of segregation on young
African American adults found that the
elimination of segregation would erase
black-white differences in - Earnings
- High School Graduation Rate
- Unemployment
- And reduce racial differences in single
motherhood by two-thirds - Cutler, Glaeser Vigdor, 1997
46Segregation Distinctive for Blacks
- Blacks are more segregated than any other
racial/ethnic group. - Segregation is inversely related to income for
Latinos and Asians, but is high at all levels of
income for blacks. - The most affluent blacks (income over 50,000)
are more highly segregated than the poorest
Latinos and Asians (incomes under 15,000). - Thus, middle class blacks live in poorer areas
than whites of similar SES and poor whites live
in much better neighborhoods than poor blacks. - African Americans manifest a higher preference
for residing in integrated areas than any other
group.
Source Massey 2004
47American ApartheidSouth Africa (de jure) in
1991 U.S. (de facto) in 2000
Source Massey 2004 Iceland et al. 2002 Glaeser
Vigdor 2001
48Why Disparities Exist?
- There racial/ethic differences in access to care
and the quality of care
49Race and Medical Care
- Across virtually every therapeutic intervention,
ranging from high technology procedures to the
most elementary forms of diagnostic and treatment
interventions, minorities receive fewer
procedures and poorer quality medical care than
whites. - These differences persist even after differences
in health insurance, SES, stage and severity of
disease, co-morbidity, and the type of medical
facility are taken into account. - Moreover, they persist in contexts such as
Medicare and the VA Health System, where
differences in economic status and insurance
coverage are minimized. -
- Institute of Medicine, 2002
50Ethnicity and Analgesia
- A chart review of 139 patients with isolated
long-bone fracture at UCLA Emergency Department
(ED) - All patients aged 15 to 55 years, had the injury
within 6 hours of ER visit, had no alcohol
intoxication. - 55 of Hispanics received no analgesic compared
to 26 of non-Hispanic whites. - With simultaneous adjustment for sex, primary
language, insurance status, occupational injury,
time of presentation, total time in ED, fracture
reduction and hospital admission, Hispanic
ethnicity was the strongest predictor of no
analgesia. - After adjustment for all factors, Hispanics were
7.5 times more likely than non-Hispanic whites to
receive no analgesia. - Todd, et al. 1993
51Disparities in the Clinical Encounter The Core
Paradox
- How could well-meaning and highly educated health
professionals, working in their usual
circumstances with diverse populations of
patients, create a pattern of care that appears
to be discriminatory?
52Why Disparities Exist?
- Minorities are under-represented in the health
professions
53Enrollment in Dental SchoolBlacks, Other Races,
Women
Source National Center for Health Statistics,
2003 1 Comparison years for women are 1971-72
with 1999-2000.
54Representation in the Health Professions
- Reducing the under-representation of minorities
in the health professions is one strategy to
improve both access to care and quality of care
for minority populations. - Physicians from under-represented minority
backgrounds are more likely than others to - Care for the uninsured and those with Medicaid
- Work in primary care specialties
- Practice in urban and rural under-served areas
Komaromy et al., 1996
55Race-concordance
- A study of black white patients in 16 urban
primary care practices found that both black and
white patients in race-concordant encounters had
visits that were on average two minutes longer
than in race-discordant medical encounters. - Patients in race-concordant visits reported
higher levels of satisfaction and more positive
judgments of physicians participatory
decision-making style - Independent ratings of audiotapes of the
encounters indicated that race-concordant visits
had a more positive emotional context (as
indicated by voice tone) and a slower pace
(slower speech by both the physician and the
patient). - Thus, increasing the racial diversity of health
care providers is likely to be an effective
strategy in improving health care experiences of
minority group members
Cooper et al. 2003
56Enrollment in Medical SchoolBlacks, Other
Races, Women
Source National Center for Health Statistics,
2003 1 Comparison years for women are 1971-72
with 1999-2000.
57Where No Disparities Exist or pattern is opposite
to the expected?
- Mental Health of African Americans is better than
expected
58Disparities in Mental Health
- Blacks have lower rates than whites of
- 1. Any Affective Disorder
- 2. Any Anxiety Disorder
- 3. Any Substance Abuse/Dependence
- 4. Any disorder
- Source Kessler et.al. (1994)
59Religious Services as Therapy?
- Several aspects of some religious services are
distinctive in the provision of opportunities to
articulate and manage personal and collective
suffering. Â - The expression of emotion and active
congregational participation can promote
collective catharsis in ways that facilitate
the reduction of tension and the release of
emotional distress. - There are parallels between all the key elements
of formal psychotherapy and the rituals of some
religious services. Â
 Griffith et al. (1980) Gilkes (1980)
Pargament et al. (1983)
60U.S. Life Expectancy at Age 20by Religious
Attendance
63.5
63.4
60.1
57.9
60.1
56.1
52.4
46.4
Age
Hummer et al. 1999
61Needed Interventions
- Policies to reduce inequalities in health must
address fundamental non-medical determinants.
62Guiding Principles
- Health Policy must be re-defined to include
policies in all sectors of society that have
health consequences. - Policies which improve average health may have no
impact on social inequalities in health. - We need policies that improve health overall and
targeted interventions to address social
inequalities. - Major gains are possible through strategies that
tackle health problems that occur most
frequently. - Families with children should be a priority.
63Reducing Inequalities -IHealth Care
- Improve access to care and the quality of care
- Give emphasis to the prevention of illness
- Provide effective treatment
- Develop incentives to reduce inequalities in the
quality of care
64A meaningful interpersonal relationship
- A good interpersonal relationship is the
cornerstone of a successful interaction between
provider client - Empathy, warmth, acceptance, and encouragement
must be present in the provider-client
relationship and communicated in a way that is
readily evident to the client. - Patients tend to be more dissatisfied about the
information they receive from their physicians
than about any other aspect of medical care
65Common Patient complaints
- Limited consultation and communication of
information - The provider's manner
- Waiting too long
- No privacy
- Receiving little respect from the office staff
- Bills,
- Perception that providers are more interested in
the disease than in the patient's health concerns
Smedley, Stith and Nelson, 2003 Stoeckle, 1987
Waitzkin Waterman, 1976
66Simple Language
- Many healthcare providers greatly over-estimate
the comprehension level of their patients - Often providers speak at a level that many of
their clients are not able to understand. - Health care information must be communicated in
simple, readily understood language. Specific
inquiry should be made regarding any
dissatisfaction with information received and any
additional information needed.
Smedley, Stith and Nelson, 2003
67Making Care Accessible
- Especially important for vulnerable populations
- National study found that
- 55 of uninsured persons delay seeking health
care because of inability to pay. - 30 of uninsured did not get the medical care
that they felt they needed, - 24 had times when they did not fill their
prescriptions - Ensuring access to care requires identifying and
eliminating both real and perceived barriers
Blendon et al., 1989 Politzer et al. 2001
Smedley, Stith and Nelson, 2003
68More Primary Care
- Care that will improve health and reduce
disparities must be primary care - Access to regular primary care can improve health
status and reduce health disparities at all
levels of income - Primary care is the most significant health care
variable associated with better health status
Politzer et al. 2001
69What is Effective Primary Care?
- Care that is regular and usual, user-friendly,
and engenders the trust of its patients - Services that are integrated and accessible
- Care delivered by providers who are accountable
for addressing majority of health care needs and
who develop and sustain effective
provider-patient relationships - Considers the context of family and community
- Care that emphasizes prevention
Institute of Medicine report 1996
70Need for Primary Care
- Minority and other economically vulnerable
populations are less likely to receive health
counseling on nutrition, physical activity,
smoking, drinking drug use, STDs, etc. - Racial disparities exist even on simple
preventive screening measures such as pap smears,
mammograms, and clinical breast exams - Healthy behaviors and preventive screenings can
reduce disease risks, detect disease in its early
stages, reduce illness premature death
Politzer et al, 2001 Smedley, Stith and Nelson,
2003.
71Culturally Sensitive Care
- Effective health care delivery must utilize
culturally sensitive approaches - Ethnic-specific health programs that use
culturally responsive techniques can be effective
in increasing utilization among minority groups - BUT, there are no clear standards of what
constitutes good cultural sensitivity training
and little rigorous evaluation of the impact that
such programs have on improving quality of care - Little attention is given in discussions of
cultural sensitivity to routine processes of
unconscious and unthinking discrimination
Takeuchi, Sue Yeh 1995 Smedley, Stith and
Nelson, 2003
72Cautions Regarding Cultural competence
- Some forms of content-oriented culturally
competent training that emphasize negative
stereotypes and lead to unconscious
discrimination. - Such unconscious bias is a likely contributor to
the pervasive pattern of racial and ethnic
differences in the quality and intensity of
medical care in the U.S. - In contrast, process-oriented approaches
emphasize understanding and responding to the
unique needs of every patient - Key aspects of culturally appropriate care
include devoting adequate time and attention to
the patient, providing individual or group
support, or both, and improved quality of care.
Smedley et al. 2003 Kehoe et al. 2003.
73Care that Addresses the Social context
- Effective health care delivery must take the
socio-economic context of the patients life
seriously - The health problems of vulnerable groups must be
understood within the larger context of their
lives - The delivery of health services must address the
many challenges that they face - Taking the special characteristics and needs of
vulnerable populations into account is crucial to
the effective delivery of health care services. - This will involve consideration of
extra-therapeutic change factors the strengths
of the client, the support and barriers in the
clients environment and the non-medical
resources that may be mobilized to assist the
client
74Active Outreach By Nurses
- A prospective randomized trial of 1,554 high-risk
pregnant women (72 Black) found that telephone
calls by nurses, one or two times each week - Were effective in reducing low birth weight
births - Resulted in cost saving for African American
mothers age 19 and over
Muender et al., 2000
75Community Workers
- A randomized controlled trial of young mothers
(97 Black) studied the effects of home visits by
nurses during pregnancy and the first two years
of life. - Women who received home visits had
- fewer subsequent pregnancies
- longer intervals between the 1st and 2nd births
- fewer months of using AFDC and food stamps
- and were more likely to live with the childs
father
Hayward, 2000
76Telemonitoring
- A randomized trial with African American
hypertensive clients found that nurse-managed
telemonitoring of the clients at home and in the
community, was successful in reducing both
systolic and diastolic pressure
Artinian, Washington and Templin, 2001
77Prenatal care in Guilford County, NC -I
- Standard prenatal care from private MDs compared
to a program developed by a group of nurse
practitioners - All women had incomes below the poverty level and
65 of the health departments clients and 82 of
the MDs clients were Nonwhite - The nurse practitioners attempted to
comprehensively address the medical and social
needs of the pregnant mothers. - At prenatal care visits nurses counseled about
nutrition, and other aspects of personal care,
and made referrals to WIC - These referrals missed clinic appointments were
aggressively followed up
Buescher et al., 1987
78Prenatal care in Guilford County, NC -II
- Women who received care from the community-based
physicians were twice as likely to have a low
birth weight baby, compared to those visiting the
nurse practitioners at the health department - The interpersonal quality of care and the
positive cultural features of the care provided
by the nurse practitioners may have been the key
to the observed differences in outcome - The nurse practitioners offered these low-income
women an extended network of social support,
capable of meeting their needs in the same way
that older, more knowledgeable women have
traditionally guided and supported young
inexperienced mothers
Buescher et al., 1987 James 1993
79Health Centers of Excellence
- Multiple strategies can be combined and
integrated into a package of care offered by
health centers - Health care centers have been shown to be very
successful in improving access to appropriate
healthcare and reducing disparities in health
status - These community centers work to reduce
eliminate access barriers in order to ensure that
clients have a usual and regular source of health
care - These centers provide
- comprehensive preventive and primary health care
services at low or no cost - a broad spectrum of assistance and enabling
services health education, nutritional
counseling, transportation, translation,
childcare, parenting classes, case management
Politzer et al., 2001
80The Center for Health and Wellness, Wichita, KS
- A state-of-the-art primary health care facility
- Illustrates how barriers to health care for
African Americans can be reduced - Started in 1998 and is directed by nurse
practitioner, Arneatha Martin - Almost 8,000 sq. ft. 6 exam rooms, the center
sees about 15,000 patients annually - Less than 30 percent of patients are insured and
the center uses a sliding fee scale for persons
without insurance provides uncompensated care
to the very poor
Center for Health and Wellness, 2002 MPH
Newsletter 2001
81The Center for Health and Wellness, Wichita, KS -
II
- A heavy emphasis on prevention and wellness
education and on decreasing high-risk behaviors.
- Attempts to deliver a seamless continuum of
comprehensive healthcare services - Has partnered with a broad range of service
providers to offer a coordinated network of
community support
82The Center for Health and Wellness Innovation
- All clients of the center know that their
insurance coverage and economic status are
unrelated to the care and quantity of services
that they will receive - This is dramatically communicated to every client
in that questions about insurance coverage or
payment for care are not raised at the end of the
health care visit, when the individual has
already received all their needed medical care - Clients can pay for services by volunteering at
the clinic 10 deducted from bill for every
hour volunteered at the center - Clients also deduct from bill for each hour spent
in health education classes. - Points earned by expectant mothers for each
prenatal appointment kept can be used to shop in
the centers Storks Nest a room full of baby
supplies
83Reducing Inequalities IIReducing Negative Health
Behaviors?
Behavioral risk factors account for only 10-20
of SES differences in mortality and morbidity
Interventions addressing health behaviors
alone are unlikely to eliminate
disparities. The experience of the last 100
years suggests that interventions on intermediary
risk factors will have limited success in
reducing social inequalities in health as long as
the more fundamental social inequalities
themselves remain intact.
House Williams 2000 Lantz et al. 1998 Lantz
et al. 2000
84Changes in Smoking Over Time -I
- Successful interventions require a coordinated
and comprehensive approach - The active involvement of professionals and
volunteers from many organizations (government,
health professional organizations, community
agencies and businesses) - The use of multiple intervention channels
(media, workplaces, schools, churches, medical
and health societies) -
Warner 2000
85Changes in Smoking Over Time -2
- The use of multiple interventions
- Efforts to inform the public about the dangers
of cigarette smoking (smoking cessation programs,
warning labels on cigarette packs) - Economic inducements to avoid tobacco use
(excise taxes, differential life insurance rates) - Laws and regulations restricting tobacco use
(clean indoor air laws, restricting smoking in
public places and restricting sales to minors) - Even with all of these initiatives, success has
been only partial -
Warner 2000
86Reducing Inequalities IIIAddress Underlying
Determinants of Health
- Improve conditions of work, re-design workplaces
to reduce injuries and job stress - Enrich the quality of neighborhood environments
and increase economic development in poor areas - Improve housing quality and the safety of
neighborhood environments
87Neighborhood Renewal and Health - I
- A ten-year follow-up study of residents in five
neighborhood types in Norway found that changes
in neighborhood quality was associated with
improved health. - Neighborhood improvements in a poorly functioning
neighborhood included a new public school,
playground extensions, a new shopping center with
restaurants and a cinema, a subway line extension
into the neighborhood, establishment of a sports
arena and park, and organization of activities
for adolescents by the municipal sports
association. - Residents of the area that had experienced these
dramatic improvements in its social environment
reported improved mental health 10 years later - This effect was not explained by selective
migration
Dalgard and Tambs 1997
88Neighborhood Renewal and Health - II
- An intervention in a poorly functioning
neighborhood in England was linked to improved
social interaction/cohesion and health. - This project refurbished housing (made it safe
sheltered from strangers), improved traffic
regulations, improved lighting strengthening of
windows, enclosed gardens for apartments, closed
alleyways, and landscaping. Residents involved in
planning process. - One year after the intervention had been in
place - Level of optimism, belief in the future,
identification with their neighborhood, trust in
other neighbors, and contact between the
neighbors had all increased. - Symptoms of anxiety and depression had declined.
Halpern, 1995
89Neighborhood Change and Health
- The Moving to Opportunity Program randomized
families with children in high poverty
neighborhoods to move to less poor neighborhoods. - It found, three years later, that there were
improvements in the mental health of both the
parents and the sons who moved to the low-poverty
neighborhoods.
Leventhal and Brooks-Gunn, 2003
90Reducing Inequalities IVAddress Underlying
Determinants of Health
- Improve living standards for poor persons and
households - Increase access to employment opportunities
- Increase education and training that provide
basic skills for the unskilled and better job
ladders for the least skilled - Invest in improved educational quality in the
early years and reduce educational failure
91Increased Income and Health
- A study conducted in the early 1970s found that
mothers in the experimental income group who
received expanded income support had infants with
higher birth weight than that of mothers in the
control group. - Neither group experienced any experimental
manipulation of health services. - Improved nutrition, probably a result of the
income manipulation, appeared to have been the
key intervening factor.
Kehrer and Wolin, 1979
92Income Change and Health
- A natural experiment assessed the impact of an
income supplement on the mental health of
American Indian children. - It found that increased family income (because of
the opening of a casino) was associated with
declining rates of deviant and aggressive
behavior.
Costello et al. 2003
93Economic Policy Health Policy!
- In the last 50 years, black-white differences in
health have narrowed and widened with black-white
differences in income
94Changes in Mortality Rates per 100,000
Population, Age 35-74, Between 1968 and 1978 (Men)
Cooper et al., 1981b
95Changes in Mortality Rates per 100,000
Population, Age 35-74, Between 1968 and 1978
(Women)
Cooper et al., 1981b
96Changes in Life Expectancy at Birth Between 1968
and 1978 (Men)
Cooper et al., 1981b
97Changes in Life Expectancy at Birth Between 1968
and 1978 (Women)
Cooper et al., 1981b
98Median Family Income of Blacks per 1 of Whites
Source Economic Report of the President, 1998
99Health Status Changes, 1980-1991
- Indicator 1980 1991
- Excess Deaths (Blacks) 59,000
66,000 - Infant Mortality
- Black/White Ratio, Males 1.9 2.1
- Black/White Ratio, Females 2.0 2.3
- Life Expectancy
- Black/White Gap, Males 6.9 8.3
- Black/White Gap, Females 5.6 5.8
-
Source NCHS, 1994.
100U.S. Life Expectancy at Birth, 1984-1992
NCHS, 1995
101Reducing Inequalities VEngage Multiple
Communities
- Knowledge of the extent of disparities and their
causes is a prerequisite for effective action - In the U.S., over 50 of whites and over 50 of
blacks are unaware that racial disparities in
health exist. - Partnerships needed with government, industry,
and other private organizations - Important role for community involvement in the
identification and management of interventions - Strengthen the capacity of community
organizations to take action
102A Call to Action
- The only thing necessary for the triumph of
evil is for good men to do nothing.
Edmund Burke, British Philosopher