Population Health Blog

Population Health Blog

Why It Matters

Unequal Rates of Poverty and Access to Care Play a Role in Widening Health Disparities

By Sara Grossman

America’s alarming racial disparities have come to the forefront of our national consciousness in recent years, at least partly thanks to the activism of the Black Lives Matter movement and increased media coverage of racial inequality. Although this awareness is today more sensitized to disparities in incarceration, educational attainment, and poverty, there is in fact another area in which racial disparities run deep: health.

Some of the most concerning disparities exist in rates of chronic disease, such as diabetesobesity, and cardiovascular disease. Most recently, however, the Centers for Disease Control announced projections that, if current rates persist, one in two Black gay men and one in four Latino gay men in the United States will be diagnosed with HIV in their lifetime. This is compared to a projected 1 in 11 diagnoses for white gay men, and 1 in 99 for the general public.

Researchers say that heightened stress, unequal poverty rates, biases in healthcare, and disparate environmental factors may all contribute to these distressing outcomes. In the case of disparate HIV diagnoses, it is similarly difficult to pin down a single cause, although many public health researchers say that Black and Latino men may be particularly vulnerable to HIV infection due to continued stigmatization of homosexuality in their own communities.

“Stigma and marginalization are real barriers for minority MSM [men who have sex with men],” said Tina Sacks, a professor in the University of California Berkeley School of Public Health and a member of the Haas Institute’s Health Disparities research cluster. Sacks called the CDC’s predictions on HIV “astonishing.”

Unequal rates of poverty and access to care also play a role.

About 25 percent of African Americans are living below the federal poverty line, compared to around 12 percent for whites, according to the US Census. This is particularly notable as income is highly influential on health status, access to health care, and health insurance coverage, according to a report from the Commonwealth Fund. This means that a larger percentage of Blacks and Latinos are living in neighborhoods with poor housing options, perhaps in areas with greater pollution and environmental degradation, and reduced access to basic healthcare services.

Additionally, educational attainment is much lower for Blacks and Latinos than for whites and Asians. Educational achievement, like income, is correlated with access to (and use of) preventive services (such as yearly visits to the doctor or regular STD checks) and extended life expectancy.

Although “HIV infection is among the starkest disparities, other chronic disease conditions are similarly stark, like breast cancer,” Prof. Sacks added. “Black women are less likely to be diagnosed but more likely to die from it.”

However, “There’s no question that implicit and explicit bias in healthcare exists,” said Prof. Sacks.

“We know that Latinos and African Americans often don’t get the same standard of care [as other groups].” A doctor, for example, may assume that an individual won’t comply with standard treatment, so he or she doesn’t prescribe the treatment at all. “We see all kinds of biases within treatment,” she said.

The effects of these factors manifest in distressing health outcomes: Black Americans are significantly more likely to have a chronic illness or disability, with around half reporting a chronic condition, according to the Commonwealth Fund report. Additionally, nearly 7 in 10 Black individuals are overweight or obese, compared to around half of whites.

Broadly, Americans of color are more likely to have diabetes, which is “is especially important given diabetes’ role as a major risk factor for many other disorders,” write the authors of the Commonwealth Fund report. American Indians have the greatest risk of diabetes, and are twice as likely as whites to suffer from this condition. Black and Latino individuals are also significantly more likely to be diagnosed with diabetes than whites.

While some of these disparities are undoubtedly related to unequal poverty rates and lack of access to healthcare, even within particular groups at the same income level, people of color — African Americans in particular — fare worse. Although Black and white individuals with incomes at or above 200 percent of the poverty level are less likely to be living with a chronic illness than those with lower incomes, the disparity between the two races is actually greater at this income level than at lower ones.

One contributor that many health researchers highlight is that many people of color face higher stress levels than whites — both from daily racism and general life stress. According to the Mayo Clinic, long-term stress can “disrupt almost all of the body’s processes and increase the risk for numerous health problems.”

Some health researchers point to the persistence of poor birth outcomes for pregnant African American women as a prime example of the effects of such stress. Even as socioeconomic status increases, Black women continue to have far worse birth outcomes than women of other groups. Most starkly, black infants are 2.6 times more likely to die within the first year than white infants, generally due to low birth weight, birth defects, or premature birth.

Health disparities are a serious public health concern, with difficult and tangible effects on our society as a whole, as our health systems become strained under the weight of treating large groups of people whose conditions could have been avoided with better care, education, and resources.

The World Health Organization [WHO] notes that the unequal distribution of health-damaging experiences is in no way a ‘natural’ phenomenon. Rather, it says, is ‘the result of a toxic combination of poor social policies, unfair economic arrangements [where the already well-off and healthy become even richer and the poor who are already more likely to be ill become even poorer] and bad politics.”

Furthermore, the WHO writes, the development of a society can be judged “by the quality of its population’s health, how fairly health is distributed across the social spectrum, and the degree of protection provided from disadvantage as a result of ill-health.”

If these are the criteria of development, the United States has a lot of work to do.

Sara  Grossman is the communications and media specialist for the Haas Institute for a Fair and Inclusive Society, Berkeley, California.


Health is a critical component of prosperity

By Chris Allen

The following comments were offered to the Southeast Michigan Council of Governments during a public comment period earlier this year.The Southeast Michigan Council of Governments’ “Partnering for Prosperity – Economic Development Strategy for Southeast Michigan” is an impressive document. It certainly addresses most of the indicators of a healthy economy, at least from a traditional perspective: creating an environment conducive to business and residential growth, as well as tourism.

We were struck by how little health plays in this vision. Yes, health care systems are represented as an “amenity” in the region. But are comprehensive academic and research health systems merely amenities of a regional economy? They are part of the infrastructure that sustains an economic culture. It cures disease, repairs injuries, and keeps us going. Arguably, the health systems are as important to the infrastructure as the traditional water and sewer pipes, roads and bridges, and power grids are, as noted in this document.

As essential as high quality medical and surgical capabilities are — and the degree to which they bring return on investment to their communities — the economy of a region relies not on the ability of its health system to cure disease and repair injury, but the ability of a community to create health (rhymes with “wealth”). Health lessens the cost of sophisticated health care services. Health lessens the cost of absenteeism. Health lessens the cost of disability and un-productivity. It has been well-documented that the quality of a work environment is largely influenced by the mental and physical well-being of its workers, as well as its infants and elders.

We noted that “Strengthening Quality of Place” as an important consideration in business and personal location decisions.” Your document references “the quality of K-12 and post-secondary education systems, public infrastructure, and transportation connections…” You note the importance of culture, natural recreational experiences, entertainment. But how does health play a role in the quality of place? Wouldn’t a family want to know the quality of their regional health systems? And wouldn’t a business want to locate in a community that is healthy and prides itself on becoming healthier? They certainly would. After all, a healthy, fit employee thinks more clearly and is more productive. Increasingly, young families are choosing to live in communities that are healthy, and are proud of living healthy lives. And older residents are choosing to remain in their community, also looking to aging well.

All of what you say about place is valuable. But we would like you to consider one aspect of place that goes beyond the role of the health care industry as infrastructure for medical treatment or as an employer. Look upon health as wealth, and look at healthy communities as assets that enhance the definition of a “quality of place.” Consider the economic and social value of a community steeped in a “culture of health,” as opposed to a “culture of sickness and disability.” Would you want to live here?

Consider what is happening in Trenton, Taylor, Dearborn, Wayne, Westland, Inkster, and other communities that are adopting health as an essential value of their communities. People are walking and riding bicycles, they’re promoting more fresh and nutritious food consumption, and they’re learning how to cook a new way. they are improving their parks and digging community gardens. They also learning how to use their primary care medical home in a preventive way, not just when they’re sick or hurt.

Many of the attributes in your strategy fall into what we refer to as “population health,” the structural and environmental improvements that create a healthy place — one which promotes well-being, and thereby productive and a happier population. Housing, education, public safety, clean natural environment, transportation — you touch on all of these, some to a greater extent than others. But you don’t define them int he context of a healthy sense of place.

This is the lens through which we view our communities and region. We know that we need a robust economy to support our quality of life. We also know that we need a health and human infrastructure to create a healthy social fabric. We need more than water and sewer pipes, electrical lines, and roads. We need a public health system that is prepared to prevent disease, protect us in routine occurrences and during emergencies. We certainly agree that we need to invest in “critical infrastructure.” But why isn’t public health part of that infrastructure? Why is it assumed that somehow it will be there when the next epidemic strikes? We agree that “our infrastructure is an asset upon which we can build the economy, much of it is aging and in disrepair.” With all due respect to our public health departments, when was the last time they received significant investment?
We agree that we need to “enhance transportation connections,” with the key word being connections. Just as the “Walking Man” demonstrated how difficult it is for many workers to get to work, it is equally difficult for workers to get to health facilities, quality food retailers, and safe places to exercise. We need a creative transportation infrastructure that not only responds to needs, but anticipates opportunity to serve before there is need.

You note the demand for the top 10, high-wage careers. In this manufacturing, technological culture, this seems to make sense. But what about the health provider shortage? What about the critical need for health professionals at all levels of the industry? What about the crisis in managing the care of our elderly population? These may not be high wage jobs, but they certainly are in demand.

You have done a good job of focusing on many of the challenges and opportunities facing our region, from a strict economic lens. But what’s missing is the essential component of health. As we have noted, if we are able to create a culture of health in Southeast Michigan, we will be more productive and more attractive to businesses and people who are looking for a place to live and raise their families. If we can envision an economically prosperous region that cites health as the essential component of their wealth, imagine how much further we’ll be ahead.
Chris Allen is CEO of Authority Health.