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The State of
Racial Inequalitiesin Health
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“As this generation comes
of age, the health status of
the nation will be areection of the health
of the people whom we
currently refer to as racial
and ethnic minorities.”
THE STATE OF RACIAL INEQUALITIES
IN HEALTH
Thomas A. LaVeist, PhD
William C. and Nancy F. Richardson Professor in Health Policy
Director, Hopkins Center for Health Disparities Solutions
Johns Hopkins Bloomberg School of Public Health
INTRODUCTION
The 20th century witnessed a literal change in the “face of America.” At the dawn of
the century, the racial “color-line” described by W.E.B. DuBois1 was mainly drawn
between black and white Americans. The 19th century’s Manifest Destiny policies
had rendered Mexicans as immigrants in their native land, and left what remained
of the American Indian nations defeated and living on reservations. The countrywas only a few decades removed from slavery, but former slaves lived among whites
as constant reminders of an ignoble history at odds with the noble principles of the
nation’s founding declaration that all men are created equal.
As the 20th century approached its nal decades, there was increasing recognition
that the nation’s demographic prole was experiencing a transition. In 1950 non-
Hispanic whites comprised about 90 percent of the population. By 2010 the per-
centage had declined to about 69 percent. The Census Bureau projects that by the
middle of the 21st century, non-Hispanic whites will comprise a numerical minority
of the population. Already, more than 50 percent of the population younger than age
5 are minorities. And, according to the U.S. Department of Education, the majority
of public school students in the United States are racial or ethnic minorities. As this
generation comes of age, the health status of the nation will be a reection of the
health of the people whom we currently refer to as racial and ethnic minorities. This
portends a signicant decline in the overall health of the nation if we do not make
progress in improving minority health.
This paper presents an overview of the state of health inequalities in the United
States. The rst section provides a brief history of the major developments in the
national effort to address health inequalities, from publication of The Report of the
Secretary’s Task Force on Black and Minority Health, also known as the Heckler
Report , to the present. Part Two focuses on alternative methods for quantifying
disparities, the impact on individual health, broader economic effects, and the role
of social determinants. The nal section outlines directions for future efforts to
eliminate health inequalities.
PART 1: A BRIEF RECENT HISTORY OF EFFORTS TO
ADDRESS HEALTH INEQUALITIES
The year 1985 marked the emergence of minority health and health disparities into
the nation’s consciousness2. That year the U.S. Department of Health and Human
Services (DHHS) issued the Heckler Report , in honor of Margaret M. Heckler, the
department’s secretary. Based mainly on data from 1980, the 10-volume report
documented the dire state of the health of racial and ethnic minorities across key
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health indicators. In response to that report, DHHS received congressional authori -
zation to establish the Ofce of Minority Health (OMH) in 1986 and the Ofce of
Minority Health Resource Center in 1987.
Other developments followed: In 1990, DHHS Secretary Louis Sullivan appointed John Rufn as associate
director of Minority Programs and director of the newly established Ofce of
Minority Programs (OMP) at the National Institutes of Health.
Also in 1990, the Ofce of Disease Prevention and Health Promotion coor -
dinated federal agencies, businesses, and community organizations to establish
Healthy People 1990, a comprehensive, nationwide health promotion and dis-
ease-prevention agenda that included a set of goals to “increase quality and years
of life” and “eliminate health disparities.”
In 1993, Congress replaced OMP by establishing the Ofce of Research on
Minority Health (ORMH).
In 2010 DHHS released Healthy People 2020 with a new set of 10-year goalsand objectives for health promotion and disease prevention.
The rst decade of the 21st century brought renewed attention to minority health and
health inequalities. President Clinton signed the Minority Health and Health Dispar-
ities Research and Education Act of 2000, which enhanced support for biomedical
and behavioral research on minority health, supported training, and established
the National Center on Minority Health and Health Disparities to replace ORMH.
The center was elevated to institute status at NIH when the Patient Protection
and Affordable Care Act renamed it the National Institute on Minority Health and
Health Disparities.
Reports from such venerable sources as the National Research Council, the sur -
geon general, and the Institute of Medicine brought much needed gravitas to the
health-disparities issue, which was still ghting to gain credibility in the face of
some who argued, in spite of the overwhelming evidence, that health disparities did
not exist (Klick and Satel 2006).
Between 1998 and 2002, Surgeon General David Satcher issued a series of reports
documenting dramatic disparities across a variety of health-related topics, includ-
ing tobacco (DHHS 1998, DHHS 2000, and DHHS 2001), mental health (DHHS
1999 and DHHS 2001), oral health (DHHS 2000), and youth violence (DHHS 2001).
The Institute of Medicine (IOM) of the National Academies also published several
relevant reports. These included Crossing the Quality Chasm: A New Health System
for the 21st Century (IOM 2001), which highlighted the importance of attending to
health care quality and not just expanding access to care, and Unequal Treatment:
Confronting Racial and Ethnic Disparities in Health Care (IOM 2002), comprehen-
sive documentation that racial and ethnic minorities have less access to health careand that the care they get is often of poor quality. The National Research Council
(NRC) of the National Academies conducted a series of assessments and analyses
of the NIH minority research and training programs that had been initiated by the
ORMH. This resulted in the 2005 report Assessment of NIH Minority Research and
Training Programs: Phase 3 (NRC 2005), which examined the effectiveness of the
programs and provided recommendations for improvement. And in 2006, the IOM
issued the report Examining the Health Disparities Research Plan of the National
Institutes of Health: Unnished Business (IOM 2006).
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Perhaps more than any other report, IOM’s Unequal Treatment presented a com-
pelling case supporting the existence of health care disparities and placed the issue
rmly on the national health policy agenda. This report was so successful because
it limited its scope in two fundamental ways: (1) the report was not about disparities
in health status, and (2) the report was not about health care access. With some past
reports on disparities, opponents of devoting resources to addressing race inequal-
ities in health pointed out that limitations in access to care resulted from multiple
complex societal factors, including employment status, and geography. Some would
even argue that there were racial/ethnic differences in patient behavior, with minori-
ties more likely to delay seeking care and/or refusing to consent to some procedures.
This line of reasoning offered the position that these were broad societal problems
not easily addressed through medical intervention, health policy, or reallocation of
health care resources. Unequal Treatment brilliantly avoided this pitfall by exclud-
ing these topics. Instead, the report compiled the results of well-designed studies of
racial and ethnic differences in quality of health care among patients who were both
insured and sought care. The mountain of evidence the IOM committee uncovered
was impossible to ignore.While the issue of health disparities became common knowledge among policymak-
ers and health researchers, it was not as widespread among the general public. A
2010 poll surveyed 3,159 American adults of diverse racial/ethnic backgrounds, rep-
licating a similar poll conducted in 1999 (Benz et al. 2011). Results of the poll are
summarized in Table 4. The study found that 59 percent of Americans in 2010 were
aware of racial and ethnic disparities among African-Americans and Hispanics, a
modest increase over the 55 percent recorded in 1999. Also, while 89 percent of
African-American respondents were aware of the disparities compared with whites,
only 55 percent of whites were aware. While the African-American awareness rate
was strong, there was relatively little awareness among racial and ethnic minority
groups about disparities that disproportionately affected their own communities.
For example, only 54 percent of African-Americans were aware of disparities in the
rate of HIV/AIDS between African-Americans and whites, and only 21 percent of
Hispanics were aware of those disparities between their group and whites.
Table 4.
Changes in public awareness of racial and ethnic disparities, 1999–2010
Percent of respondents aware
Disparities between whites and: 1999 2010
African-Americans and Hispanics or Latinos and
Asian-Americans or Pacific Islanders–a 52
African-Americans and Hispanics or Latinos 55 59
African-Americans 57 59
Hispanics or Latinos 53 61*
Asian-Americans or Pacific Islanders –a 18
a = data not collected
Note: Significance is between 1999 and 2010.
*=p
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PART 2: HEALTH COST OF THE COLOR LINE
The most commonly used method for summarizing racial and ethnic inequalities
in health is to report age-adjusted mortality rates, as in Figure 1. The chart
shows substantial variation in mortality rates by race/ethnicity and gender, withAfrican-American males having the highest mortality rate and Asian/Pacic
Islander females
having the lowest rate.
Regardless of race/
ethnicity, females have
a lower age-adjusted
mortality rate com-
pared with men, and
African-American
females have a higher
mortality rate than all
men with the exception
of African-American
and non-Hispanic
whites.
Age-adjustment is
done to account for
the differences in
the age distributions
of the various racial/
ethnic groups. As age
is strongly associated
with every major cause
of death, failing to
adjust for age when making racial or ethnic comparisons could lead to misleadingstatistics. As Table 1 displays, non-Hispanic whites have the highest median age
(41.2) compared with Hispanics, whose median age is nearly 14 years younger (27.4).
The oldest of the racial minority groups, Asians, have a median age nearly six years
younger than non-Hispanic whites.
However, while age-
adjustment can be useful
for making broad com-
parisons, it is important
to be cautious when using
only age-adjusted mor-
tality rates for comparing
racial/ethnic groups as thiscan also be misleading.
Age-adjustment alone does
not account for two other
sources of complication
when making statistical
comparisons between
the racial/ethnic groups.
Specically, some ma-
jor causes of death tend
Figure 1.
Deaths per 100,000 Persons
Age-adjusted mortality rates by
race/ethnicity and gender, 2011
0
200
400
600
800
1000Female
Male
Hispanic API Am IndianBlackWhite
Source: U.S. National Center for Health Statistics, National
Vital Statistics Reports, Volume 63, Number 3, Table 1
Table 1.
Median age of U.S. resident population byrace and Hispanic origin, 2009
Race/Ethnic Group Median Age
Non-Hispanic White 41.2
Non-Hispanic Black 31.3
American Indian, Alaska Native 29.5
Asian 35.3
Native Hawaiian, Other Pacific Islander 29.9
Hispanic 27.4
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to occur at younger ages than others. For example, homicide deaths tend to occur
among persons under age 35, while cancers deaths are more likely to occur among
persons over 60. Also, racial/ethnic minorities tend to acquire chronic diseases
(such as cardiovascular disease and cancer) at younger ages and also die of these
diseases at younger ages compared with non-Hispanic whites and Asians/Pacic
Islanders (APIs). As a result, the impact of some causes of death can be greater than
others with respect to lost human potential. The statistic “years of potential life lost”
(YPLL) accounts for this. YPLL computes the years of potential life lost, assuming
the person would have lived to age 75 if not for the untimely death. YPLL expresses
not only the fact that the deaths have occurred, but also that these premature deaths
take a heavy toll on a community by way of lost potential productivity within the
economy as well as the loss of the contributions of individuals to their families and
communities.
Table 2 displays YPLL by race and ethnicity for 2010. The table shows substantial
differences across the groups, with APIs having the lowest number of years of
potential life lost and African-Americans with the highest. The table also computes
the disparity in age-adjusted mortality rates and YPLL by comparing each groupto Asians/Pacic Islanders. The table shows that estimates of the racial/ethnic
disparities as measured by years of potential life lost reveal greater inequalities
compared with age-adjusted mortality. For example, the age-adjusted mortality rate
ratio for African-Americans compared with Asians/Pacic Islanders is 2.1, indicat-
ing that African-Americans’ deaths occur at about double the rate of deaths among
APIs. However, the rate ratio for YPLL of 3.2 indicates that the impact of wasted
potential that health disparities represent is even greater. The rate of YPLL among
African-Americans is more than triple the YPLL among Asians/Pacic Islanders.
Table 2.
Years of potential life lost by race and ethnicity, 2010
YPLLYPLL rate ratio
compared with API
Age-adjusted rate
ratio compared
with API
Total 6642.9
White 8329.5 2.7 1.7
African-Americans 9832.5 3.2 2.1
AIAN 6771.3 2.2 1.5
API 3061.2 1.0 1.0
Hispanic 4795.1 2.6 1.3
Comparisons of disparities in total mortality can also obscure the magnitude of
health inequalities, because there are differences by race/ethnicity in the proportions
of deaths from specic causes. Table 3 displays YPLL for leading causes of death
by race and ethnicity. The table also shows the percentage that each cause of death
contributes to total YPLL. While heart disease is the leading cause of death for all
American racial/ethnic groups, it is instructive to observe that cancer contributes the
greatest number of years of potential life lost for each group.
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Stroke accounts for more than 8 percent of all YPLL for Asians/Pacic Islanders.
This is more than double the percentage for all other racial/ethnic groups. Chronic
liver disease and cirrhosis accounts for 7.5 percent of YPLL for American Indians
and Alaska Natives, while Hispanics are the only other group with a YPLL per -
centage over 4. These two groups also have higher numbers of YPLL due to motor
vehicle injuries compared with all other groups. For African-Americans, both HIV
and homicide stand out as large contributors to YPLL. HIV accounts for 3.4 percent,more than double any other group, and homicide accounts for 8.4 percent. Together,
HIV and homicide account for nearly 12 percent of all years of potential life lost for
African-Americans. On the other hand, suicide only accounts for 2 percent of YPLL
for African-Americans, which is the lowest of all racial/ethnic groups. For whites
and Asians/Pacic Islanders, suicide accounts for more than three times as many
YPLL compared with African-Americans.
In addition to the complication of racial/ethnic differences in age distributions and
causes of death, another consideration for producing group comparisons of health
Table 3.
Years of potential life lost by selected leading causes of death by race and ethnicity, 2010
White African American AIAN API Hispanic/Latino
YPLL % of
total
YPLL % of
total
YPLL % of
total
YPLL % of
total
YPLL % of
total
All 6342.8 9832.5 6771.3 3061.2 4795.1
Heart disease 900.9 14.2 1691.1 17.2 820.6 12.1 400.1 13.1 598.1 12.5
Stroke 142.7 2.3 358.1 3.6 129.7 1.9 250.6 8.2 150.4 3.1
Cancer 1375.8 21.6 1796.7 18.2 929.5 13.7 874.7 28.6 951.2 19.8
Chronic lower respiratory
diseases
176.1 2.8 187.7 1.9 154.5 2.3 33.2 1.1 59.6 1.2
Influenza and pneumonia 66.7 1.0 109.8 1.1 99.3 1.5 38.4 1.3 57.5 1.2
Chronic liver disease and
cirrhosis
173.5 2.7 120.2 1.2 510.8 7.5 41.7 1.4 201.6 4.2
Diabetes mellitus 139.0 2.2 316.4 3.2 267.6 4.0 69.5 2.3 158.5 3.3
Alzheimer’s disease 12.4 0.2 10.0 0.1 8.8 0.1 3.2 0.1 8.4 0.2
HIV 39.9 0.6 329.5 3.4 46.1 0.7 10.7 0.4 74.9 1.6
Motor vehicle injuries 419.0 6.6 393.4 4.0 570.6 8.4 147.9 4.8 340.3 7.1
Other unintended injuries 435.0 6.9 218.9 2.2 449.6 6.6 46.5 1.5 191.2 4.0
Suicide 430.8 6.8 196.4 2.0 256.4 3.8 199.7 6.5 193.6 4.0
Homicide 138.7 2.2 821.2 8.4 256.4 3.8 68.8 2.3 238.0 5.0
All other causes 1892.3 29.8 3283.1 33.4 2271.4 33.5 876.2 28.6 1571.8 32.8
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inequalities is the substantial variation within groups. For example, age-adjust-
ed mortality rates and years of potential life lost both show that Hispanics have
a relatively good health prole compared with non-Hispanic whites. However, a
closer look at within-group variation among Hispanics reveals a more complex
story. Figure 2 displays age-adjusted mortality rates for specic Hispanic subgroups.
The gure shows substantial variation, whereby the age-adjusted mortality rate for
Central Americans is similar to the Asians/Pacic Islander population. However, the
Puerto Rican rate is comparable to non-Hispanic whites. Data similar to what is pre-
sented in Figure 2 is not readily available for other racial groups. However, several
studies suggest that nativity, where you are born, is an important source of variation
in health for other groups as well, including Asians/Pacic Islanders (Kandula et
al. 2007; Yu et al. 2004; Cho and Hummer 2001), and blacks or African-Americans
(Elo and Culhane 2010; Grifth et al. 2011).
In addition to variations in nativity, immigration status has also been identied
as an important source of variation. The “Hispanic paradox” has been well docu-
mented (see Medina-Inojosa et al. 2014 or Franzini et al. 2001 for reviews of this
literature). The Hispanic paradox refers to the phenomenon that Hispanics arecharacterized by low
socioeconomic status,
but have better than
expected health and
mortality outcomes.
There is robust litera-
ture in this area, and
some recent studies
have added nuance
to this pattern. For
example, a recent
study by Hayward et
al. (2014) supported
the Hispanic paradox
for mortality, but did
not nd the same
pattern for disability.
Instead they docu-
mented a substantially
higher rate of disabil-
ity compared with
non-Hispanic whites.
Additionally, a study
led by LaVeist-Ramos
(2012) compared health status, health behavior, and health services utilization of black Hispanics (people who are both black and Hispanic, such as from the Domin-
ican Republic, Cuba, or Puerto Rico) against non-Hispanic blacks (African-Amer -
icans who do not have Hispanic heritage) and non-black Hispanics (Hispanics who
do not have black heritage). Black Hispanics’ health behaviors resembled those of
non-black Hispanics or were similar to both non-black Hispanics and non-Hispanic
blacks. For health services outcomes, they resembled non-Hispanic blacks. However,
their health status was inuenced by both race and ethnicity, with black Hispanics
resembling both non-black Hispanic and non-Hispanic black people.
Figure 2.
Deaths per 100,000 persons
Age-adjusted mortality rates by
specific Hispanic origin and gender, 2011
Source: U.S. National Center for Health Statistics, NationalVital Statistics Reports, Volume 63, Number 3, Table 5
Other
Hispanic
Central
American
CubanPuerto
Rican
Mexican0
200
400
600
800
1000Female
Male
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PART 3: THE ECONOMIC COSTS OF UNEQUAL HEALTH
Since the publication of Unequal Treatment , health care advocates have relied on a
compelling social justice argument to press policymakers to direct resources toward
efforts to address racial and ethnic inequities in health, with the premise that doingso is in keeping with American values. LaVeist and colleagues (2011) tested whether
there was more to racial health inequities than the moral argument, given the enor-
mous social and psychic costs premature deaths impose on families and commu-
nities. The premature death of a working mother or father has negative impacts on
families that ripple throughout the economy in the form of lost income and wages,
forgone taxes, increased need for social and community services, and increased
need for Social Security survivors’ benets.
Three sets of analyses were conducted to estimate the economic burden of health
disparities in the United States: (1) direct medical costs of health inequalities, (2)
indirect costs of health inequalities, and (3) costs of premature death. The analyses
found:
1. In the four-year period between 2003 and 2006, 30.6 percent of medical care
expenditures for African-Americans, Asians, and Latinos were excess costs
that were the result of inequities in the health status of these groups.
2. Between 2003 and 2006, the combined direct and indirect cost of health
disparities in the United States was $1.24 trillion (in 2008 ination-adjusted
dollars). This is more than the gross domestic product of India, the world’s
12th-largest economy in 2008, and equates to $309.3 billion annually lost to
the economy.
3. Eliminating health disparities for minorities would have reduced direct medi-
cal care expenditures by $229.4 billion for the years 2003–2006.
4. Eliminating health inequalities for minorities would have reduced indirect
costs associated with illness and premature death by more than a trilliondollars between 2003 and 2006.
The large number of premature deaths among American racial and ethnic minority
groups represents a substantial loss of human potential, a loss of talent and pro-
ductivity that might otherwise have contributed to the betterment of society. By
imposing a substantial burden on the economy, health disparities cause suffering for
the entire society. While the scope of the challenge in addressing these inequities is
large, these ndings indicate that the same is true for the potential savings.
PART 4: SOCIAL DETERMINANTS AND HEALTH
INEQUALITIES
Social determinants of health refer to conditions in the environments in which
people live, work, learn, and play that affect a wide range of health, physical func-
tioning, and quality-of-life outcomes and risks. The social-determinants perspective
observes that conditions (e.g., social, economic, and physical) in these settings (e.g.,
school, church, workplace, and neighborhood) can affect health by placing persons
at increased exposure to health risks as well as limiting access to resources needed
to live a healthy lifestyle. In addition to the more material attributes of “place,” the
patterns of social engagement and sense of security and well-being are also affected
“The large number of
premature deaths among
American racial and eth-nic minority groups rep-
resents a substantial loss
of human potential, a loss
of talent and productivity
that might otherwise have
contributed to the better-
ment of society.”
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by where people live. Resources that enhance quality of life can have a signicant
inuence on population health outcomes. Examples of these resources include safe
and affordable housing, access to education, public safety, availability of healthy
foods, local emergency/health services, and environments free of life-threatening
toxins.
The World Health Organization’s Commission on Social Determinants of Health
published a comprehensive conceptual framework for understanding how social de-
terminants produce ill health, summarized in Figure 3. The framework recognizes
that the socioeconomic and political context of a society (both through formal policy
and through social norms and customs) interacts with characteristics of individuals
that are used to assign social status, such as income status, race, gender, and social
position. The society’s cultural norms determine the degree to which policies are set
that may benet or harm powerless individuals. Some possible examples to consider
are policies that produce income inequality, limit voting rights, or allocate insuf-
cient educational resources to low-income communities. Social norms can also im-
pact health through informal processes that create hierarchy from characteristics of
individuals, such as race, gender, or income status. For example, exposure to racismis an example of a social norm that has been well documented to affect health3.
Racism can affect health and produce health inequalities through three related
pathways: (1) structural factors such as the organization of society, (2) interpersonal
interactions such as discrimination, and (3) internalized racism. Perhaps the best-
documented example of structural racism and health is through racial residential
segregation (Williams and Collins 2001). Segregation has been documented to result
Social cohesion &
social capital
Material circumstances(living and working
conditions, food
availability, etc.)
Psychosocial factors
Behaviors and
biological factors
Health system
Socioeconomic
position
Social class
Gender
Ethnicity (racism)
Education
Occupation
Income
Socioeconiomic
and political
contest
Macroeconomicpolicies
Public policieseducation, health,
social protection
Culture andsocietal values
Social policies labour market,
housing, land
Governance
Impact on
equity in
health and
well-being
Structural determinants social determinants of
health inequities
intermediary determinants social determinants
of health
Figure 3.
The Commission on Social Determinants of
Health, Social Determinants Framework
Source: Solar O, et al. A Conceptual Framework for Action on the Social
Determinants of Health: Social Determinants of Health Discussion Paper 2.Geneva: World Health Organization; 2010.
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in race differences in health risks (LaVeist and Wallace 2000; Kwate 2008) and less
availability of resources needed to live a healthy lifestyle (Morland and Filomena
2007; Smith et al. 2007).
The effects of interpersonal racism stress have also been well documented. Forexample, racial discrimination has been associated with blood pressure (Dolezsar
et al. 2014; Krieger and Sidney 1996), substance use and abuse (Sanders-Phillips
et al. 2014), mental health (Hurd et al. 2014), and physical health (De Vogli et al.
2007). There is also large research literature on the effects of internalized racism
on health. Studies have demonstrated associations between internalized racism and
obesity and blood pressure (Tull et al. 1999), as well as mental health (Williams and
Williams-Morris 2000).
Since the 1990s several studies have examined the role of implicit bias in health
inequalities. Implicit bias is a positive or negative attitude toward a person, thing, or
group. Implicit bias is unconscious, and it sometimes is referred to as unconscious
bias (Greenwald and Banaji 1995). This differs from explicit bias, which is an at ti-
tude that somebody is consciously aware of having. Implicit bias has aspects of bothinterpersonal and internalized racism. It can be the underlying cause of interper-
sonal racism, for example, health care providers offering differential levels of care
to patients based on race/ethnicity (Green et al. 2007; Cooper et al. 2012; Sabin and
Greenwald 2014; Moskowitz et al. 2012 ). Individuals can also harbor implicit nega-
tive bias against their own racial/ethnic group (Ashburn-Nardo et al. 2003). This can
be a cause or consequence of internalized racism.
PART 5: SUGGESTED WAYS FOR MAKING PROGRESS IN
ADDRESSING DISPARITIES
The World Health Organization’s Commission on Social Determinants of Health
(WHO 2011) suggested four strategies in which policy can be deployed to addresshealth inequalities: (1) decreasing social stratication (e.g., power, prestige, wealth,
human capital, etc.); (2) decreasing exposure to risk; (3) lessening the vulnerability
or improving the ability of disadvantaged persons to cope with risk; or (4) interven -
ing through health care to reduce the unequal consequences of social determinants.
Decreasing social stratifcation would likely be the most impactful of these strat-
egies, yet seems the least likely remedy to be adopted. Several studies have docu -
mented better health in countries with less income inequality (Torre and Myrskyla
2014; Hiilamo 2014; Harling et al. 2014).
There is also evidence that decreasing exposure to health risks can eliminate
disparities. A study of black and white persons living together in an integrated
community found no race disparities in diabetes (LaVeist et al. 2009) or obesity
among women (Bleich et al. 2010), and a greatly reduced disparity in blood pressure(Thorpe et al. 2008). In this study, race differences in health risks exposures were
controlled because both race groups lived in similar social conditions. That dispar-
ities were mostly not present in this community indicates that racial/ethnic dispari-
ties are not immutable, and that when people are exposed to similar health risks they
have similar health outcomes.
Adopting a “Health in All Policies” (HiAP) approach can lessen the vulnerability
of disadvantaged populations. HiAP is based on the realization that policies in
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virtually every sector, e.g., education, housing, and criminal justice, can have an
impact on health. The HiAP approach is to conduct an assessment of all proposed
policies for their potential health impact (Collins et al. 2009). By conducting a
health impact assessment, the differential health impacts of a potential policy de-
cision are understood, public health is included in the policy discourse, and policy-
makers are able to see how their decisions can maximize positive health impacts,
minimize negative health impacts, and ensure that health impacts are distributed in
an equitable manner.
The Centers for Disease Control and Prevention (CDC) established Racial and
Ethnic Approaches to Community Health (REACH) in 1999 to address its Healthy
People 2010 goals of improving minority health and eliminating health disparities
(Jenkins et al. 2011; Liao et al. 2010). The REACH program empowers community
based-organizations to mitigate health risks in their communities. Evaluations
of REACH found that it was effective in addressing cholesterol screening and
diabetes-related amputations (Jenkins, et al. 2011; Liao et al. 2010), suggesting that
community-based approaches can be effective for improving the health of minority
populations.
Perhaps the most common (and likely least effective) approach to addressing racial/
ethnic disparities is to intervene through health care. The expansion of Medicaid
as part of the Patient Protection and Affordable Care Act attempts to address health
inequalities by increasing access to care to millions of uninsured Americans. This
is a necessary and appropriate step. However, there is overwhelming evidence that
expanding access to health care alone will not solve the health inequalities problem.
For example, this is precisely what the Institute of Medicine’s report Unequal Treat-
ment documented.
The elimination of health disparities, it seems, will likely be achieved through
multi-sectored approaches, bringing together stakeholders from various sectors
(including health care) and community members empowered with the resources
to nd solutions. Broad partnerships and collaboration are essential to eliminating
risks, transforming communities, and ending health inequality for all.
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NOTES
[1] In his seminal book The Souls of Black Folk (1903), W.E.B. Du Bois proposed
that “the problem of the Twentieth Century is the problem of the color-line.”
[2] There certainly were efforts to address health disparities before 1985, for exam-
ple, the creation of the Indian Health Service in 1955, and Medicare and Medicaid a
decade later. There were other efforts in the earlier part of the century as well. How-
ever, I focus on 1985 as the beginning of the modern national governmental effort
in policy and public health programming targeted to health inequalities by race
and ethnicity across the various groups. The post-1985 era is also distinct in that it
went beyond improving health care access, but also attempted to address population
health issues.
[3] See Feagin and Benneeld (2014); Dolezsar et al. (2014); and Paradies et al.
(2014) for recent reviews of the literature. Also see Paradies (2006) and Williams et
al. (2003), and Williams and Mohammed (2009).
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