1. Challenges to Eliminating Disparities in the US
Maternal and Child Health Epidemiology Conference
Plenary I: Measuring and Eliminating Racism and Racial Disparities in MCH: 
The Need for New Paradigms
Wednesday, December 10, 2008
Atlanta, GA
Challenges to Eliminating Disparities in the US
Vijaya K. Hogan, MPH, DrPH
Clinical Associate Professor, Dept Maternal and Child Health
Adjunct Assistant Professor, Dept OBGYN, UNC School of Medicine
Director, Curriculum on Health Disparities
Gillings Global School of Public Health
University of North Carolina at Chapel Hill

2. Outline What are disparities? What do disparities look like?
What causes disparities in health?
What challenges do we face in eliminating them?

3. What are disparities?

4. Disparity (definition)
When one group of people gets sick and/or dies at a higher rate than other groups of people

5. NIH definition
“differences in the incidence, prevalence, mortality and burden of diseases and other adverse health conditions that exist among specific population subgroups in the US”. (NIH)

6. UNC-CH definition
Inequities in disease and well-being that come from discrimination and unequal access to society’s benefits, such as quality education, good jobs, decent and affordable housing, safe neighborhoods and environments, nutritious foods, and adequate healthcare. These inequities result in disproportionately higher rates of death, disease, and disability and have adverse consequences on the physical, mental, spiritual, and social well-being of population groups who, historically and currently, do not experience equivalent social advantage. These groups include, for example, African Americans, American Indians, Hispanics/Latinos, Asian Americans, Hawaiians and Pacific Islanders, people with disabilities, Lesbian/Gay/Bisexual/Transgender/Queer persons, and people with lower incomes.
Workgroup on Engaged Institution for Eliminating Racial and Ethnic Health Disparities, 2007

7. In the US:
African Americans, Native Americans and subgroups of Latinos and Asians are more likely to get sick and die sooner than other groups of people.

8. What do disparities look like?

9. How Long People Are Expected To Live
Years
White
Black
This graph shows disparity in life expectancy for black vs whites in USWhites have about a 10 year advnatage over blacks in the US
1900
1950
1970
1990
1960
1980
1996
SOURCE: CDC/NCHS, National Vital Statistics Systems,

10. Age-Adjusted Death Rates United States

11. How likely it is that a baby will die before age 1 in the US

12. How likely it is that a baby will be born too soon

13. Respondent-Assessed Health Status
Fair or Poor health (age-adjusted)
Total Hispanic
Non-Hispanic White
Non-Hispanic black
Percentage
SOURCE: CDC/NCHS, National Health Interview Survey,

14. Obesity (BMI<= 30.0) Female Whites Blacks Mexican Americans Percent
SOURCE: CDC/NCHS, Second National Health and Nutrition Examination Survey, Third National Health and Nutrition Examination Survey,

15. Percent of Philadelphia Childbearing Women with a Shelter Episode: By Race/Ethnicity, Education, and Parity
Culhane, 2003

16. Now what do we do to get rid of them?
Disparities exist.
Okay, we get that.
Now what do we do to get rid of them?

17. All knowledge production in the area of health disparities should be aimed toward understanding why they exist and most importantly, what can we do to eliminate them.

18. What causes disparities?

19. The Circles of Influence on Health
-This figure, which is adapted from George Kaplan’s framework for a multilevel approach to epidemiology, draws heavily from a socio-ecologic understanding of health and health behavior.
-Basically, social ecology posits that individual, and in turn, population health reflects the dynamic interplay between multiple levels of effect. Social ecology acknowledges the nesting of individuals within other, higher domains of influence including social relationships, organizations, neighborhoods, etc., and suggests that such domains affect health alone, and in interaction with, each other. These domains serve as the context for individual action, including health behaviors, and thus, can facilitate or impede individual and/or population ability to achieve health.
-Extending this logic to the dilemma of health disparity and disparity in mammography outcomes specifically, forces a shift in the conceptualization of disparity as explained by primarily individual-level characteristics (or differences between groups of individuals) to being a consequence of determinants existing on all levels of the social ecological framework. From this perspective, understanding disparity in mammography outcomes necessitates identifying what these other, higher-level influences of screening behavior are and examining how and why such determinants condition disparate screening outcomes between groups of women.
Kaplan, et al. (2000). A Multilevel Framework for Health in :Promoting Health. Washington, DC: National Academy Press

20. Disparity: Contributing factors
Racism
Economic factors
Neighborhood factors
National, state or local Policies
Behavior* * Not shown to be consistent contributor across all diseases
Culture
Social factors
Environmental factors
Stress and “Weathering”
Health care
(Kington and Nickens)
in: America Becoming: Racial Trends
and their Consequences,
National Academy Press,2000

21. What challenges do we face in eliminating disparities?

22. Challenge # 1
Limitations in knowledge, research and clinical practice present barriers to eliminating disparities
Example: prenatal care and preterm birth
We have to actually have an effective prevention strategy or treatment for the disease to be able to make a difference in the disparity

23. Preterm Delivery Rates by Maternal Race/Ethnicity and Trimester of Initial Prenatal Care Singletons, United States, 2000

24. Challenge #2
Reducing disease is not the same as reducing the disparity
Reducing disparity requires different actions above and beyond evidence-based risk/prevention interventions

25. Infant Mortality Rates Due to SIDS, United States by race, 1973-1998
AAP
SIDS Campaign
Evidence based strategies to create declines in disease do not necessarily create decline in disparity.

26. Challenge #3
We do not consistently distinguish between health care disparity and health outcome disparity
Differences in medical care is only one of many contributors to overall health disparities

27. Is it this?
But not if the distribution looks like this…which for most cases is probably a little closer to the truth. Currently I’d estimate the US spends 80% of resources on health care factors without really knowing if this is the largest contributor and with most thinkers believing social causes are larger.

28. Or this?
But not if the distribution looks like this…which for most cases is probably a little closer to the truth. Currently I’d estimate the US spends 80% of resources on health care factors without really knowing if this is the largest contributor and with most thinkers believing social causes are larger.

29. Challenge #4
Causality is more complex than we acknowledge: intersecting risks

30. What makes African American populations different and at higher risk
What makes African American populations different and at higher risk? Complexity of causality: Overlapping of risk
Prevalence
Risk Factor Pop A Pop B
A 20% 19%
B 20% 18%
C 20% 22%
D 10% 10%
Any 3 5% 45%
Another analytic issue to make note of: these po’s look similar. Prevalence's look the same, therefore we would conclude no difference in populations. However,. If we look at the structure of how these risks are distrib relative to each other, we see an entirely different picture. Pop B has more women with a multitude of these individual risks.

31. Similar population risk prevalence; different configurations between populations: multiple interacting risks
Subpopulation of B
with multiple overlapping risks
Population B
Population A

32. Qualitative Evidence: Harlem BirthRight Project
Identified unique stressors for African American women (race X class X gender interactions)
Documented existence of stress in all aspects of African American women’s lives
Documented multiple concurrent stressors among African American women
The stress of constantly dealing with multiple burdens
“Sojourner Truth Syndrome”
Racism exacerbates other risks, limits resources to “unstress”
Mullings and Wali, 2001:
Stress and Resilience-the Social Context of Pregnancy in Central Harlem

33. Economic and Social Hardships during pregnancy, by ethnicity MIHA, 2002-2003
African American Anglo
< Poverty
Hard to make ends meet
Food insecurity
Food insecurity and hunger
No practical support
No emotional support
Separated or divorced
Homeless
Involuntary job loss
Partner job loss
Incarceration of partner
Domestic Violence
1-5 hardships
Source: Braverman P. (Center on Social Disparities in Health, UC-SF)) Presented at Jacobs Institute of Woman’s Health Conference, May 2005

34. Challenge # 5 Historical insults contribute to current disparities
Until the effects of past historical ills are undone, disparities will not be eliminated

35. American Slavery:
“The bound labor of at least twelve generations of black people”.
Slavery created wealth for slaveholders, wealth that was translated into extraordinary political power. The slave trade and the products created by slaves’ labor, particularly cotton, provided the basis for America’s wealth as a nation, underwriting the country’s industrial revolution and enabling it to project its power into the rest of the world.
Slavery and the Making of America (PBS)
We endured slavery for 246 years…

37. AFRICAN AMERICAN CITIZENSHIP STATUS & HEALTH EXPERIENCE
TIME SPAN
CITIZENSHIP STATUS -YRS
Experience accounts for this proportion of time in US
STATUS
HEALTH & HEALTH SYSTEM EXPERIENCE
246 years
64%
Chattel slavery
Disparate/inequitable treatment poor health status & outcomes. “Slave health deficit” & “Slave health sub-system” in effect
100 years
26%
Virtually no citizenship rights
Absent or inferior treatment and facilities. De jure segregation/ discrimination in South, de facto throughout most of health system. “Slave health deficit” uncorrected
41 years
10%
 Most citizenship rights: USA struggles to transition from segregation & discrimination to integration of AA
So. med school desegregation Imhotep Hospital Integration Conf , hospital desegregation in federal courts Disparate health status, outcomes, and services with apartheid, discrimination, institutional racism and bias in effect.
TOTAL
387 years
100%
HEALTH DISPARITIES/
INEQUITIES
 AFRICAN AMERICAN CITIZENSHIP STATUS & HEALTH EXPERIENCE
FROM 1619 TO 2006
Another important notion to keep in mind is the h/o AA’s in this country…250 years as slaves years under de jure segregation and discrimination. It has only been about 40 years since the passage of the Civil Rights Act, so only 10% of our existence in this country has been with most citizenship rights. Hence, African Americas have a 350 year handicap, we have a lot to “make-up” in order for AA’s to have an opportunity to eliminate these disparities.
“Struggle”
Source: Byrd, WM, Clayton, LA. An American Health Dilemma, Volume 1, A Medical History of African Americans and the Problem of Race: Beginnings to 1900, New York, NY: Routledge

38. Historical experiences of slavery, segregation, discrimination created economic and environmental disparities
Median family income for Blacks and Hispanics <$28K, Whites and Asians $>45K (Census, 1990)
Net wealth: Blacks $4,418, Whites $45,740
(Eller and Fraser 1995)
Blacks more likely to live in low-income, segregated areas-”concentration of risk”; residential segregation implies restriction in options for mobility
Blacks less likely to own homes
17% African Americans (in metro areas) live in extreme poverty; 1.4% Whites (in metro areas) live in
extreme poverty
Census, 1990

39. Challenge #6
Social factors are largest contributor to disparities; but often ignored. Medical factors get most focus and funding

40. “The causes of health disparities are multiple
“The causes of health disparities are multiple. They include poverty, level of education, inadequate access to medical care, lack of health insurance, societal discrimination and lack of complete knowledge of the causes, treatment and prevention of serious diseases affecting different populations. The causes {of health disparities} are not genetic, except in rare diseases like sickle cell…….Eliminating health disparities will require a cross-cutting effort, involving not only various components of the Federal government, but the private sector as well…
Ruth Kirstein, Acting Director of NIH. 2001

41. “….racial and ethnic disparities in health status largely reflect differences in social, socioeconomic, behavioral risk factors and environmental living conditions. Health care is therefore necessary but insufficient in and of itself to redress racial and ethnic disparities in health status. A broad and intensive strategy to address social-economic inequality, concentrated poverty, inequitable and segregated housing and education…individual risk behaviors as well as disparate access to medical care is needed to seriously address racial and ethnic disparities in health status”
Institute of Medicine—Unequal Treatment Report 2002

42. Potential Targets for intervention: Social Environment
The organization of the home we live in
The connections we have to other people
The neighborhood in which we live
Organization of our workplace (or school)
Our level of access to goods, services and resources of society
The built environment that surrounds us
Socioeconomic status
The way others in society treat us; the amount of power and/or control others have over us
The dominant political ethos/environment

43. Challenge #7
There does not yet exist an evidence base for how to eliminate disparities
And there is limited support for the development of one

44. Challenge # 8
Our way of doing business in health precludes the development of an evidence base.
We consistently and systematically eliminate any possibility of addressing social contributors (e.g. the largest contributors)
“Feasibility” as a criteria for choosing intervention strategies limits progress toward eliminating disparities

45. Change the question
How do we make it more feasible to address social contributors to health and health disparities?
I’ll come back to this in a moment

46. Summary of Challenges
We need more and better science to address today’s complex health issues, including disparities
Having an evidence based intervention for eliminating the disease does not necessarily eliminate the disparity
Health care disparity is only one of MANY contributors to health status disparities. Social factors, not just medical care factors contribute to adverse perinatal outcomes
Causality is more complex than we acknowledge: risks overlapping risk is one characteristic of populations vulnerability
Historical insults create current vulnerability; contribute to current disparities
Asked to give this talk to HS. Not sure of its relevance to you because I am certain that everyone here knows these things already. I am preaching to the converted. What I hope it will do is two things (1) remind you of the role of HS in this arena of disparity elimination and (2) recommit you to working and advocating for the critical programmatic needs to make a difference in your communities

47. Summary, cont
Social factors are the LARGEST contributors to health disparities. Medical factors and behaviors get most focus and funding
Evidence base for eliminating disparities does not exist; no dedicated funding source to support its development
“Feasibility” as criteria for choosing intervention strategies limits progress toward eliminating disparities

48. Conclusion Entails ALL of the following: Undoing historical inequities
Developing strategies for the elimination of disparities in perinatal health is complex:
Entails ALL of the following:
Undoing historical inequities
Undoing current social inequities
Addressing health system factors
Including Minority representation in practice and research
Addressing provider practices
Inequities in care
Non-action and accumulation of risk
Clinical practice standards
Timing of intervention
Improving health education for women
Improving the conditions under which woman can practice healthy behaviors
Improving relevance and quality of research
Developing an evidence base
Adopting authentic Community partnered processes for planning research and interventions

49. Racism Weathering Stress Poverty Smoking Family Support
Disparities
Weathering
Bad Housing
Unemployment
Social policy
Bad Neighborhoods
Hopelessness
Stress
Poverty
Limited Access
to Care
Adverse Environmental conditions
Smoking
And for AA families who continue to experience all of the sequela that accompany marginalized citizenship, we will continue to experience substantial health care disparities.
Under-
Education
Family Support
Poor Working Conditions
Racism
Lack of access
to good Nutrition
Adapted from A. R. James

50. Contact Vijaya K. Hogan, MPH, DrPH
Department of Maternal and Child Health
University of N Carolina at Chapel Hill