1. A model for understanding disparities in health and health care Scott Commins & Dr. Raymond Greenberg

2. Figure 1 - Survival of males to the age of 65 in Harlem, Bangladesh, and among U.S. Whites in 1980 ( NEJM, 1990; 174).

3. Figure 2 - Life expectancy (in years) at birth by race and sex, United States, 1998. (Source: Health, United States, 2000 ) White Male Black Male Black Female Life expectancy at birth (years) White Female

4. Life Expectancy RACE Cause of Death

5. Figure 3 - Age-adjusted death rates from all causes by race and sex, United States, 1998. (Source: National Vital Statistics Reports 2000; 48 (11): 63) White Male Black Male Black Female Deaths per 100,000 persons White Female

6. Figure 4 - Age-adjusted death rates from heart disease by race and sex, United States, 1998. (Source: Natl. Vital Stat. Rep. 2000; 48 (11): 63) White Male Black Male Black Female Deaths per 100,000 persons White Female 50

7. Figure 5 - Age-adjusted death rates from cancer by race and sex, United States, 1998. (Source: Natl. Vital Stat. Rep. 2000; 48 (11): 63) White Male Black Male Black Female Deaths per 100,000 persons White Female 0

8. Figure 6 - Age-adjusted death rates from stroke by race and sex, United States, 1998. (Source: Natl. Vital Stat. Rep. 2000; 48 (11): 64) White Male Black Male Black Female Deaths per 100,000 persons White Female 0

9. Figure 7 - Age-adjusted death rates from diabetes mellitus by race and sex, United States, 1998. (Source: Natl. Vital Stat. Rep. 2000; 48 (11): 63) White Male Black Male Black Female Deaths per 100,000 persons White Female 0

10. Figure 8 - Age-adjusted death rates from hypertension by race and sex, United States, 1998. (Source: Natl. Vital Stat. Rep. 2000; 48 (11): 63) White Male Black Male Black Female Deaths per 100,000 persons White Female 0

11. II. What is it about race? Understanding the basics: Do racial differences exist in socioeconomic indicators?

12. Figure 9 - People living in poverty by race, United States, 1999. (Source: US Census Bureau ) WhiteBlack 0

13. Figure 10 - Educational attainment of adults 25 years or older by race, United States, 2000. (Source: US Census Bureau ) < H S Grad H S Grad Some College Grad + 0

14. Figure 11 - Quintiles of household income by race, United States, 1999. (Source: US Census Bureau ) IIIIIIIVV 0

15. III. Do the differences in SES indicators affect health? Proposing a model: How do we examine the cause(s) of disparities in health?

16. Substandard Living Conditions Unemployment Poor Nutrition Risk- Promoting Lifestyle Diminished Access to Health Care Poverty/Lower SES

17. Figure 12 - Percentage of persons under age 65 years with private medical insurance by income, United States, 1997. (Source: Health, United States, 2000 ) % of Poverty Level <100100-149150-199 200 + Private Medical Insurance (%) 0

18. Figure 13 - Percentage of persons under age 65 years with private medical insurance by race, United States, 1997. (Source: Health, United States, 2000 ) WhiteBlack Private Medical Insurance (%) 0

19. Figure 14 - Percentage of persons 18 years or older with 2 or more emergency room visits in the past year, United States, 1998. (Source: Health, United States, 2000 ) Poor Near Poor Non- Poor Persons with two or more ER visits/year (%) 0

20. Figure 15 - Percentage of children less than 18 years old with no usual source of health care, United States, 1997-98. (Source: Health, United States, 2000 ) Poor Near Poor Non- Poor Children with no usual source of health care (%) 0

21. Substandard Living Conditions Unemployment Poor Nutrition Risk- Promoting Lifestyle Diminished Access to Health Care Poverty/Lower SES

22. Figure 16 - Percentage of children 1-5 years old with blood lead levels  10 ug/dl by family income, United States, 1991-94. (Source: NHANES III, 1996) Children with high blood lead levels (%) Low MiddleHigh 0

23. Figure 17 - Percentage of persons with blood lead levels  10 ug/dl by family income, United States, 1991-94. (Source: NHANES III, 1996) Persons with high blood lead levels (%) Low MiddleHigh 0

24. Substandard Living Conditions Unemployment Poor Nutrition Risk- Promoting Lifestyle Diminished Access to Health Care Poverty/Lower SES

25. Figure 18 - Percentage of children age 16 years or less with food insufficiency by family income, United States, 1988-94. (Source: NHANES III, 1996) Children with food insufficiency (%) Low MiddleHigh 0

26. Figure 19 - Percentage of children 6-16 years old with iron deficiency by family income, United States, 1988-94. (Source: NHANES III, 1996) Children with iron deficiency (%) Low MiddleHigh 0

27. Substandard Living Conditions Unemployment Poor Nutrition Risk- Promoting Lifestyle Diminished Access to Health Care Poverty/Lower SES

28. Figure 20 - Unemployment rate of civilian labor force age 20 years or older by race and sex, United States, July, 2001. (Source: Bureau of Labor Stats., July, 2001) White Male Black Male Black Female Percent unemployed White Female

29. Substandard Living Conditions Unemployment Poor Nutrition Risk- Promoting Lifestyle Diminished Access to Health Care Poverty/Lower SES

30. Figure 21 - Prevalence of cigarette smoking among white males 25 years or older by educational attainment, United States, 1998. (Source: Health, United States, 2000 ) < H S Grad H S Grad College Grad + Prevalence of cigarette smoking (%) Some College 0

31. Figure 22 - Prevalence of cigarette smoking among adults by employment status, South Carolina, 1995-96. (Source: SC Prevention Adult Household Telephone Survey, 1995-96) UnemployedEmployed Prevalence of cigarette smoking (%)

32. Figure 23 - Prevalence of cigarette smoking among persons 25 years or older by race and sex, United States, 1998. (Source: Health, United States, 2000 ) White Male Black Male Black Female Prevalence of cigarette smoking (%) White Female 15

33. Figure 24 - Prevalence of obesity by race and sex, United States, 1988-94. (Source: Health, United States, 2000 ) White Male Black Male Black Female Prevalence of obesity (%) White Female 10

34. Substandard Living Conditions Unemployment Poor Nutrition Risk- Promoting Lifestyle Diminished Access to Health Care Poverty/Lower SES

35. An Illustrative Example: Childhood Lead Toxicity IV. Employing the Model

36. Good Health Care? You memorized the high lead threshold and used proper medical intervention, but have you addressed the underlying issues? Probably not, because doing so requires identification of the contributing factors and intervening on numerous levels...

37. Contributing Factors Unhealthy environment - Increased risk of exposure to lead-based paint Parental education - Lack of knowledge regarding hazards Access to care - Poor screening results in delayed detection and treatment

38. Public Health Perspective Treating the lead poisoning alone may not be sufficient for this child Treating this child alone may not be sufficient for the community