4.8: Health Disparities and Inequalities
- Page ID
- 124749
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\(\newcommand{\avec}{\mathbf a}\) \(\newcommand{\bvec}{\mathbf b}\) \(\newcommand{\cvec}{\mathbf c}\) \(\newcommand{\dvec}{\mathbf d}\) \(\newcommand{\dtil}{\widetilde{\mathbf d}}\) \(\newcommand{\evec}{\mathbf e}\) \(\newcommand{\fvec}{\mathbf f}\) \(\newcommand{\nvec}{\mathbf n}\) \(\newcommand{\pvec}{\mathbf p}\) \(\newcommand{\qvec}{\mathbf q}\) \(\newcommand{\svec}{\mathbf s}\) \(\newcommand{\tvec}{\mathbf t}\) \(\newcommand{\uvec}{\mathbf u}\) \(\newcommand{\vvec}{\mathbf v}\) \(\newcommand{\wvec}{\mathbf w}\) \(\newcommand{\xvec}{\mathbf x}\) \(\newcommand{\yvec}{\mathbf y}\) \(\newcommand{\zvec}{\mathbf z}\) \(\newcommand{\rvec}{\mathbf r}\) \(\newcommand{\mvec}{\mathbf m}\) \(\newcommand{\zerovec}{\mathbf 0}\) \(\newcommand{\onevec}{\mathbf 1}\) \(\newcommand{\real}{\mathbb R}\) \(\newcommand{\twovec}[2]{\left[\begin{array}{r}#1 \\ #2 \end{array}\right]}\) \(\newcommand{\ctwovec}[2]{\left[\begin{array}{c}#1 \\ #2 \end{array}\right]}\) \(\newcommand{\threevec}[3]{\left[\begin{array}{r}#1 \\ #2 \\ #3 \end{array}\right]}\) \(\newcommand{\cthreevec}[3]{\left[\begin{array}{c}#1 \\ #2 \\ #3 \end{array}\right]}\) \(\newcommand{\fourvec}[4]{\left[\begin{array}{r}#1 \\ #2 \\ #3 \\ #4 \end{array}\right]}\) \(\newcommand{\cfourvec}[4]{\left[\begin{array}{c}#1 \\ #2 \\ #3 \\ #4 \end{array}\right]}\) \(\newcommand{\fivevec}[5]{\left[\begin{array}{r}#1 \\ #2 \\ #3 \\ #4 \\ #5 \\ \end{array}\right]}\) \(\newcommand{\cfivevec}[5]{\left[\begin{array}{c}#1 \\ #2 \\ #3 \\ #4 \\ #5 \\ \end{array}\right]}\) \(\newcommand{\mattwo}[4]{\left[\begin{array}{rr}#1 \amp #2 \\ #3 \amp #4 \\ \end{array}\right]}\) \(\newcommand{\laspan}[1]{\text{Span}\{#1\}}\) \(\newcommand{\bcal}{\cal B}\) \(\newcommand{\ccal}{\cal C}\) \(\newcommand{\scal}{\cal S}\) \(\newcommand{\wcal}{\cal W}\) \(\newcommand{\ecal}{\cal E}\) \(\newcommand{\coords}[2]{\left\{#1\right\}_{#2}}\) \(\newcommand{\gray}[1]{\color{gray}{#1}}\) \(\newcommand{\lgray}[1]{\color{lightgray}{#1}}\) \(\newcommand{\rank}{\operatorname{rank}}\) \(\newcommand{\row}{\text{Row}}\) \(\newcommand{\col}{\text{Col}}\) \(\renewcommand{\row}{\text{Row}}\) \(\newcommand{\nul}{\text{Nul}}\) \(\newcommand{\var}{\text{Var}}\) \(\newcommand{\corr}{\text{corr}}\) \(\newcommand{\len}[1]{\left|#1\right|}\) \(\newcommand{\bbar}{\overline{\bvec}}\) \(\newcommand{\bhat}{\widehat{\bvec}}\) \(\newcommand{\bperp}{\bvec^\perp}\) \(\newcommand{\xhat}{\widehat{\xvec}}\) \(\newcommand{\vhat}{\widehat{\vvec}}\) \(\newcommand{\uhat}{\widehat{\uvec}}\) \(\newcommand{\what}{\widehat{\wvec}}\) \(\newcommand{\Sighat}{\widehat{\Sigma}}\) \(\newcommand{\lt}{<}\) \(\newcommand{\gt}{>}\) \(\newcommand{\amp}{&}\) \(\definecolor{fillinmathshade}{gray}{0.9}\)In this book, the terms "health disparities," "health inequities," and "health inequalities" are usually used interchangeably. In my own reading of the literature, I've noticed that the term "disparities" is more often used by US-based researchers and "inequities" more commonly by international researchers. They all point to preventable and unfair differences in health outcomes between populations. Below, however, I share a discussion of some of the nuances in these terms, from Erin Calderone, to better frame how public health works toward greater health equity.
Health disparities are measurable differences (incidence, prevalence, and mortality) in health outcomes among specific populations. These health disparities are one reason why HIV, viral hepatitis, STDs, and TB take a greater toll in one population group over another (CDC, 2024). Race and ethnicity are created and shaped by societal perceptions, historical policies, and practices (social constructs). Race and ethnicity are, both, some of the main factors in health inequalities (Williams et al, 2010).
Health inequalities arise from social economic, environmental, and structural differences among groups within a population. These inequalities are rooted in both historical and ongoing institutional and societal structures, policies, and norms (National Academy of Sciences, 2017). In the United States, health disparities among racial and ethnic groups include higher rates of chronic disease and premature death in comparison to rates in the Caucasian population. The disparities are due to a variety of factors, including racial discrimination, low income and education levels, poor residential environments, lack of medical insurance, and treatment at low-quality hospitals.
A recent report from the Office of Minority Health, an agency of the U.S. Department of Health and Human Services (DHHS), outlines how federal policies have caused and maintained structural disadvantages to obtaining long, healthy lives in minoritized communities. This report also uses the term minoritized groups rather than minority or minorities to further describe how structures and policies have affected populations, rather than these disparities being a result of numbers of a specific demographic in a population. (These terms will also be adopted in this text). The assertion is that racial and ethnic disparities in health and health outcomes are significantly caused or made worse by historical or existing governmental policies, and therefore a path toward health equity involves new federal policies and accountability (National Academies of Sciences, Engineering, and Medicine, 2023).
The United States’ early history of Native American extermination, land seizure, kidnapping of native children, and required assimilation has caused, and continues to perpetuate significant health repercussions for American Indians and Alaskan Natives (AIAN). Concurrently, the forced immigration and enslavement of Africans, subsequent Jim Crow laws, and even purposeful public health abuses (such as the Tuskegee Syphilis Study), have negatively affected the health of Black Americans for centuries. Additionally, federal policies relating to immigration and social services also play a role in health disparities, particularly those experienced by immigrants and asylum seekers, and their children. Although health disparities are also correlated with poverty and lack of education, those racial and ethnic inequities exist at all socioeconomic strata - indicating that the explanation lies beyond income or education alone. A section in the report summarizes just some of the health inequities in America:
There are higher rates of childhood asthma among low-income households, higher morbidity and mortality from chronic diseases among individuals with lower educational attainment, and higher exposure to air pollution among residents of disinvested communities—disproportionately individuals who are racially and ethnically minoritized. Moreover, the effects of the structural determinants of health on many health outcomes persist when accounting for income and education (National Academies of Sciences, Engineering, and Medicine, 2023).
According to an earlier DHHS Health Equity Report in 2019-2020, significant racial disparities in health and social determinants of health have persisted across the decades. Although measures like life expectancy and educational status have improved for all Americans, there are still differences in these and other measures between racial groups. Racially minoritized groups have twice or higher the poverty rates as non-Hispanic Whites do (Health Resources and Services Administration, 2020). According to the most recent report from the U.S. Census Bureau tracking poverty rates for the year 2022, the poverty rate for those identifying as non-Hispanic White or Asian was 8.6%, whereas it was 17.1% and 16.9% for those identifying as Black and Hispanic respectively, and 25% for American Indian and Alaskan Natives (Shrider & Creamer, 2023).
This disparity in poverty rates is also reflected in the increased likelihood of minoritized populations living in impoverished zip codes. Southeastern and Southwestern states tend to have the highest poverty rates, a trend which has remained consistent over time, and is consistent with higher unemployment rates in these areas. Neighborhoods that have been historically racially segregated as “non-White” have associations with lower life expectancy and higher rates of homicide, infant mortality, and all-cause mortality, as well as higher rates of mental distress, community violence, excessive drinking and smoking, and HIV prevalence (Health Resources and Services Administration, 2020). These neighborhoods often also have higher exposures to environmental toxins like air pollution and lead (Doctrow, 2022).
According to the KFF (formerly known as the Kaiser Family Foundation) health tracking polling, many disparities exist with how safe minoritized groups feel in their homes and neighborhoods, and how discrimination impacts everything from housing to healthcare. This foundation conducted a survey on racism, discrimination, and health in a representative sample of 6,000 Americans in 2023. Hispanic, Black, Asian and AIAN individuals are less likely to report feeling safe in their neighborhoods. About twice as many racially minoritized respondents reported a family member being victimized by violence as did White respondents. Also consistent with earlier surveys, minoritized groups are significantly more likely to have a family member who has experienced mistreatment from law enforcement (Artiga, 2023). “Nearly half of Black Americans say they have been afraid their life was in danger due to their racial background,” (Reich, 2022). All of these disparities impact health on multiple levels across the lifespan; not the least of which is the heightened chronic stress due to discrimination, racism, and poverty.
Systemic Racism
Systemic and structural racism cause disparities in access to goods, services, and opportunities using laws, policies, practices, or attitudes. Systemic racism is often hidden, and practices or social values are accepted as the norm without questioning whether racism had any influence on their creation. Below are two examples of how systemic and structural racism continue to impact racially minoritized communities and cause health inequities.
Systemic racism has influenced neighborhoods through redlining: a practice of segregating Black Americans into urban neighborhoods and denying them residential loans. Black neighborhoods were considered financial “risks” by banks and lenders. Newly-built housing tracts often came with contracts requiring that anyone who purchased one of the new houses could not sell it later on to folks from other races or ethnicities - thus keeping suburban communities segregated. Even when the Fair Housing Act of 1968 opened up FHA loans for Black Americans legally, the practice of discrimination continued on within financial institutions. At the same time, home prices continued to increase in the suburbs, which continued to keep loans out of reach for many (Rose, 2023). A majority of those communities that were redlined almost a century ago are still low income, minoritized neighborhoods. Since home ownership is one of the primary mechanisms of building wealth for the middle class, this had a generational effect on racial wealth disparities (Reich, 2019).
Structural racism also influences access to education and economic advancement via funding for public schools. Public schools are funded primarily by state taxes and local property taxes, with much smaller portions from federal funds or community fundraising. This means that if home values are lower in a particular neighborhood, their school district gets less money compared to a school district with higher home values. In those states that have approved them, voucher programs also redirect tax dollars from public schools into private, charter schools - cutting into public school budgets even further. Schools in lower income neighborhoods tend to have more trouble attracting and maintaining teachers, and they may spend more of their limited resources on safety measures and behavioral interventions rather than enhancing learning programs (Reich, 2023). In school, young Black men are more likely to receive harsher punishments, and schools are more likely to call the police when disciplining them - thus increasing the risk of incarceration and eroding trust (Braveman et al., 2022). In these ways and many others, both current and historic policies continue to create structures and systems that provide fewer opportunities for wealth and impact long-term health outcomes in racially minoritized neighborhoods.
To conclude:
Although the terms “disparities” and “inequities” are often used interchangeably (even in this text), it is the inequities in health opportunities that often lead to the disparities we see in health outcomes of different groups. In other words, we are recognizing that there are differences in how long we live and what diseases affect us (and how seriously sick we become) that have more to do with social, economic, political, and environmental factors than any genetic or biological influence. Why do people in one zip code live longer than those in another? Why is income or education level such a strong predictor of health? In recognizing that the social determinants of health are perhaps the strongest predictors of overall population health. “Health inequities refer to inequalities that are unfair, unjust, avoidable or unnecessary, and that can be reduced or remedied through policy action” (Health Resources & Services Administration, 2020). Pursuing health equity - providing opportunities for all to attain their highest level of health - is a paramount role for public health (U.S. Department of Health and Human Services, 2024).
Reference
Artiga, S. et al. (2023). Survey on racism, discrimination and health: Experiences and impacts across racial and ethnic groups. KFF. https://www.kff.org/racial-equity-an...on-and-health/
Braveman, P. A., Arkin, E., Proctor, D., Kauh, T., & Holm, N. (2022). Systemic and structural racism: Definitions, examples, health damages, and approaches to dismantling. Health Affairs, 41(2), 171–178. https://doi.org/10.1377/hlthaff.2021.01394
Doctrow, B. (2022). Racial residential segregation and airborne toxic metals. National Institutes of Health (NIH). https://www.nih.gov/news-events/nih-...e-toxic-metals
Health Resources and Services Administration. (2020). HRSA Releases 2019-2020 Report on Health Equity: Special Feature on Housing and Health Inequalities. https://www.hrsa.gov/about/news/pres...report-housing
National Academy of Sciences, Engineering, and Medicine. (2017). Board on population health and public health practice; committee on community-based solutions to promote health equity in the United States. National Academies Press. https://www.ncbi.nlm.nih.gov/books/NBK425845/
National Academies of Sciences, Engineering, and Medicine. (2023). Federal policy to advance racial, ethnic, and tribal health equity. National Academies Press. https://doi.org/10.17226/26834
Reich, R. (2019). How America created its shameful wealth gap [Video]. In YouTube. https://www.youtube.com/watch?app=de...e=emb_imp_woyt
Reich, R. (2022). Class 11: “Reducing health inequities” by UC Berkeley professor Reich [Video]. In YouTube. https://www.youtube.com/watch?v=q9getidk8Yo
Reich, R. (2023). Class 4: “Widening Inequalities of Place” by UC Berkeley professor Reich [Video]. In YouTube. https://www.youtube.com/watch?v=owqQ..._Rfsit&index=4
Shrider, E. A., & Creamer, J. (2023). Poverty in the United States: 2022. U.S. Census Bureau, Current Population Reports, 60–280. U.S. Government Publishing Office, Washington, DC. https://www.census.gov/content/dam/C...mo/p60-280.pdf
U.S. Department of Health and Human Services. (2024). Healthy People 2030. Discrimination. Office of Disease Prevention and Health Promotion. https://odphp.health.gov/healthypeop...discrimination
Williams, D.R., Mohammed, S. A., Leavell, J. Collins, C. (2010). Race, socioeconomic status, and health: complexities, ongoing challenges, and research opportunities. Annals of the new York Academy of Sciences. doi: 10.1111/j.1749-6632.2009.05339.x