I was recently listening to the Jamaica dancehall song, "Tell Me How Come" by Morgan Heritage, and interestingly enough, it made me think of health disparities -- because Heritage talks about social and health ills such as AIDS plaguing his society and says, "life is so unfair."
I first learned of the concept of "health disparities" (sometimes referred to as health inequalities or health inequities) at Morehouse College, studying for a minor in Public Health Sciences. Whether you call them health disparities, health inequalities, or health inequities they are marked differences in the health of subgroups in the population (e.g. differences in health by race/ethnicity, socioeconomic position, gender, sexual orientation and geographic locality) in a variety of diseases and health-related behaviors such as obesity, type 2 diabetes, hypertension, suicide, tobacco use, asthma, violence, depression, lung cancer, prostate cancer, HIV/AIDS and the list goes on and on and on. Notably, disparities exist when certain groups are affected more adversely than others.
There are disparities in health within countries, including in the U.S. For instance, there are disparities in obesity within the U.S., whereby black and Hispanic children and adolescents, have a substantially higher prevalence of obesity than their white peers. The "stroke belt", which refers to a clustering of high stroke prevalence in several southern states in the U.S., is another example. These types of disparities in health have been routinely documented in the U.S., but also span across the globe. In addition to within country disparities, there are between country disparities. For instance, while HIV/AIDS is a noted global public health problem, countries are differentially impacted by the condition. Several countries in Africa, such as Swaziland and Botswana, have an exorbitantly high prevalence of HIV, while other countries (such as Syria and Finland) have an extremely low (almost non-existent) prevalence.
In college, I was inspired to write about health disparities on a few occasions (see here and here), and had the optimistic view that health disparities would be "cured" by 2010. At that time, in 2005, one of Healthy People 2010's goals was to reduce health disparities by that date. Now eight years later, Healthy People 2020 has the same goal.
The constitution of the World Health Organization states, "The highest attainable standard of health is one of the fundamental rights of every human being" and, in 1966, at the Second National Convention of the Medical Committee for Human Rights, Dr. Martin Luther King Jr. said, "Of all the forms of inequality, injustice in health care is the most shocking and inhumane." Ergo, I believe there is little disagreement that health disparities are... to put it simplistically, wrong and unjust. However, I'm not convinced that public health and medical researchers, and others, including health practitioners and policymakers, think about health disparities enough or approach the issue in the correct way. Public health researchers and practitioners certainly study and aim to improve health via understanding etiologic risk factors for disease and via designing/evaluating health-promoting interventions. While health achievements are gained in certain population groups (via these health efforts), I believe we, professionals interested in improving public health, don't always think about how improvements in Group A may further exacerbate the differences in health between Group A and Group B, especially when considering health disparities from a global context. If a health promotion program is targeted to an entire community and improves health overall, it could future exacerbate disparities in health between the disadvantaged groups and those who are better off -- as those who are better off will likely be more prepared to uptake the program. Improving health outcomes across populations is important, but the level of improvements needs to be more rapid and maintained among disadvantaged populations to impact health disparities across domains and contexts. Perhaps obvious, but group-based differences need to be systematically and rigorously integrated into research and evaluation efforts if we are going to make significant inroads in reducing within and between country health disparities. Health promotion efforts are especially needed in countries experiencing health disparities to reduce between country disparities.
I have had these thoughts for quite some time (and others also have expressed similar thoughts), but these thoughts were re-sparked at a recent talk that Dr. Lovell Jones, Professor and Director of the Dorothy I. Height Center for Health Equity and Evaluation Research at the University of Texas MD Anderson Cancer Center, gave as the keynote speaker for the Dana-Farber/Harvard Cancer Center's Cancer Research Disparities Symposium. Jones provided unique and important insights. One particularly salient quote was, "Health alone will not solve the problems of health disparities." Similarly, I believe efforts to ameliorate health disparities must engage individuals from a variety of disciplines, including (but not limited to) elected policymakers, urban planners, economists, social workers, health care practitioners, community and faith leaders, epidemiologists, psychologists, sociologists, geographers, demographers etc. I'm glad to see that many of my colleagues and the health field more generally have embraced teams with members from different types of expertise (known as trans- and inter-disciplinary teams); I think this will lead to improvements in public health and reductions in health disparities, but these teams need to be truly collaborative and sustained. Jones also talked about the importance of rigorously thinking and accounting for historical influences that may perpetuate health disparities. Recent work gives me hope that reducing health disparities is possible in the 21st century. Some recent work by Dr. Nancy Krieger, Professor of Social Epidemiology at Harvard School of Public Health, demonstrates that the magnitude of health disparities in cancer mortality and more broadly premature morality change over time, suggesting that health disparities can indeed be ameliorated.
While I am quite dubious that health disparities will be eliminated over the next few years, I am hopeful that in my lifetime we can make significant strides in closing health gaps and improving on the numerous poor health and other conditions that befall inner cities and blighted areas. This is a key mission that motivates my work and thinking. When I hear Morgan Heritage's words about life being unfair, I think: it can be made fair, but all hands must be on deck.
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