2
The Impact of Geography on Health Disparities in the United States: Different Perspectives

Where an individual chooses to live can have a profound effect on their short- and long-term health. “Eight Americas: Investigating Mortality Disparities Across Races, Counties, and Race-Counties in the United States,” a paper by Murray et al. (2006), examines the gap in life expectancies found in different parts of the United States in order to more fully elucidate issues related to health disparities in this country. During the public workshop, Dr. Murray presented this paper, along with additional research investigating mortality and causes of death at the local level in the United States. Dr. Acevedo-Garcia further discussed the connection between a person’s place of residence and health disparities, focusing her comments on the impacts of living in specific neighborhood settings or metropolitan areas.

Their presentations are recounted here. Other discussion topics and general comments raised during the session by Roundtable members, sponsors, and audience members are included in the Addressing Health Disparities—Different Perspectives section at the end of the chapter. The Murray et al. paper appears in Appendix C.

EIGHT AMERICAS1

The Eight Americas presentation is based on analyses of county-level mortality data from the National Center for Health Statistics (NCHS), collected between 1960 and 2001, explained Dr. Murray. Graphic repre-

1

This section is an edited transcript of Dr. Christopher Murray’s remarks at the workshop.



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2 The Impact of Geography on Health Disparities in the United States: Different Perspectives W here an individual chooses to live can have a profound effect on their short- and long-term health. “Eight Americas: Investigating Mortality Disparities Across Races, Counties, and Race-Counties in the United States,” a paper by Murray et al. (2006), examines the gap in life expectancies found in different parts of the United States in order to more fully elucidate issues related to health disparities in this country. During the public workshop, Dr. Murray presented this paper, along with additional research investigating mortality and causes of death at the local level in the United States. Dr. Acevedo-Garcia further discussed the connec- tion between a person’s place of residence and health disparities, focusing her comments on the impacts of living in specific neighborhood settings or metropolitan areas. Their presentations are recounted here. Other discussion topics and general comments raised during the session by Roundtable members, sponsors, and audience members are included in the Addressing Health Disparities—Different Perspectives section at the end of the chapter. The Murray et al. paper appears in Appendix C. EIGHT AMERICAS1 The Eight Americas presentation is based on analyses of county-level mortality data from the National Center for Health Statistics (NCHS), collected between 1960 and 2001, explained Dr. Murray. Graphic repre- 1 This section is an edited transcript of Dr. Christopher Murray’s remarks at the workshop. 

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 CHALLENGES AND SUCCESSES IN REDUCING HEALTH DISPARITIES sentations of county-level mortality data from 1997–2001 show how life expectancy rates for men (ranging from age 62.0 to age 80.2) and women (ranging from age 71.8 to age 84.5) vary depending on an individual’s county of birth (Figure 2-1). Like a mosaic, the shades depicting differ- ent life expectancy rates appear random and unrelated at first; however, further examination reveals that mortality patterns seem to follow specific geographic patterns. Data comparing county-level life expectancy rates for men and women over time can be examined in several ways. Figure 2-2 shows the standard deviation of the distribution of life expectancy across counties for men and women between 1960 and 2000. Although the lines depicting the standard deviation of county life expectancies for men and women follow similar trajectories, the differences across counties began to steadily increase after 1980. Similarly, tracking life expectancies for counties in the top and bottom 2.5 percentiles over time for men and women shows a similar result (Figure 2-3). Although the gap in life expectancies for the counties in the top and bottom 2.5 percent of all U.S. counties remained fairly constant from 1960 until around 1980, it has been growing since that time. Among the bottom 2.5 percent of counties, little or no progress in increasing life expectancies has been seen over the past 20 years. In absolute terms, the differentiation in life expectancies in U.S. counties continues to widen. According to the U.S. national average, and as seen in data from coun- ties that have historically had the highest life expectancies, male life expec- tancy has been increasing faster than female life expectancy. The counties with the highest life expectancies in the United States are at levels that surpass those seen in Japan, the country with the highest life expectancies globally. Defining the Eight Americas In addition to summarizing county-level analysis, race-counties— referring to the county of death and the race of the deceased—were ana- lyzed using 5-year moving averages. Life expectancies were calculated for race groups in every county where mortality among members of a certain race was large enough for the analysis. Data show that the range of life expectancies seen in the United States is even larger when comparing race- counties. Life expectancies as low as 58 years of age were calculated for Native Americans in southwestern South Dakota, and Asian women in Ber- gen County, New Jersey, have average life expectancies reaching 91 years of age. There is no evidence that the magnitude of the gaps is closing. Further analysis was conducted using the amassed county and race- county data to identify which diseases accounted for the existing mortality

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 THE IMPACT OF GEOGRAPHY ON HEALTH DISPARITIES Males Females FIGURE 2-1 County life expectancy 1997–2001. 2-01.eps bitmap images

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0 CHALLENGES AND SUCCESSES IN REDUCING HEALTH DISPARITIES 2.5 Standard deviation of county life expectancies (years) 2 1.5 Male Female 1 1960 1970 1980 1990 2000 Year FIGURE 2-2 Width of cross-country distribution of life expectancy. 2-02.eps patterns and the age groups for which the greatest differences in mortality were seen. Using county-level mortality figures proved problematic because they lacked statistical power; too few people were included in the figures from each county to track individual causes of death. The objective in using the new Eight Americas analysis was to identify a discrete number of sub- groups, each consisting of a population large enough to statistically analyze mortality by age, sex, and cause. The choice of eight Americas—versus any other number—was to identify a discrete number of subgroups that would have the power to capture most of the broad variation that is seen across counties and race-counties. The Eight Americas are defined in Table 2-1 and represented in Figures 2-4 and 2-5. Mortality and Cause of Death: Comparisons of the Eight Americas Using statistical analyses, it is possible to explore life expectancy and causes of death in the Eight Americas. Comparing trends in life expectancy between men and women in the Eight Americas did not show significant changes, indicating on a broad level that disparities are not decreasing and

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 THE IMPACT OF GEOGRAPHY ON HEALTH DISPARITIES Male 85 Top 2.5% 80 Bottom 2.5% Life expectancy (years) 75 70 65 60 1960 1970 1980 1990 2000 Year Female Top 2.5% 85 Bottom 2.5% 80 Life expectancy (years) 75 70 65 60 1960 1970 1980 1990 2000 Year FIGURE 2-3 Life expectancy for top and bottom 2.5 percent of counties. 2-03.eps

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 CHALLENGES AND SUCCESSES IN REDUCING HEALTH DISPARITIES TABLE 2-1 The Eight Americas Average Income General Population Per America Description (millions) Capita Definition 1 Asian 10.4 $21,566 Asians living in counties where Pacific Islanders make up less than 40% of total Asian population 2 Northland 3.6 $17,758 Whites in northern plains and low-income Dakotas with 1990 county-level rural white per capita income below $11,775 and population density less than 100 persons/km2 3 Middle 214.0 $24,640 All other whites not included in America Americas 2 and 4; Asians not in America 1, and Native Americans not in America 5 4 Low-income 16.6 $16,390 Whites in Appalachia and the whites in Mississippi Valley with 1990 Appalachia county-level per capita income below and the $11,775 Mississippi Valley 5 Western 1.0 $10,029 Native American populations in Native the mountain and plains areas, American predominantly on reservations 6 Black Middle 23.4 $15,412 All other black populations living in America counties not included in Americas 7 and 8 7 Southern 5.8 $10,463 Blacks living in counties in low-income Mississippi and the Deep South rural black with population density below 100 persons/km2; 1990 per capita income below $7,500, and total population size above 1,000 persons (to avoid small numbers) 8 High-risk 7.5 $14,800 Urban populations of more than urban black 150,000 blacks living in counties with cumulative probability of homicide death between 15 and 74 years greater than 1.0% SOURCE: Adapted from Murray et al. (2006).

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 THE IMPACT OF GEOGRAPHY ON HEALTH DISPARITIES America 2 America 3 America 4 FIGURE 2-4 Americas 2, 3, and 4. 2-04.eps America 6 America 7 America 8 FIGURE 2-5 Americas 6, 7, and 8. 2-05.eps in some cases they are on the rise (see Figure 2-6). However the subtleties found in the graphs do show some interesting patterns in the data. America One, comprised of Asian Americans living in communities in which Pacific Islanders make up fewer than 40 percent of the total Asian population, has a high life expectancy that continues to increase. America Two shows a dwindling advantage over America Three (Middle America) among men and is showing marked improvement among women. America Four has had a very slow but steady rate of increase. The Appalachian,

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 CHALLENGES AND SUCCESSES IN REDUCING HEALTH DISPARITIES Males 90 America 1 America 2 America 3 America 4 Life expectancy at birth (years) America 5 America 6 America 7 America 8 80 70 60 2000 1990 1996 1984 1986 1988 1998 1994 1992 1982 Year Females 90 Life expectancy at birth (years) 80 70 60 2000 1990 1996 1984 1986 1988 1998 1994 1992 1982 Year FIGURE 2-6 Life expectancy at birth in the Eight Americas. 2-06.eps

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 THE IMPACT OF GEOGRAPHY ON HEALTH DISPARITIES Mississippi Valley white populations are increasingly falling behind the rest of white America. Among Native American populations there has been little or no increase in life expectancy for women and moderate increases for men. A similar story holds true for Americas Six and Seven, the African American populations. The large dip in the line depicting life expectancies for men living in America Eight reflects, for the most part, the increase in HIV-related mortality and its subsequent decline. Overall, comparing the graphs for men and women in Americas One through Eight shows that there is very little change in the net effect between the early 1980s and 2000. County Trends in Life Expectancy The Eight Americas mortality database contains county-level data dating back to 1960, and an analysis of those data shows a pattern of growing inequalities since 1983. To examine this phenomenon, county-level life expectancy data from 1961 to 1983 were compared with analogous data from 1983 to 1999. Male life expectancy data from 1961 to 1983 (Figure 2-7a) show several areas that have a statistically significant increase in life expectancy greater than the national average; several areas that are equal to or indistinguishable from the national average; and several coun- ties that have life expectancies that are statistically significant below the national average. Counties in red show areas in which there has been no statistically significant decline in life expectancy at the county level for the 22-year time period. Analysis showing life expectancy for men from 1983 to 1999 (Figure 2-7b) shows less progress; there are many more counties with a rate of change that is indistinguishable from zero, and some coun- ties near the Mississippi Valley have life expectancies that dropped. Among women, similar findings are seen when comparisons are made between life expectancy data from 1961 and 1983 (Figure 2-8a); however, data from 1983–1999 show that life expectancy among women in several counties is dropping (Figure 2-8b). With the exception of the Spanish flu pandemic of 1918 and 1920, there have been constant increases in life expectancy in the United States for more than 100 years, a finding consistent with life expectancy rates seen in other high-income countries. Yet there is a subset of the United States for which life expectancy at the county level for women, in particular, is dropping. This finding is quite unusual in recent mortality history among high-income countries. To help explain why life expectancy has been decreasing in certain segments of the United States, the cause of death for men and woman, compared by age group, was analyzed using county-level data. Analyses show that, among both men and women, mortality attributable to cardio-

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 CHALLENGES AND SUCCESSES IN REDUCING HEALTH DISPARITIES A 2-07a.eps bitmap image B 2-07a.eps bitmap image 2-07b.eps bitmap image FIGURE 2-7 Change in male life expectancy: (a) 1961–1983, (b) 1983–1999.

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 THE IMPACT OF GEOGRAPHY ON HEALTH DISPARITIES A 2-08a.eps bitmap image B 2-08a.eps bitmap image 2-08b.eps FIGURE 2-8 Change in female life expectancy: (a) 1961–1983, (b) 1983–1999. bitmap image 2-08b.eps bitmap image

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 CHALLENGES AND SUCCESSES IN REDUCING HEALTH DISPARITIES are needed to try to eliminate some of the inequalities among children. Another solution would be to move children to better neighborhoods so that, ultimately, fewer expensive public health interventions or early child- hood education programs would be required. In response, Dr. Escarce commented that programs such as these seem unlikely to happen politically, although he agreed that this was probably the only feasible approach for children. New York has a similar program in which small high schools are being created in communities. He also mentioned programs funded by the Bill and Melinda Gates Foundation and their investment in the Global Alliance for Vaccines and Immunization (GAVI). As described by Dr. Murray, GAVI was created as a public–private partnership through a grant from the Bill and Melinda Gates Foundation, to find a way to increase immunization rates using local innovation. The Global Alliance asked countries to apply and propose how they were going to raise childhood immunization; it did not say how they should do it. They simply said that after three years they would pay $20 for every child who is immunized. In order to develop programs to alleviate health disparities, explained Dr. Escarce, it will be necessary to stop trying to decide whether problems are caused by social determinants or whether or not they are public health problems. There is need to move beyond descriptive academic analyses to testing innovative solutions. There needs to be a national fund for innova- tive health improvement that has the same attributes that GAVI has shown will work. A public–private partnership, a large pool of resources, local applications, payment for progress, and a strongly embedded monitoring and evaluation program are all necessary in order to learn what is work- ing, continued Dr. Escarce. Further academic debate is also very useful and important to make a shift from describing the inequalities that either stabilize or grow to actually narrowing them. The only way to accomplish this is to take models that foster innovation and subject them to rigorous assessment. ADDRESSING HEALTH DISPARITIES—DIFFERENT PERSPECTIVES5 Reaction to the discussions regarding the relationship between health disparities and geography was thoughtful and, at times, passionate. Several of the issues discussed by the panelists and audience members—the current state of politics in the United States, language and framing, institutional racism, data collection problems, collaborations and community innova- tions, and health disparities approaches in St. Louis—are detailed here. 5 The following discussions were edited and organized around major themes to provide a more readable summary and to eliminate duplication of topics.

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 THE IMPACT OF GEOGRAPHY ON HEALTH DISPARITIES Health Disparities and U.S. Politics Several audience members shared concerns about the difficulty of addressing health disparities concerns in the current political environment. President Bush plans to veto a bipartisan bill that would enhance cover- age for young people and improve access to basic health care, commented Dr. Suggs, because it would be a step toward what President Bush referred to as socialized medicine. However, in Dr. Suggs’ opinion, this kind of con- text to discuss problems inhibits the opportunity to find satisfactory conclu- sions or remedies. Using a highly charged term like “socialized medicine” polarizes the issue and refocuses the debate to one of ideology rather than finding appropriate solutions to complex issues such as health care reform. Some of the problems that are being dealt with could benefit from a more open, objective, and candid discussion, continued Dr. Suggs. For example, if socialized medicine is untenable, then how can the programs that are in place for elected officials in Congress, for members of the U.S. military through the Department of Veterans Affairs, or, to some extent, for people who benefit from Medicare or Medicaid be rationalized? Today’s burgeoning health care costs have a tremendous effect on society and on general access to quality health care, Dr. Suggs continued. Having power and wealth concentrated among a few industries, such as the pharmaceutical industry and the professional health care industry, can make it difficult to try to enact the reforms necessary to alleviate health disparities in the United States. Medical advancements have increased life expectancies and led to medical interventions that save lives. This also means that individuals who may have died from an illness in years past, can now lead long lives with the aid of hospice or long-term medical care. Yet a disproportionate percentage of people needing these long-term health care options are not protected by the health care policies that are in place today, stated Dr. Suggs. Alternatively, there are people who benefit from the current system without having paid into it. When my mother was growing up as a poor black woman in Mississippi, Dr. Suggs said, the actuary said that she would be dead by the time she was 50 years old. Therefore, when the Social Security system was put into place, it did not include my mother. My mother is now 94 years old and has, in a sense, been a beneficiary of a program that was never intended for black people. This example demon- strates some if the unintended consequences that occur when people who shape public policy ignore the problems related to disparities, concluded Dr. Suggs. When a pronouncement is made that universal health insurance alone is not enough, it should be expressed with the caveat that people should not step back from advocating for universal coverage, commented another audience member. People need to abandon the notion that health insurance

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 CHALLENGES AND SUCCESSES IN REDUCING HEALTH DISPARITIES is unnecessary because emergency room care is accessible to everyone. It is important to continue to advocate for insurance, but simultaneously to convince people that an insurance plan or universal coverage alone is not enough, he continued. The health industry in the United States should be based on a foundation of ensuring good health rather than administering sick care as it does now. True health care would take up issues like housing, healthy environments, employment, and income disparities. These are the important things that impact people’s lives. Many health issues are not going to have simple, clinical, insurable inter- ventions, added another member of the audience. Consideration should be given to the environment in which people live and the effects of the choices that people are able to make given the options that they have available. This would ideally lead to a general population approach that, along with changes to insurance policies, could help ensure that people are healthier and, ultimately, that maintaining good health would be less costly. Framing Health Disparity Issues for a Broader Audience Several workshop participants were concerned with finding a way to discuss or frame issues related to health disparities in a way that will reso- nate with policy makers and government workers, and also to capture the public’s attention, both locally and nationally. Fifty years ago the world adopted national income and product accounting, such that the field of macroeconomics was created, explained Dr. Murray. After World War II, people started benchmarking income per capita, and the annual growth rate at income per capita became a central policy target. In the 1970s, when Japan had a higher income growth rate than the United States, it had an incredible affect on the media, the Ameri- can public, and the U.S. policy debate, continued Dr. Murray. People were very concerned about why the Japanese were pulling ahead of the United States. What is needed now is a situation in which the American public focuses on why the nation is falling behind other high-income countries in terms of health. Dr. Levi added that an abundance of data suggests that neither poli- ticians nor the American public like hearing or admitting that another country’s systems or programs are superior. Americans want an American solution; embracing a French solution or a Canadian solution is not some- thing that resonates. The challenge is to find a way to frame health dispari- ties issues in this country so that people recognize that a problem exists, but to do so without making comparisons that could make people feel that the American way is inferior or that the proposed approach may not be a uniquely American approach. Dr. Lurie added that there is a great deal to learn from less developed countries as well as developed countries.

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 THE IMPACT OF GEOGRAPHY ON HEALTH DISPARITIES Framing issues related to health disparities is extremely hard to do in this country, added Dr. Murray, because when you focus on health out- comes, you get one of four apologies. The first apology is that the United States is more diverse than other countries, as if diversity is a sort of scourge that makes it impossible for all residents to be healthy. Even if this argument were taken seriously, it cannot explain why the trends are not very good for the United States. The second and third apologies are that the health problems are caused by HIV or homicide, but it can be easily demonstrated that this is not true. The fourth apology is that it is a lack of insurance. Although that is a component of the problem, the entire issue is much more complex. The solution to framing issues related to health disparities is to shift from benchmarking health problems to benchmarking the coverage or by tracking care, continued Dr. Murray. This causes the argument to shift from saying that the United States has really bad outcomes and obesity is getting worse, for example, to determining what fraction of Americans or Missourians or people in the Mississippi delta are getting appropriate management of their diabetes. What fractions of those people are receiving appropriate interventions focused on diet or physical activity? If analyses show what is happening and provide comparisons from other settings, either nationally or internationally, it is very difficult to shift the onus of responsibility for those types of performance measures to somebody else. Ms. Glover Blackwell agreed that it is important to find the appropriate language because the way in which disparities are discussed will determine whether or not there will ever be the political and public will to be able to eliminate disparities. It is also important to try to identify what is making a difference, what is working. At PolicyLink, she explained, we invest in learning how to frame something and how to talk about and understand why it is important to invest in framing. We rarely think that, once we have figured out what needs to happen, there is a need to go out and start a new initiative, because there are so many programs out there already. Yet if we could determine which programs are truly the most successful, we could lift up what works. After lifting up what works, we could determine the ele- ments that make it work. Once the successful elements are identified, those elements could be infused into policy so that the original programs can be expanded and copied. Framing is absolutely important. She went on: it is also important to join with other people in this coun- try who are committed to trying to transform society so that everybody can participate and everybody can prosper. This is a movement, which is com- prised of many people working toward similar goals. Some of these people are in politics or working on housing issues. Some of them are working in environmental health, and some of them are in the workforce. We have to figure out how to join all of these people together.

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0 CHALLENGES AND SUCCESSES IN REDUCING HEALTH DISPARITIES When legitimate discussions about some of these difficult issues do not take place, the issues sometimes get obscured because ideology keeps people who have vested interests from making necessary changes, com- mented Dr. Suggs. It makes it impossible to have the kind of honest and open discussions that will be necessary to address issues related to health disparities. It is, after all, a very daunting problem that needs a more aggres- sive kind of approach. Ms. Boyce spoke about the power of words. She said: there are con- cepts I cannot abide and one of them is evidence-based practice. If we knew what evidence was going to work, we would not have health disparities. Evidence-based practice has been used to exclude community-based agen- cies from funding. Another concept that should be changed is data-driven decision making, when we know that the existing available data are faulty and that individuals are looking at the data disproportionately because of disparities. The words that are being used to describe the system do not match what is really going on in the communities. In addition, existing policies do not match what needs to happen in communities, continued Ms. Boyce. People are talking about paradigm shifts, and we keep searching for the words to define something different that needs to happen. Dr. Murray said that there needs to be a large pool of money to fund innovation and that only then will the system help us legitimize what works and what will make a difference. But can new words or concepts be coined that will better mirror what needs to happen? Other- wise, we are going to keep using words like “evidence-based practice” and the people who need to be funded will never get the money, because the words that are used for awarding grants and justifying that a program is successful do not fit reality. Most of us were motivated to come here because we view access to quality health care as a human right, commented Dr. Rhee. The health movement that we are talking about here today mirrors the history of the Civil Rights Movement. As I reflect on my own experience as a physician and medical director and the language that I have been trained to use, I realize that the language I use gives me a lot of power in my community, Dr. Rhee continued. In the world of clinical care, we talk much more about survival, rather than viability. We focus on disease and not wellness. Our emphasis is on immediate gratification or using pills to fix things. We do not necessarily track many of the value kind of outcomes that are really important. It is important to recognize that language is a major part of the power that we as health care providers wield, continued Dr. Rhee. Nearly 20 per- cent of gross national product will soon be devoted to health care. Yet the focus of medicine has been on the bench side or bedside, rather than on the curbside (in the community). Ultimately, when you are talking about health

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 THE IMPACT OF GEOGRAPHY ON HEALTH DISPARITIES disparities improvements, it really is about the curbside interventions and whether or not they work. Framing Issues About Race and Institutional Racism The topics of racism and institutional racism spurred a great deal of discussion and debate. It is challenging to find a way to talk about some- thing that causes so many people to recoil, explained Ms. Glover Blackwell. However, race problems will not be solved if we do not talk about them. There must also be recognition that this is a charged discussion that cannot be approached in a way that isolates, accuses, or causes people to want to stay away. The challenge is finding appropriate language to frame the dis- cussion, while also understanding that we have to call it what it is. Dr. Rhee suggested that the terminology used to discuss these issues must strike a balance. The term “health disparities” might not resonate with the public, but terms such as “racism” or “institutionalized racism” can be very powerful. The language that is used must be forceful and spe- cific, yet it should not cause people to disengage or make them unwilling to join in the discussion to find resolutions. There is great opposition to changing the status quo, stated Dr. Suggs. Racism is not going to be eliminated using the kind of arguments presented today. Some people are increasingly marginalized on the basis of race or social class and the price that society has to pay for that is enormous. Racial disparities are a disgrace, but they are also enormously expensive for the country. Our discussions should not simply focus on the injustice that health disparities cause, but also consider that it is terribly inefficient and costly if large segments of the population are ignored. Ms. Wright shared her belief that the message about institutional rac- ism must be targeted to specific audiences, because the variations between audiences can be quite significant. There are multiple approaches to having a constructive dialogue and to bring more people into the conversation in a meaningful way. Ms. Schwartz noted that all races and ethnicity are going to have to pay attention to this problem because the demographics in this country are changing so rapidly. It used to be that New Jersey was the most diverse state in the country; there was parity in the ratio of African Americans and Hispanics. Today New Jersey is losing citizens, and the only source of new residents is through immigration. These trends are going to drive all of these issues and attention should be paid, because these issues are going to impact everyone. Dr. Bracho shared her belief that it would be dangerous to talk about geography without highlighting issues regarding poverty and race. Clini- cal workers and public health professionals must talk about these issues

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 CHALLENGES AND SUCCESSES IN REDUCING HEALTH DISPARITIES and develop solutions for reducing disparities. The link between poverty and disparities, and racism and disparities has been established. Yet little is being done because health disparities are not on the national political agenda. Dr. Suggs added that there are some issues that need to be discussed regarding the relationship between blacks and Hispanics. Had blacks and poor whites been able to come together in the 1960s and form an effec- tive political coalition, the course of this nation may have changed. Today there is a similar opportunity. If Hispanics and blacks, the largest growing minority and the established minority in this society, respectively, could join together and form an effective coalition focused on addressing the problems of their collective communities, their political clout would be enormous and effective change might be realized. A member of the audience responded that there have been times during this country’s history when disparate groups have successfully joined forces for the greater good, and these efforts significantly changed the political scene both at the time and into the future. People should look for lessons in the annals of history. It is also very important to begin to tie similar issues together, so that people do not think in terms of one isolated problem. Especially in health care, people should merge issues together and work to see the connections between disparate problems. Data Concerns Many of the workshop participants expressed concerns about issues related to data accessibility. According to Dr. Murray, his analysis would have gone beyond 2001; however, NCHS stopped releasing data from sub- sequent years, citing privacy concerns. Yet, continued Dr. Murray, because the NCHS data originate from death certificates that are in the public domain at the local level, this seems peculiar. Since NCHS collects and tabulates data from documents that are in the public domain, it stands to reason that these data should be available to the public. Despite multiple requests to NCHS, the county-level death files have not been made avail- able, stated Dr. Murray. He surmises that it will require pressure on NCHS from policy makers in Washington in order to make the agency reverse its current policy. In any event, he concluded, it is impossible to continue monitoring disparities at the local level unless this policy is reversed. Dr. Acevedo-Garcia agreed that the lack of data makes her work more challenging and expressed frustration that county data on mortality were no longer available. The county-level data are essential for tracking dispari- ties in the United States, she explained. Although disparities are apparent in the metropolitan-area data, no health surveys are specifically representa- tive of people living in metropolitan areas. Similarly, surveys done at the

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 THE IMPACT OF GEOGRAPHY ON HEALTH DISPARITIES county, state, and national level are not structured in a way that adequately captures data on health disparity, opportunity, or inequality by geographic region. Dr. Acevedo-Garcia believes that her greatest challenge will be to con- duct simulation work. Her group is planning to combine empirical esti- mates of neighborhood effects on health with analyses of census data to try to simulate what the impact of policy changes would be on metropoli- tan areas. These analyses, based on estimates on neighborhood effects on health, would look at such issues as the availability of rental housing to see how this could impact residential segregation and, in turn, how this change would affect some child health outcomes. This kind of simulation work is very hard to do, she said, because it is based on quite a few assumptions. Yet it is important because the information in the current data sets does not provide the data necessary to simulate the health effects of neighborhoods and segregation. Her group wants health data sets that are representative of metropolitan areas and have information about neighborhoods, because without them it is possible to lose track of the real issues that are shaping the unequal opportunity structures. Dr. Bracho also had concerns regarding data collection. Her group, Latino Health Access, collects data from census tracts and from communi- ties. She argues that these data need to be revised for public health environ- ments, so that health disparities affecting young communities, which may not be evident in life expectancy data, can be identified with data that use smaller numbers of cases as the unit of analysis. There is a need for local comparisons to evaluate school performance, public safety, and environ- mental indicators such as open space on various concentrations of dispari- ties. Those are the data that are useful to advance interventions. Statistics do not always give a clear indication of what is really happening, continued Dr. Bracho. If someone analyzed the statistics for Orange County, California, for example, they would find that the life expectancy for Hispanics would seem quite high since it is a very young community. Yet the disparities are there if you know where to look. Accord- ing to the census tract, only 3 percent of the senior citizens in the county do not have health insurance. If you segment the population and look specifi- cally at Hispanics, however, you would find that 56 percent of Hispanic elders do not have health insurance. Collaborations and Community Innovation It is important to recognize that many of these problems involve more than one sector, stressed Dr. Acevedo-Garcia. She works with the housing policy community and the public health community in metropolitan areas, but these groups rarely participate at the same meetings. Although there

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 CHALLENGES AND SUCCESSES IN REDUCING HEALTH DISPARITIES is a great deal of discussion about how difficult those collaborations are, she is aware of few incentives to collaborate with other groups or sectors to reduce disparities. Any community innovation template should have at least eight mini- mum characteristics, said Mr. Dotson. It needs to be multidimensional rather than focused on one issue, and it must be accessible, affordable, and available. We need to think of local implementation and local control as part of that innovative template. The final two characteristics needed are constancy—Can the community in which we are trying to implement this innovation depend on the program being there at a certain period of time on a regular basis?—and sustainability. Addressing Health Disparities in St. Louis The St. Louis Health Department has been advocating for a coordi- nated comprehensive approach to reducing health disparities for nearly a decade, said workshop participant William Dotson. In the next few months, the city will release a report, Public Health: Understanding Our Needs, the third in a series of biennial reports. This series of reports provides commu- nity needs assessments examining 64 variables categorized by demographic and socioeconomic factors and issues related to access and equality, racial polarization, epidemics, environmental issues, and injury behavior related to mortality. People use this report to gain a deeper understanding of the challenges of reducing health disparities and as a guide for writing grants and advocating for new programs. Another effort by the city of St. Louis was the Racial and Ethnic Approaches to Community Health (REACH) 2010 project, which spon- sored a community program targeting heart disease prevention. Despite developing innovative programs, establishing strong community partner- ships, and countless hours of planning and hard work, St. Louis was not awarded one of the demonstration projects. There was an effort to continue the program with support from local foundations and private entities, but adequate funding did not materialize. Ultimately the decision has to be made whether or not to continue a program at a lower funding level, know- ing that the reduction in funding could ultimately compromise the integrity of the original effort. This is a very hard choice to make. Over the past three years there have been some changes in the city of St. Louis. Life expectancy has gone up, mortality from HIV/AIDS has declined, and more women have taken advantage of first trimester care. There have been improvements, but they are small. St Louis has a long way to go in terms of organizing in order to increase the momentum toward reaching set goals. The challenge now is focused on providing, implementing, and creating momentum for solutions that will address health disparities.

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 THE IMPACT OF GEOGRAPHY ON HEALTH DISPARITIES A member of the audience representing the St. Louis Health Commis- sion, an organization created with a mission of increasing access, improving health outcomes, and reducing health disparities within the public safety net system, shared some information from their recent reports examining issues that affect communities in the city of St. Louis. Among their findings, the commission found that primary care access in the public safety net system has increased by 13 percent in the past three to four years due to regional collaborative efforts, and there has been an 85 percent reduction in the time that people have to wait for specialty care. REFERENCES Acevedo-Garcia, D., N. McArdle, T. L. Osypuk, B. Lefkowitz, and B. K. Krimgold. 2007. Children left behind: How metropolitan areas are failing America’s children. Diversity Report Number 1. Harvard School of Public Health, and Center for the Advancement of Health, January 2007. Boston, MA. http://diversitydata.sph.harvard.edu/children_left_ behind_final_report.pdf (accessed July 11, 2007). BRFSS (Behavioral Risk Factor Surveillance System). 2008. About the BRFSS. http://www.cdc. gov/brfss/about.htm (accessed March 19, 2008). Brooks-Gunn, J., G. J. Duncan, and J. L. Aber. 1997. Neighborhood poerty. New York: Russell Sage Foundation. IOM (Institute of Medicine). 2000. From neurons to neighborhoods: The science of early childhood deelopment. Washington, DC: National Academy Press. IOM. 2002. Care without coerage: Too little, too late. Washington, DC: The National Academies Press. Murray, C. J. L., S. C. Kulkarni, C. Michaud, N. Tomijima, M. T. Bulzacchelli, T. J. Iandiorio, and M. Ezzati. 2006. Eight Americas: Investigating mortality disparities across races, counties, and race-counties in the United States. PLOS Medicine 3(9):1–12. NCHS (National Center for Health Statistics). 2008. National Health and Nutrition Exami- nation Surey. http://www.cdc.gov/nchs/data/factsheets/nhanes.pdf (accessed March 19, 2008). WHO (World Health Organization). 2002. The world health report 00: Reducing risks, promoting healthy life. Geneva, Switzerland: World Health Organization. http://www. who.int/whr/2002/en/whr02_en.pdf (accessed July 11, 2006).

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