job applicants (one African American with no criminal record, one white applicant with a criminal record) were reviewed, the white applicant with a criminal record is even more likely to get hired than the African American applicant (Pager et al., 2009).

More focus on the issue of structural racism is needed, Smedley said. He commented that the reason that it is possible to use indirect estimation (as described in the previous chapter) to predict an individual’s race is because white people and people of color live in separate and unequal communities, with people of color concentrated in neighborhoods with high levels of poverty. Regardless of income level, living in a majority African American community means a higher concentration of poverty, few jobs, underresourced schools, fewer grocery stores, and fewer basic services and amenities necessary to enhance health outcomes. This is true even for African Americans with middle or upper levels of income. Residential segregation is a key structural element that must be addressed through state and local strategies to reduce health disparities.

Eliminating racial segregation relies on two different strategies. Place-based strategies can improve investment in low-income communities that suffer from disinvestment. People-based strategies allow people the mobility to move to communities with opportunity. Opportunity programs such as Section 8 housing vouchers are a strategy to accomplish this.

Community health planning is another strategy that state and local authorities can use. Of the few models that exist today, those models have been successful in bringing together a wide range of stakeholders, including health plans, employers, hospitals, other health care systems, and community groups. The goal is to better align the available resources with community needs. Similarly, at the state level, “certificate of need” policies help to keep resources from moving out of those communities that need them most.

Smedley concluded by asking the group how a focus on reports like Unequal Treatment can be maintained so that issues of health disparities stay on the table going forward.


Winston Wong is medical director of Community Benefits and director of Disparities Improvement and Quality Initiatives at Kaiser Permanente, an integrated health care delivery system. Kaiser Permanente has 8.7 million members in eight different regions across the country. The focus of Wong’s comments was on the personal experience and internal dialogue that people of color experience in confronting racism. He noted that it is not surprising that disparities in health care exist, given that inequities exist in every other aspect of American life. Awareness of health care disparities came about

The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement