Historically in the United States, disparities in health across populations have been well documented. Research has shown that certain groups suffer disproportionately from auto-immune and other infectious diseases, such as diabetes, asthma, cancer and cardiovascular disease. The causes of these disparities are wide-ranging and involve a number of variables, including: accessibility of health care, environmental threats (i.e. air pollution), increased risk of disease from occupational exposure as well as underlying genetic, ethnic and familial factors (NIH, 2014). While it would be unfair to try and tackle a topic this big in a single blog post, I do want to shine some light on the subject because I feel that it can present opportunities to engage in dialogue. On a personal level, I am extremely passionate about the issue of health disparities and plan on studying it moving forward. In this post, I take a critical look at health disparities in the US, identifying issues of access, infrastructure, and cultural barriers.
What are Health Disparities?
According to Braveman et al. (2004), health disparities are defined as, “a difference in which disadvantaged social groups such as the poor, racial/ethnic minorities, women and other groups who have persistently experienced social disadvantage or discrimination systematically experience worse health or greater health risks than more advantaged social groups.” Although disparities in health have existed for centuries in this country, they have received increased attention as a legitimate crisis over the past couple of decades. In terms of percentages, while these problems affect people of all walks of life, they are particularly prevalent among racial and ethnic minorities. Indeed, compelling evidence indicates that race and ethnicity correlate with persistent, and often increasing, health disparities among U.S. populations (OMHD, 2007). Evidence of disparities in the U.S. are most pronounced among the African-American and Hispanic communities, respectively, with growing numbers within the American Indian community. Studies have shown that these groups are more likely to live in poverty, have lower levels of education, work in jobs with higher rates of occupational hazards and have a lower median income than Whites and Asians (Mead et al., 2008). These groups are also more susceptible to chronic health conditions.
To begin, these groups are overrepresented among the numbers of uninsured, with Hispanics, for example, representing 13% of the population, but 25% of those without health insurance (U.S. Census, 2013). As noted by Betancourt et al. (2008), “Lack of insurance takes a significant toll on these [minority] populations, with health effects including less access to preventive care than among people with insurance, high rates of emergency department use and avoidable hospitalizations, later-stage diagnosis of cancer, and the inability to obtain prescription medications” (p. 294). Coinciding with this, the difference in disease and illness between minority populations and Whites continues to grow. For example, a 2010 study in the Journal of the American Medical Association found that adult obesity rates for African-Americans are higher than those for Whites in nearly every state in the nation, with 37% of men and 50% of women, respectively, suffering from obesity (Flegal et al., 2010). In the same study, evidence found that Hispanic women contract cervical cancer at twice the rate of White women. As it relates to diabetes, hypertension and heart disease, African-Americans were shown to possess the highest rates of all populations, with 15% of Blacks nationwide affected by diabetes compared with 8% for Whites (Mainous et al., 2004).
And the problem is only getting worse, as disparities in health and quality of care are not getting smaller. So how do we go about finding solutions? The problem is obviously extremely complex and hinges upon a number of important factors. To start, we have to take a critical look at some of the root causes.
How Disparities are Reinforced through Dominant Discourse
More so now than ever, the issue of health disparities in the United States remains a hot button topic among government policymakers and the mainstream public alike – and with good reason. In 2009, health disparities cost the U.S. economy $82.2 billion in direct health care spending and lost productivity (NUL, 2012). African Americans bore the majority of that cost with $54.9 billion, followed by Hispanics with $22 billion (NUL, 2012). Coinciding with this, the minority population is only expected to grow, with estimates of more than 40% of the U.S. population by 2035 and 47% by 2050. Thus addressing their health needs has become an increasingly visible public policy goal (Brach & Fraserirector, 2000). More importantly, as the gap between the haves and have-nots continues to widen each year, so does the hierarchy in health across populations. In an attempt to alleviate the problem, government involvement and spending on health-related research has increased. In 2012, the US spent $119 billion on health research, which equaled more than double the totals from the previous decade (Chakma et al., 2014). The health crisis has become so significant that political leaders often hinge entire campaigns on their policies towards health (i.e. Obamacare).
Nevertheless, this increased attention among policymakers has resulted in little to no consensus on what can be done and should be done to reduce these disparities, as the issue continues to be a pressing concern for society as a whole. Even more troubling is the fact that the leading health indicators have demonstrated little improvement in disparities over the past decade. In charting government progress, a recent study by the US Department of Health and Human Services found “less than adequate progress toward eliminating health disparities for the majority of objectives among segments of the U.S. population, defined by race/ethnicity, sex, education, income, geographic location, and disability status” (p. 2). Similarly, recent analyses of progress on Healthy People 2020 objectives found that “significant racial and ethnic health disparities continue to permeate the major dimensions of health care, the health care workforce, population health, and data collection and research” (HHS,2011). And while the increase in governmental spending and awareness is acknowledgeable, there remain many underlying frameworks which allow an existing status quo to persist. Examples of this are wide-ranging and include everything from exclusionary issues to concerns with zoning and access.
Infrastructural Concerns: Federal Food Subsidy Programs
In terms of nutritional disparities, one area where inequities become reinforced is through some of our federal food subsidy programs. A pertinent example of this is the availability of organic and local foods for low income families. For instance, the federal supplemental nutrition program for Women, Infants and Children (WIC) is a program which provides subsidies for low-income families to purchase nutritious food. The USDA (2014) describes the program as “providing supplemental foods designed to safeguard the health of low-income women, infants, and children up to age 5 who are at nutrition risk by providing nutritious foods to supplement diets, information on healthy eating, and referrals to health care.” The federal program, which is overrepresented by racial and ethnic minorities (the African-American and Hispanic demographic combined participation in the program is 58%) establishes minimum nutritional guidelines for states to follow, and individual states then determine specifically what is excluded (Doherty, 2006). The acceptable foods include items such as: juice, cereal, eggs, cheese, milk, peanut butter, beans, infant formula, tuna, and carrots. The problem with many of these state-run programs is that they completely exclude organic foods from being purchased. In fact, there are currently 31 states that explicitly say no to all organic foods, with 13 states (including California) that exclude certain foods (such as eggs and milk).
Similarly, the current WIC framework enforces many of the same restrictions as it pertains to farmer’s markets, as only about 58% of states currently participate in the WIC Farmer’s Market Nutrition Program (FMNP), and only 21 states currently authorize farmers to accept WIC cash value vouchers (USDA, 2014). Although it is not only the WIC program that has implemented these restrictions, as the current federal EBT and food stamp program also have very limited participation in farmer’s markets, mainly due to cost considerations and lack of technical infrastructure (Doherty, 2006).
This is not say that these programs are not effective or do not provide great benefit to those that need it, but without the option of being able to purchase organic or locally grown food, lower income families are forced to comply to a list of products laden with pesticides, unknown growth hormones, added sugars, artificial sweeteners, and GMO-ingredients, further contributing to the proliferation of health disparities nationally. In addition, on a broader scale, the food processing methods by which these products are made are unsustainable for future generations.
Accessibility Concerns: Food Insecurity
Another pressing concern in the incidence of health disparities nationally is the issue of food insecurity and availability. According to Andersen (1990), food insecurity refers to the “limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable foods in socially acceptable ways.” Also referred to as “food deserts” by academics, policy makers and community groups alike, many lower income and underserved communities in the U.S. (particularly populated urban areas) do not have access to an affordable and healthy diet (Cummins & Macintyre, 2006).
The primary concern with food deserts is that members of these communities (which are predominately comprised of racial/ethnic minorities) do not have access to supermarkets, grocery stores, or other retailers that offer foods needed for a healthy diet (i.e., fresh fruit, veggies, whole grains, dairy. etc.), or do not have adequate transportation to get there. Instead, residents of these areas become reliant on small grocery stores or convenience stores which offer more limited varieties and carry fewer fruits and veggies (USDA, 2009). More importantly, the foods that are carried by these smaller retailers often have higher sugar and sodium content, not to mention highly processed and genetically modified. The end result is that these communities suffer from an inadequate diet, thus reinforcing the prevalence of disparities, particularly among minority groups.
Indeed, interest in the relationship of food access to diet and health is rooted in an extensive body of literature that shows disparities in many health outcomes across race, ethnicity, and socioeconomic status (Institute of Medicine, 2003; National Research Council, 2004; USDA, 2009). Along these lines, research has shown that limited access to nutritious food and relatively easier access to less nutritious food may be linked to poor diets and, ultimately, to obesity and diet-related diseases. For example, a study by Larson et al. (2009) found that better access to a supermarket is associated with reduced risk of obesity and better access to convenience stores is associated with increased risk of obesity. Similarly, a study by Currie et al. (2009) found a connection between school-level obesity rates among 9th graders in California and relative distance between the school and fast food and full-service restaurants.
In examining the larger implications of food deserts, while perhaps the largest contributor is disparity in socio-economic status, a closer analysis uncovers bigger concerns of power and privilege. More specifically in terms of zoning and regulation, dominant health discourses allow inequalities to persist by maintaining control of the geographical spaces of food system infrastructures. As these spaces are strategically placed, and tend to cater to a specific consumer base, dominant frameworks become reflected not only by the people who frequent them, but also along the lines of the cultural codings that are performed within these spaces.
Exclusionary Concerns: Disparities in Healthcare
Collectively, as we continue to gain understanding into the root causes of health disparities, we recognize just how complex of an issue it is. The problem is indeed multi-factorial, and solutions must be adopted both at the federal and local levels. However, one area where I think we drop the ball as a society is dismissing disparities in health as simply a socio-economic problem. Particularly as it relates to health care, while it is commonly believed that health disparities occur simply because of a lack of health insurance and access to health care, disparities in quality of care for those with access to the healthcare system are equally troubling. In fact, there is a growing amount of research that shows evidence of racial/ethnic disparities in quality of care for those with access to health care. A recent Institute of Medicine report titled Unequal Treatment: Confronting Racial/Ethnic Disparities in Health Care found over 175 studies illustrating racial and ethnic health disparities in the diagnosis and treatment of various conditions, even when analyses were controlled for socioeconomic status, insurance status, site of care, stage of disease, comorbidity, and age, among other causes (IOM, 2002; Betancourt et al., 2003). This issue has required researchers to seek out other potential factors, and one area of inquiry that has gained a good amount of attention recently is the role that the patient-practitioner relationship plays in reinforcing health disparities.
Particularly as it relates to intercultural health, as the U.S. continues to grow in terms of diversity, there continue to be an increase in patients with a wide range of perspectives regarding health, often influenced by their social or cultural backgrounds (Betancourt et al., 2005). According to a number of studies, one particular area in the context of healthcare; patient-practitioner communication; has been hypothesized as a mechanism for racial/ethnic health disparities. There is a good amount of research on this topic alone. In fact, a large majority of research in the health communication field is dedicated specifically to the study of “cultural competency” within healthcare contexts. As it relates to the connection between culture and health, numerous studies have shown that disparities can manifest themselves in many different ways.
One instance where this plays out is in the power dynamics that exist between healthcare provider and patient. For example, in many health care settings, clinicians may intentionally or unintentionally reflect and reinforce dominant societal messages regarding value, self-reliance, competence, and deservingness (Roter, 2000). In addition, as noted by van Ryn & Fu (2003), providers may unknowingly communicate lower expectations for patients in disadvantaged social positions (i.e. race/ethnicity, income, education, class, etc.) than for their more advantaged counterparts. This is problematic because not only can it influence patients’ expectations for the future, but also the extent to which they expect to gain the resources and help that they need.
Similarly along these lines, there is the issue of language barriers. For instance, patients with certain ethnic backgrounds may present their symptoms differently from the way they are presented in medical textbooks (Betancourt et al., 2005). In many instances, these patients may have limited English proficiency, different pathways for seeking care, and unfamiliar beliefs that influence whether or not they adhere to provider recommendations (Berger, 1998). Consequently, as issues of access continue to persist, this remains a major problem in our national healthcare system. According to a study by Bailey (2009), health care providers nationally cite language difficulties and inadequate funding of language services to be major barriers to access to health care for limited English proficiency individuals and a serious threat to the quality of care they receive. As it relates to overall quality of care, research has shown that patient-practitioner communication is linked to patient satisfaction and adherence to medical instructions and health outcomes (Stewart et al., 1999). Accordingly, if socio-cultural differences are not addressed, poorer health outcomes will continue to persist.
The overall purpose of this post was to inspire dialogue as it relates to understanding disparities. I understand how important delving into a topic like this is and do not go into it lightly. While the issue is extremely complex and there are many sides to which people’s opinions may fall, I think that it is always important to get topics like these on the table. For me personally, I have found that writing on issues such as these to be very eye-opening, in that it has allowed me to be made aware of my space as it relates to privilege, access etc. By striving for this sense of self-awareness, it has allowed me to better understand the implications of my voice, actions and ideas.
In terms of the issue itself, where do we start? I think to begin we have to cultivate this sense of awareness not only as it relates to ourselves, but also how it relates to our understanding of dominant health frameworks. While on the surface, many of these issues appear benign and unassuming; it is important to remember that it is these very nuances that underpin the existence and propagation of disparities. On a broader level, collectively we have to continue to push for systemic change, as the elimination of health disparities would benefit all members of society, not only from an ethical and moral standpoint, but economically as well. In a 2009 report from the Urban Institute, research found that by simply addressing racial and ethnic health disparities, overall national health care costs could be reduced by nearly $24 billion per year, including $15.6 billion in the Medicare program alone (Waidmann, 2009). Definitely some food for thought!
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