Which Health Disparities Do We Want to Reduce?

Originally posted 2/22/2011

Over the past few weeks, I have been blogging on population health measurement, under the headline that you can’t manage what you can’t measure. While I’ve given quite a bit of attention to overall outcomes, I haven’t directly addressed disparities.

Improving the length and/or quality of life overall doesn’t necessarily translate to improved health for all population groups. Policies and programs can have a differential affect on subpopulations that exacerbate rather than diminish disparities.

Deciding which outcomes to target to improve overall health involves value judgments – whether the goal is improving overall health or reducing disparities. There is not a “correct” formula for simultaneously improving overall health and reducing disparities. The 50:50 weighting suggested by the figure below represents just one possible approach but the ethical dimensions of such choices cannot be ignored; in a resource limited world, should we focus on raising the bar overall or narrowing the gaps?This is a value choice to be made by individuals and groups in light of their local, state or national situations and perspectives.

As the figure shows, disparities in outcomes exist across a spectrum of categories. These include race and ethnicity but also social and economic status, gender, and geography (and other dimensions as well). However, people often focus on disparities primarily in the race/ethnicity dimension. Last month the CDC released its first ever report on disparities and inequalities. Despite the report’s emphasis on the social determinants of health (the first section focuses on income and education), media coverage focused on the findings about racial disparities.

Here in Wisconsin, our ethnic minority populations are relatively small and geographically concentrated, but every county in the state has substantial health disparities by education level and income. In fact, the state earned a “C-” overall for health disparities in its 2010 Health of Wisconsin Report Card (which employs an innovative multidomain disparity index). The figure below from this report shows the distribution of death rates for various population segments both above and below the state average. It illustrates the point that racial disparities are significant but that there are also other critical differences across other population segments, such as those with different levels of education.

Chronic racism has been shown to have a biologic effect on health through stress pathways, and institutional racism has created many of the disparities in income, education, and health services that influence health outcomes. We clearly need to develop and support policies to address and eliminate racism on every level in our communities.

But focusing our attention too narrowly may make us think of obstacles instead of opportunities. To improve population health, we need to think beyond race to recognize the many factors that affect health differentially. In a country still battling racial stereotypes and prejudice, this broader perspective on disparities may help create a unified and constructive approach to addressing our collective health challenges.

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