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DISSECTING INEQUALITY Gail Henderson, Ph.D. Department of Social Medicine Slide 2 INEQUALITY Absolute Poverty Relative Poverty Distribution of Resources Slide 3 INEQUITY Refers to differences which are considered unfair and unjust Slide 4 RUDOLPH VIRCHOW Medical statistics will be our standard of measurement: we will weigh life for life and see where the dead lie thicker, among the workers or among the privileged. 1848 Slide 5 PAUL FARMER, MD Inequality itself constitutes our modern plague. (Infections and Inequalities, 1999) Slide 6 HOW DOES SOCIAL POSITION AFFECT HEALTH? MATERIAL CONDITIONS OF WORK AND LIFE SOCIAL ENVIRONMENT HEALTH-RELATED BEHAVIORS PSYCHOLOGICAL FACTORS EFFECTS OF HIERARCHICAL ORDERING Slide 7 PER CAPITA INCOME AND IMR Slide 8 RESEARCH FINDINGS (Adler et al. 1993) ITS A GRADIENT, NOT A DICHOTOMY THE CAUSAL DIRECTION IS MAINLY SOCIAL POSITION HEALTH ITS A FUNDAMENTAL CAUSE, NO MATTER WHAT INTERVENING OR PROXIMATE VARIABLES Slide 9 BREAKTHROUGH STUDIES Kitagawa and Hauser (1973) Differential Mortality in the United States: A Study in Socioeconomic Epidemiology National Followback Mortality Survey Pappas et al. (1993) Comparing 1960-1986 Rogers et al. (1992) The Black Report (England) 1980 Slide 10 DISTRIBUTION OF RESOURCES WITHIN A SOCIETY AFFECTS HEALTH Slide 11 RACE AND HEALTH IN THE US Slide 12 WHAT RACE IS SHE? New York Times Sunday Magazine Slide 13 CONFLICTING TRENDS 1. RACE IS INCREASINGLY CHALLENGED AS A VALID GENETIC CLASSIFICATION Some geographically or culturally isolated populations can properly be studied for genetic influences on physiological phenomena or diseases After 400 years of social disruption, geographic dispersion, and genetic intermingling, there are no alleles that define the black people of North America as a unique population or race. (Schwartz NEJM 2001) Slide 14 U.S. CENSUS CATEGORIES, 2000 1. White 2. Black, African American, or Negro 3. American Indian or Alaska Native 4. Asian or Pacific Islander [Asian Indian; Chinese; Filipino; Japanese; Korean; Vietnamese; Native Hawaiian; Guamanian or Chamorro; Samoan; Other Asian (print race); Other Pacific Islander (print)] 5. Some other race (print) HISPANIC ETHNICITY? Slide 15 CENSUS QUESTION ON HISPANIC ORIGIN OR DESCENT Mexican, Mexican-American, or Chicano; Puerto Rican; Cuban; Other What about Criollo, Mestizo, Mulato, LatiNegro, Afro- Latino, and Indigena (categories in Central and South America)? What Makes Asian-American a race, with 25 different populations of diverse origin, while Hispanics and Latinos are an ethnic group? Slide 16 IMR Differences Within Categories, 1997-1998 Hispanic 6.0 Cuban 3.6 Central and South American 5.3 Mexican 5.6 Puerto Rican 7.8 Slide 17 CONFLICTING TRENDS 2. PHYSICIANS ARE TRAINED TO USE RACE FOR DIAGNOSIS AND TREATMENT DECISIONS, AND PHARMACO-GENOMICS AND GENETIC EPIDEMIOLOGY EXAMINE VARIATIONS WITHIN RACE GROUPS An imprecise clue is better than no clue at all. (Satel 2002) Slide 18 CONFLICTING TRENDS 3. MOST HEALTH DISPARITIES ARE NOT GENETIC IN ORIGIN. THE U.S. HAS SET AS A NATIONAL PRIORITY ELIMINATION OF HEALTH DISPARITIES WHICH ARE MOST FREQUENTLY MEASURED BETWEEN RACE AND ETHNIC GROUPS Slide 19 Renal Transplantation in Black Americans (NEJM 2000) RACE INCIDENCE OF ESRD PREVALENCE OF ESRD BLACKS 873 / Million 3579 / Million WHITE 218 / Million 803 / Million Slide 20 INFANT MORTALITY RATES BY RACE IN THE U.S., 1950-1997 YEARBLACKNATIVEWHITEHISPANCHINESE 195043.982.126.8 --19.3 196044.349.322.9 --14.7 197032.622.017.8 -- 8.4 198418.714.3 8.9 9.3 8.3 199116.611.3 7.0 7.1 4.6 199713.7 8.7 6.0 3.1 Slide 21 1998 AGE-ADJUSTED DEATH RATES/100,000 BY CAUSE CAUSESBLACKNATIVEWHITEHISPANASIAN ALL 690.9458.1450.4342.8264.6 HEART 183.3 97.1121.9 84.2 67.4 CEREBR 41.4 19.6 23.3 19.0 22.7 CANCER 161.2 83.4121.0 76.1 74.8 AIDS 20.6 2.2 2.6 6.2 0.8 ACCID 35.7 55.6 29.8 28.0 14.4 SUICIDE 5.9 13.4 11.2 6.0 5.9 HOM 25.2 9.9 4.4 9.9 3.7 Slide 22 IF RACE IS A POLITICAL AND CULTURAL CONSTRUCTION, WHAT IS IT MEASURING? Slide 23 IS RACE A PROXY FOR SOCIAL CLASS? Socioeconomic status (SES) predicts variation in health within minority and white populations and accounts for much of the racial differences in health. (David Williams, Race, SES and Health, 2001) Slide 24 Mortality and Income in the US, 1986 (Pappas et al.) Slide 25 Effect of Known Risk Factors on Excess Mortality of Black Adults in the US (NEJM, Otten et al. 1990) 2.3 -- Unadjusted mortality rate ratio 1.9 -- Adjust for 6 risk factors (smoking, systolic BP, cholesterol, BMI, alcohol, and diabetes). Explains 31% of difference. 1.4 -- Adjust for family inc. Explains 38% 31% -- Unexplained Slide 26 Racial Differences in the Treatment of Early Stage Lung Cancer (NEJM, 1999) What explain different survival rates? 5-YR SURVIVAL RATE: blacks 26.4%, whites 34.1% SURGERY RATE: 12.7% lower for blacks (64% vs. 77% P < 0.001) SURGICAL SURVIVAL RATE: similar NON-SURGICAL SURVIVAL RATE: similar Slide 27 MEASURING RACISM (LaVeist 1996) Structural racism: Policy intentionally or unintentionally injurious to a race group (segregation; mortgage underwriting; environmental toxins) Individual racism: Application of power or influence with personal prejudice (differential clinical care; different intensity of services for same diagnosis) Racism as social stressor: Internalization of victimization of racism (blood pressure; mental health) Slide 28 The Future of Research on Race, Racism, and Health Only when we move beyond race as a proxy and directly measure those concepts believed to be measured by race, will we make truly important advances in describing the true nature of racial variation in health. And, only then can we begin what is really the important work: eliminating disparities in health status. (LaVeist, 1996) Slide 29 PROBLEMS WITH USING RACE IN HEALTH RESEARCH 1. When race, genetics, and disease are linked, a calculus of risk associates race with disease; race as a risk factor produces social harms of stigma and discrimination. 2. Race is often used uncritically (e.g., skin color as independent variable), failing to engage with the complex biological and environmental factors that may produce statistical significance. 3. NIH rules produce uncritical inclusion of race in research, reinforcing notion of racial differences. 4. Use of race is caught in a tautology: We assume race differences to exist and proceed to find them. Slide 30 WHY WE CANT DROP RACE 1.It remains a powerful social category, strongly associated with health disparities. 2.To assess improvement, we need to measure change over time. 3.Why else? Slide 31 HOW DO WE MAKE SENSE OF THIS INEQUALITY? Slide 32 NEW YORK TIMES POLL 85% of Americans agreed with this statement: It is possible in America to be pretty much who you want to be. Slide 33 PERCEPTIONS OF INEQUALITY AND JUSTICE IN U.S. 1991 [THE LAND OF OPPORTUNITY] People are rich because of hard work (58%), and ability/talent (52%) People are poor because of lack of effort (37%), loose morals and drink (22%) Slide 34 HOW MUCH MOBILITY DO WE HAVE IN THE U.S.? MORE INTERGENERATIONAL MOBILITY IN INDUSTRIALIZED NATIONS; LESS IN LESS DEVELOPED COUNTRIES. WE HAVE ABOUT AS MUCH AS OTHER INDUSTRIAL COUNTRIES. THE TOP AND THE BOTTOM ARE HARDER TO GET INTO AND OUT OF IN THE US. SITUATION FOR BLACKS HAS IMPROVED SINCE THE 1960S, WHEN IT WAS ALMOST IMPOSSIBLE TO BEQUEATH HIGHER CLASS POSITION. Slide 35 BLACK MOBILITY HAS IMPROVED, BUT GAP REMAINS LIKEHOOD OF WHITES vs. BLACKS MOVING INTO UPPER 10% INCOME 1960-1969: 3.5 x more likely 1970-1979: 3.1 x 1980-1995: 2.5 x Slide 36 PROPORTION OF BLACKS AND WHITES IDENTIFYING THEMSELVES AS MIDDLE-CLASS YEARBLACKWHITERATIO 1966-6815%46%.33 1976-7822%50%.44 1988-9130%51%.59 199444%64%.69 Slide 37 PERCEPTIONS OF INEQUALITY AND JUSTICE IN U.S. 1991 [ STRUCTURAL INEQUALITIES] People are rich because they have the right connections (72%), and have more opportunities to begin with (55%) People are poor because of failure of the economic system (28%), and discrimination against certain groups (17%) Slide 38 EXPLAINING HEALTH INEQUALITIES SOCIO-ECONOMIC STATUS SOCIAL STRUCTURE, INCLUDING INSTITUTIONAL RACISM HEALTH BEHAVIOR/ LIFESTYLE INNATE GENETIC/ BIOLOGICAL DIFFERENCES Slide 39 WHY DOES IT MATTER? MATERIALIST VIEW PLACES RESPONSIBILITY AT SOCIETAL LEVEL EXPLANATIONS FOCUSING ON INDIVIDUAL BLAME PEOPLE FOR THEIR OWN HEALTH PROBLEMS Slide 40 INEQUITY: Differences in health which are considered unfair and unjust Depends on who/what is responsible Socio-economic status Social structure, including institutional racism Health behavior, including lifestyle Innate genetic/ biological differences Slide 41 THE GLOBAL VIEW: ONE WORLD, TWO FATES Of children who die before their 5 th birthday, 98% live in developing nations. Of millions dying prematurely from TB, malaria, tetanus, and pertussis, all but a few thousand live in the poorer nations. ( The Economist, 1999) Slide 42