CENTERS FOR DISEASE CONTROL AND PREVENTION
Volume 15 • Number 2 • Spring/Summer 2002

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Special Focus: Eliminating Health Disparities

Public Health Puzzle: Social Determinants of Health

Eliminating health disparities—one of the primary goals of Healthy People 2010, the nation’s prevention agenda—is an immense challenge to all of us in public health. Despite decades of data demonstrating the existence of health disparities and an outpouring of recent research, much remains to be learned about the causes of health disparities and how to prevent them. 

Researchers are examining such topics as socioeconomic status, racial and ethnic differences in access to health care and other resources, the effects of racism and segregation, and living and occupational conditions. What researchers do know about causes indicates that broader issues of social inequality must be addressed before the puzzle of health disparities can be solved. 

The problem is so vast that a recent Institute of Medicine (IOM) report focused on only one aspect: disparities in medical treatment. The report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, emphasized the need for immediate practical action and more study.¹ 

“Disparities in the health care delivered to racial and ethnic minorities are real and are associated with worse outcomes in many cases, which is unacceptable,” stated Alan Nelson, MD, IOM committee chair and former president of the American Medical Association, when announcing the report’s release. “The real challenge lies not in debating whether disparities exist, because the evidence is overwhelming, but in developing and implementing strategies to reduce and eliminate them.”

Why Should We Study Socioeconomic Status? 
CDC researchers are among those seeking a better understanding of how a person’s health is affected by socioeconomic status (SES), which includes income, education, occupation, and neighborhood and community characteristics. Researchers who study the effects of SES on health have much to contribute to the discussion of health disparities. 

SES is central to eliminating health disparities because it is closely tied to health and longevity. At all income levels, people with higher SES have better health than those at the level below them. SES is also a strong force behind differences in health among racial and ethnic groups. 

“There is no one reason on which to blame the health gaps we see between different levels of socioeconomic status,” said Nancy Adler, PhD, a health psychologist and director of the University of California San Francisco Center for Social and Behavioral Science. 

Because the problem has multiple causes, several disciplines are involved, including neurobiology, psychology, sociology, economics, and epidemiology. The link between SES and health remains an important research area in social and behavioral sciences and epidemiology, Dr. Adler said, because health gaps are widening between the “haves” and the “have-nots” in the United States. Such social inequalities produce ill health among the have-nots, social epidemiologist Richard Wilkinson argues in Unhealthy Societies: The Afflictions of Inequality (Routledge, 1996). People die younger in societies with greater inequalities in income. For example, the United States has a lower life expectancy than almost every other rich country, despite its wealth. According to a 1998 University of Michigan study, U.S. states and metropolitan areas with greater income inequalities report higher rates of cardiovascular disease and other diseases among their residents.² 

 
Economic Pressures Exact a Toll on Minority Populations 
African Americans, Hispanics, Native Americans, and Asian populations such as Vietnamese and Laotians are more likely than other groups to be poor. Poverty affects health by limiting access to needed resources. Other elements of SES, including education, residence, and occupation, also affect people’s quality of life, including their health. 

• Educational opportunity. Because the quality of schools is partially determined by community resources, people in poor communities often get poorquality education. As a result, they have fewer opportunities for good jobs and incomes. Students in poorer schools may also suffer from nutritional deficits and family pressures. In addition, they face the effects of lowered expectations: no one is surprised by the lower test scores and higher dropout rates at such schools. Women with less education often lack important information about reproductive health. “Our qualitative research indicated that women just don’t know basic things about their bodies and what happens normally or abnormally during pregnancy,” said CDC Epidemiologist Cynthia D. Ferré, MA.

• Residential segregation. “People don’t live randomly in neighborhoods,” observed Nancy Krieger, PhD, Associate Professor of Health and Social Behavior at the Harvard School of Public Health. “They are incredibly economically segregated.” This means that poor people live in resource-poor communities with limited health care facilities. They experience transportation problems, high crime rates, a pervasive sense of insecurity, and less control over their environments, for example, to control pests or make needed repairs. 

Income segregation is further compounded by racial segregation, which is one reason that black poverty is different from white poverty. Blacks and Hispanics are also more likely than poor white families to live in areas of concentrated poverty. Research has shown that living in neighborhoods where some residents have higher incomes and more education is healthier. Housing segregation also limits people’s access to public services, reduces their purchasing power, and makes it difficult for them to find better jobs. Thus, residential inequalities make it difficult for many members of racial minorities to improve their living conditions. 

“What puts blacks at risk is not just poverty but their race,” noted Robert G. Robinson, DrPH, Associate Director for Program Development for CDC’s Office on Smoking and Health. “Disparities go beyond SES. Indeed, interventions based solely on SES indicators will be limited in their effectiveness. To plan and develop interventions that will truly help the community, public health professionals must capture the contextual reality of racial and ethnic communities. By understanding race and ethnicity in terms of community, we can grapple with their complexity and take note of the differences between poor communities. It is a holistic approach that does not exclude poor people but rather looks at them within the communities where they live.” 

• Occupational opportunities. Most jobs that pay well require reliable transportation or higher education or are located in outlying or suburban areas. Economic segregation keeps poor families in poor areas, where escaping from low-paying service jobs (i.e., the “minimum wage ghetto”) is difficult. The U.S. minimum wage is no longer a living wage, according to advocates for the poor, who argue that full-time workers should be able to support their families without falling into poverty. Even families living above the official poverty line often cannot afford basic necessities, including health care. A June 2002 Kaiser Family Foundation poll, for example, found that families earning less than $25,000 a year are likely to have problems with health care costs. 

  Many workers, not only those in low-income jobs, struggle daily to pay for resources such as child care. Having to work more than one job, lacking health benefits, having little control over one’s schedule or pace of work, and being unable to take time off when needed can cause chronic stress and damage self-esteem. 

Low SES and health problems are related and may have a cumulative effect. The rate of diabetes among African Americans is 70% higher than for whites, and the rate of low-birth-weight infants is more than double. Illness and death from asthma are particularly high among poor, African American inner-city residents. Although asthma is only slightly more prevalent among minority children than among whites, it accounts for three times the number of deaths. 

The financial burden of these illnesses adds to the economic strain on families. 

For African Americans, such economic hardships are compounded by the inherited disadvantage of institutionalized racism, according to many researchers. For example, according to University of Michigan sociologists David R. Williams, PhD, MPH, and Chiquita Collins, PhD, income differences exist between blacks and whites even when they have similar educational levels. In addition, blacks often pay more for housing, food, insurance, and other services than whites.³ 

Racism and Discrimination
As noted by Dr. Robinson, researchers looking for causes of health disparities must consider how social conditions affect a person’s life. As a March 2000 article in the Boston Review observed, “social conditions— such as access to basic education, levels of material deprivation, a healthy workplace environment, and equality of political participation— help to determine the health of societies.”⁴

According to the article, “Health is produced not merely by having access to medical prevention and treatment but also, to a measurably greater extent, by the cumulative experience of social conditions over the course of one’s life.” 

Although lack of adequate insurance and local health care providers and facilities contributes to the poor health of poor people, disparities disproportionately affect racial and ethnic minorities despite their income or insurance status. Thus, health disparities are unlikely to be eliminated until researchers develop a better understanding of a topic many people would rather avoid—racism. 

“I have found that people don’t want to work on issues of racism,” said Ms. Ferré. “It’s a topic that makes people uneasy.” 

For many racial and ethnic minorities, negative stereotypes and low expectations are a constant reminder that their efforts are devalued and that they are regarded not as individuals but as representatives of a marginalized group. Racism may limit minorities’ access to political participation and the resources available to them. Parents worry about how racism will affect their children. 

“I believe we live in a racist society, but it’s covert,” said CDC Public Health Analyst Angel Roca. As a Latino high school student, Mr. Roca was not expected to apply for college admission. When he was a student at Syracuse University, his appearance could cause a hush to fall over the room.

“Many white people in the United States are in denial about the continued existence and impacts of racism in this country,” said CDC Social Epidemiologist Camara P. Jones, MD, MPH, PhD. “It is therefore important for us to develop measures of racism that will allow us to communicate its detrimental effects on the health and well-being of the nation.” CDC’s Measures of Racism Working Group is conducting a review of currently available scientific measures as a way to begin work on the topic. The CDC group, headed by Dr. Jones, is trying to find out how racism is associated with health and what aspects of racism can be targeted in an intervention. The group has developed a module of six survey questions that is being tested in California, Delaware, the District of Columbia, Florida, New Hampshire, New Mexico, and North Carolina as part of the 2002 Behavioral Risk Factor Surveillance System. 

“We want to learn whether people report differential treatment based on their race,” Dr. Jones said. “If they do, we want to learn how this relates to their health behaviors, their use of health services, and their chronic disease health outcomes.” The Measures of Racism Working Group is also turning its attention to conceptualizing and measuring institutionalized racism. “Indeed, the link between SES and race in this country may be due to institutionalized racism— contemporary structural factors perpetuating historical injustices,” said Dr. Jones.

Quality of Health Care Can Cause Problems 
Although people often assume that low SES is the only factor contributing to poor health outcomes, research has found that higher SES does not protect African Americans and other minorities. One surprising example of this came from a 1992 CDC study reported in the New England Journal of Medicine that found that even college-educated black women were more likely than college-educated white women to have infants born with low birth weight or who died within the first year of life. 

To try to identify the reasons for this racial disparity, CDC commissioned a study called the Harlem Birth Right Project to explore factors such as economics, environmental issues, social conditions, and individual and community assets among a sample of African American women living in Central Harlem. The study findings support the 2002 IOM report, which asserted that individual providers exhibit bias in their dealings with patients. In Stress and Resilience: The Social Context of Reproduction in Central Harlem, the 2001 book on the Harlem project, authors Leith Mullings and Alaka Wali found that black women experienced discrimination by health care professionals. For example, they reported that one “non-black obstetrician told the ethnographer that she teaches residents that even if a patient states that she misses her appointments because of child care or work difficulties, she is still irresponsible.”⁵ Such attitudes place patients in conflict with their health care providers, creating additional stress. And if patients do not have trusting relationships with their providers, many will forego regular medical visits, including preventive care. 

“Health care can alienate African American women when it fails to treat known risks and illness; provides inadequate explanations; has long waits to see the provider while the visit lasts only moments; makes no inquiry into social circumstances; makes demeaning statements and assumptions; and assumes that women are irresponsible,” said Ms. Ferré. 

Medical professionals should be trained to understand social causes in patients’ lives so they can improve the quality of care they offer, according to Loretta Jones, MA, a Los Angeles community activist who heads Healthy African American Families, a community-based health organization in Los Angeles. 

Resilience and Responses to Stress Affect Health
Another way that racism affects health is by causing chronic stress among its victims. Researchers have found that people who experience discrimination are far more likely than others to develop high blood pressure and other stress-induced health effects. Experiences of discrimination are also associated with psychologic symptoms such as anxiety, depression, and suicidal tendencies, according to a 2001 study of gay and bisexual Latino men reported in the American Journal of Public Health.⁶ 

Stress is being scrutinized as a key factor in the way social determinants of health work. Researchers say that the biological effects of repeated stress affect immunity, health, and life expectancy. Researchers increasingly believe that such factors are central to causing health disparities. But they emphasize that people can develop healthy responses to stress. More data are needed about how such responses (called resilience) protect people from the ill effects of stress. “We know relatively little about protective factors,” said Ms. Ferré. 

For example, women’s roles in what researchers call the “kinwork” of family and friends illustrate the balance of stress and resilience. Although social support is a source of informational, emotional, and material help for women, these networks may become strained, especially among low-income families during economic downturns. In addition, African American women play a central role in recruiting and maintaining support networks within the family and community. This pivotal role for the woman within the kinwork process may be at once supportive yet stressful because of disagreements, lack of resources, and the expectations of others in the network.^{5, 7}

Qualitative Research Needed 
Simply counting deaths, cases of disease, and other events will not give a complete picture of health disparities. To fully understand how stress, racism, and health are related, researchers must talk with people in the community to get their personal stories and opinions. This type of research goes beyond traditional quantitative studies. Such descriptions provide a context to help researchers understand how social interactions create health outcomes. 

“We [African Americans] are a different culture,” stated Ms. Loretta Jones, whose organization acts as cultural broker for the Los Angeles community it represents, helping residents learn to communicate more effectively with health care providers and understand research being conducted in the community. “The community needs to tell the researchers what to study, and not the other way around.” 

Qualitative research was used for the Harlem Birth Right Project, and one of the findings was that community members felt blamed by research that focused on individual behaviors. The personal stories gathered for Stress and Resilience describe the experience of daily life in Harlem. Personal narratives offer compelling evidence of needed policy changes. 

Hope for Change 
SES is far from being an immutable force. Reducing poverty and racism would limit the effects of SES on health. Childhood poverty is three times higher in the United States than in 13 other developed countries because of low wages and few benefits offered to unskilled workers and the low minimum wage, according to Sheldon Danzinger, PhD, Professor of Social Work and Public Policy at the University of Michigan’s Poverty Research and Training Center. These economic pressures represent problems that other nations have successfully overcome. 

Racism in the health professions could be reduced by increasing the numbers of minorities working in health professions. This increase would also enable the profession to be more capable of developing effective interventions for racial and ethnic communities, the poor, and the underserved. Mr. Roca suggested that members of minority racial and ethnic groups should be encouraged to consider health professions earlier in life. Programs like CDC’s Office of Science Education, which uses principles of epidemiology to teach middle and high school students about disease prevention and the use of analytic skills, can inspire students to consider careers in public health (see http://www.cdc.gov/excite). Having a doctor of the same minority/ethnic group increased patient satisfaction and participation, according to one study.⁸ Minority doctors may also be more willing to work in minority communities, where health care is lacking. And all physicians should be better trained so that patients from all racial and ethnic groups are comfortable with their health care providers and feel that their health care needs will be met. 

 
References 

1. Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Smedley BD, Stith AY, Nelson AR, editors. Washington, DC: National Academy Press; 2002. 
2. Lynch JW, Kaplan GA, Pamuk ER, Cohen RD, Heck KE, Balfour JL, Yen IH. Income inequality and mortality in metropolitan areas of the United States. American Journal of Public Health 1998; 88(7):1074–1080. 
3. Williams DR. Race, socioeconomic status, and health: the added effects of racism and discrimination. In: Adler NE, Marmot M, McEwen S, Stewart J, editors. Socioeconomic status and health in industrial nations: social, psychological, and biological pathways. New York: Annals of the New York Academy of Science; 1999: 173–188. 
4. Daniels N, Kennedy B, Kawachi I. Justice is good for our health. Boston Review 2000 February/ March. Available at www.inequality.ors/dkk2.html. Accessed June 11, 2002. 
5. Mullings L, Wali A. Stress and resilience: the social context of reproduction in central Harlem. New York: Kluwer Academic/ Plenum Publishers; 2001:107–134. 
6. Diaz RM, Ayala G, Bein E, Henne J, Marin BV. The impact of homophobia, poverty, and racism on the mental health of gay and bisexual Latino men: findings from 3 US cities. American Journal of Public Health 2001;91(6):927–932. 
7. Mullings L, Wali A, McLean D, et al. Qualitative methodologies and community participation in examining reproductive experiences: The Harlem Birth Right Project. Maternal and Child Health Journal 2001;5(2):85–93. 
8. Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patientphysician relationship. JAMA 1999; 282(6):583–589.

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