HSS 2003 Intro by xuyuzhu

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									  DISSECTING
 INEQUALITY
   Gail Henderson, Ph.D.
Department of Social Medicine
     INEQUALITY

    Absolute Poverty
    Relative Poverty
Distribution of Resources
          INEQUITY

“Refers to differences which are
 considered unfair and unjust”
    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
PAUL FARMER, MD
        “Inequality itself
         constitutes our
         modern plague.”
         (Infections and
         Inequalities,
         1999)
HOW DOES SOCIAL POSITION
    AFFECT HEALTH?
• MATERIAL CONDITIONS OF WORK
  AND LIFE
• SOCIAL ENVIRONMENT
• HEALTH-RELATED BEHAVIORS
• PSYCHOLOGICAL FACTORS
• EFFECTS OF HIERARCHICAL
  ORDERING
 PER CAPITA INCOME AND IMR
50,000                                     120
45,000
40,000                                     100

35,000                                     80
30,000
                                                 INCOME
25,000                                     60
                                                 IMR
20,000
15,000                                     40

10,000                                     20
 5,000
      0                                    0
                         IL
     Z




                                       A
          US


               UK




                                      A
                         A
   IT




                                    DI


                                    PI
                      AZ


                       IN
 SW




                                  IN
                    CH




                                  O
                    BR




                                HI
                              ET
     RESEARCH FINDINGS
       (Adler et al. 1993)
• IT’S A GRADIENT, NOT A DICHOTOMY
• THE CAUSAL DIRECTION IS MAINLY
  SOCIAL POSITION  HEALTH
• IT’S A “FUNDAMENTAL CAUSE,” NO
  MATTER WHAT INTERVENING OR
  PROXIMATE VARIABLES
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
DISTRIBUTION OF RESOURCES
WITHIN A SOCIETY AFFECTS HEALTH
Rank         Country      1997 Income GINI     1997 IMR

3       Switzerland       $43,060       27.9     5
10      United States     $29,080       40.1     7
12      Austria           $27,920       23.1     5
22      United Kingdom    $20,870       32.6     6
38      Spain             $14,490       32.5     5
73      Brazil            $ 4,790       60.1    34
75      Hungary           $ 4,510       27.9    10
82      Slovak Republic   $ 3,680       19.5     9
89      South Africa      $ 3,210       59.3    48
94      Thailand          $ 2,740       46.2    33
116     Guatemala         $ 1,580       59.6    43
145     China             $ 860         41.5    32
177     India             $ 370         29.7    71
191     Nigeria           $ 280         45.0    77
209     Ethiopia          $ 110         40.0   107

Source: 1999 World Development Indicators
RACE AND HEALTH
   IN THE US
“WHAT RACE IS SHE?”
New York Times Sunday Magazine
       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)
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?
 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?
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
      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)
     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
“Renal Transplantation in Black
  Americans” (NEJM 2000)

          INCIDENCE       PREVALENCE
RACE       OF ESRD         OF ESRD



BLACKS    873 / Million   3579 / Million



WHITE     218 / Million    803 / Million
INFANT MORTALITY RATES BY ‘RACE’
       IN THE U.S., 1950-1997
YEAR   BLACK   NATIVE   WHITE   HISPAN   CHINESE


1950   43.9    82.1     26.8     --      19.3
1960   44.3    49.3     22.9     --      14.7
1970   32.6    22.0     17.8     --       8.4
1984   18.7    14.3      8.9     9.3      8.3
1991   16.6    11.3      7.0     7.1      4.6
1997   13.7     8.7      6.0     6.0      3.1
       1998 AGE-ADJUSTED DEATH
        RATES/100,000 BY CAUSE
CAUSES    BLACK   NATIVE   WHITE   HISPAN   ASIAN

ALL       690.9   458.1    450.4   342.8    264.6
HEART     183.3    97.1    121.9    84.2     67.4
CEREBR     41.4    19.6     23.3    19.0     22.7
CANCER    161.2    83.4    121.0    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
IF ‘RACE’ IS A POLITICAL AND
 CULTURAL CONSTRUCTION,
   WHAT IS IT MEASURING?
     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)
Mortality and Income in the US,
     1986 (Pappas et al.)
20
18
16
14
12                                         <9,000
10                                         9-14,999
 8                                         15-18,000
 6                                         19-24,999
 4                                         >25,000
 2
 0
     Black Men White Men   Black   White
                           Women   Women
“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
 “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
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)
  “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)
     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.
   WHY WE CAN’T 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?
HOW DO WE MAKE
 SENSE OF THIS
  INEQUALITY?
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.”
“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%)
 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.
   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
  PROPORTION OF BLACKS AND
WHITES IDENTIFYING THEMSELVES
      AS “MIDDLE-CLASS”
 YEAR      BLACK   WHITE   RATIO
 1966-68   15%     46%     .33

 1976-78   22%     50%     .44

 1988-91   30%     51%     .59

 1994      44%     64%     .69
“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%)
       EXPLAINING HEALTH
          INEQUALITIES

• SOCIO-ECONOMIC • HEALTH
  STATUS           BEHAVIOR/
                   LIFESTYLE
• SOCIAL
  STRUCTURE,      • INNATE GENETIC/
  INCLUDING         BIOLOGICAL
  INSTITUTIONAL     DIFFERENCES
  RACISM
WHY DOES IT MATTER?
 • MATERIALIST VIEW PLACES
   RESPONSIBILITY AT SOCIETAL
   LEVEL

 • EXPLANATIONS FOCUSING ON
   INDIVIDUAL BLAME PEOPLE FOR
   THEIR OWN HEALTH PROBLEMS
INEQUITY: “Differences in health which
   are considered unfair and unjust”

 Depends on who/what is responsible…

• Socio-economic      • Health behavior,
  status                including lifestyle
• Social structure,   • Innate genetic/
  including
                        biological
  institutional
  racism                differences
     THE GLOBAL VIEW:
  “ONE WORLD, TWO FATES”

   “Of children who die before their 5th
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)

								
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