Diversity in the Context of Health Disparities Essay

Health inequity, categories and examples of which were discussed in the previous chapter, arises from social, economic, environmental, and structural disparities that contribute to intergroup differences in health outcomes both within and between societies. The report identifies two main clusters of root causes of health inequity. The first is the intrapersonal, interpersonal, institutional, and systemic mechanisms that organize the distribution of power and resources differentially across lines of race, gender, class, sexual orientation, gender expression, and other dimensions of individual and group identity (see the following section on such structural inequities for examples). The second, and more fundamental root cause of health inequity, is the unequal allocation of power and resources—including goods, services, and societal attention—which manifest in unequal social, economic, and environmental conditions, also called the social determinants of health. Box 3-1 includes the definitions of structural inequities and the social determinants of health.Diversity in the Context of Health Disparities Essay

The factors that make up the root causes of health inequity are diverse, complex, evolving, and interdependent in nature. It is important to understand the underlying causes and conditions of health inequities to inform equally complex and effective interventions to promote health equity.

The fields of public health and population health science have accumulated a robust body of literature over the past few decades that elucidates how social, political, economic, and environmental conditions and

context contribute to health inequities. Furthermore, there is mounting evidence that focusing programs, policies, and investments on addressing these conditions can improve the health of vulnerable populations and reduce health disparities (Bradley et al., 2016; Braveman and Gottlieb, 2014; Thornton et al., 2016; Williams and Mohammed, 2013). This literature is discussed below in the sections on structural inequities and the social determinants of health.Diversity in the Context of Health Disparities Essay

HOW STRUCTURAL INEQUITIES, SOCIAL DETERMINANTS OF HEALTH, AND HEALTH EQUITY CONNECT

Health inequities are systematic differences in the opportunities groups have to achieve optimal health, leading to unfair and avoidable differences in health outcomes (Braveman, 2006; WHO, 2011). The dimensions of social identity and location that organize or “structure” differential access to opportunities for health include race and ethnicity, gender, employment and socioeconomic status, disability and immigration status, geography, and more. Structural inequities are the personal, interpersonal, institutional, and systemic drivers—such as, racism, sexism, classism, able-ism, xenophobia, and homophobia—that make those identities salient to the fair distribution of health opportunities and outcomes. Policies that foster inequities at all levels (from organization to community to county, state, and nation) are critical drivers of structural inequities. The social, environmental, economic, and cultural determinants of health are the terrain on which structural inequities produce health inequities. These multiple determinants are the conditions in which people live, including access to good food, water, and housing; the quality of schools,Diversity in the Context of Health Disparities Essay

So, for example, the effect of interpersonal, institutional, and systemic biases in policies and practices (structural inequities) is the “sorting” of people into resource-rich or resource-poor neighborhoods and K–12 schools (education itself being a key determinant of health (Woolf et al., 2007) largely on the basis of race and socioeconomic status. Because the quality of neighborhoods and schools significantly shapes the life trajectory and the health of the adults and children, race- and class-differentiated access to clean, safe, resource-rich neighborhoods and schools is an important factor in producing health inequity. Such structural inequities give rise to large and preventable differences in health metrics such as life expectancy, with research indicating that one’s zip code is more important to health than one’s genetic code (RWJF, 2009).Diversity in the Context of Health Disparities Essay

The impact of structural inequities follows individuals “from womb to tomb.” For example, African American women are more likely to give birth to low-birthweight infants, and their newborns experience higher infant death rates that are not associated with any biological differences, even after accounting for socioeconomic factors (Braveman, 2008; Hamilton et al., 2016; Mathews et al., 2015). Although the science is still evolving, it is hypothesized that the chronic stress associated with being treated differently by society is responsible for these persistent differential birth outcomes (Christian, 2012; El-Sayed et al., 2015; Strutz et al., 2014; Witt et al., 2015). In elementary school there are persistent differences across racial and ethnic divisions in rates of discipline and levels of reading attainment, rates that are not associated with any differences in intelligence metrics (Howard, 2010; Losen et al., 2015; Reardon et al., 2012; Skiba et al., 2011; Smith and Harper, 2015). There also are race and class differences in adverse childhood experiences and chronic stress and trauma, which are known to affect learning ability and school performance, as well as structural inequities in environmental exposures, such as lead, which ultimately can lead to differences in intelligence quotient (IQ) (Aizer et al., 2015; Bethell et al., 2014; Jimenez et al., 2016; Levy et al., 2016). One of the strongest predictors of life expectancy is high school graduation, which varies dramatically along class and race and ethnicity divisions, as do the rates of college and vocational school participation—all of which shape employment, income, and individual and intergenerational wealth (Olshansky et al., 2012). Structural inequities affect hiring policies, with both implicit and explicit biases creating differential opportunities along racial, gender, and physical ability divisions. Lending policies continue to create differences in home ownership, small business development, and other asset development (Pager and Shepherd, 2008). Diversity in the Context of Health Disparities Essay Structural inequities create differences in the ability to participate and have a voice in policy and political decision making, and even to participate in the arguably most fundamental aspect of our democracy, voting (Blakely et al., 2001; Carter and Reardon, 2014). And implicit biases create differential health care service offerings and delivery and affect the effectiveness of care provided, including a lack of cultural competence (IOM and NRC, 2003; Sabin et al., 2009).

For many people, the challenges that structural inequities pose limit the scope of opportunities they have for reaching their full health potential. The health of communities is dependent on the determinants of health.Diversity in the Context of Health Disparities Essay

STRUCTURAL INEQUITIES

As described above, structural inequities refers to the systematic disadvantage of one social group compared to other groups with whom they coexist that are deeply embedded in the fabric of society. In Figure 3-1,

Historical Perspective and Contemporary Perceptions

Whether with respect to race, ethnicity, gender, class, or other markers of human difference, the prevailing American narrative often draws a sharp line between the United States’ “past” and its “present,” with the 1960s and 1970s marking a crucial before-and-after moment in that narrative. This narrative asserts that until the 1950s, U.S. history was shaped by the impacts of past slavery, Indian removal, lack of rights for women, Jim Crow segregation, periods of nativist restrictions on immigration and waves of mass deportation of Hispanic immigrants, eugenics, the internment of Japanese Americans, the Chinese exclusion policies, the criminalization of “homosexual acts,” and more (Gee and Ford, 2011; Gee et al., 2009). White women and people of color were effectively barred from many occupations and could not vote, serve on juries, or run for office. People with disabilities suffered widespread discrimination, institutionalization, and social exclusion.Diversity in the Context of Health Disparities Essay

Civil rights, women’s liberation, gay rights, and disability rights movements and their aftermaths may contribute to a narrative that social, political, and cultural institutions have made progress toward equity, diversity, or inclusion. Highlights of progress include the Civil Rights Act of 1964, the Voting Rights Act of 1965, the Fair Housing Act, Title IX of the Education Amendments of 1972, the Americans with Disabilities Act, the Patient Protection and Affordable Care Act, and, most recently, the Supreme Court case¹ that legalized marriage equality in the United States. With a few notable exceptions—undocumented immigrants and Muslims, for example—these advances in law and policy have been mirrored by the liberalization of attitudes toward previously marginalized identity groups.

Today, polls and surveys indicate that most Americans believe that interpersonal and societal bias on the basis of identity no longer shapes individual or group social outcomes. For example, 6 in 10 respondents to a recent national poll said they thought the country has struck a

reasonable balance” or even gone “too far” in “accepting transgender people” (Polling Report, n.d.). In 2015, 72 percent of respondents, including 81 percent of whites, said they believe that “blacks have as good a chance as white people in your community to get any kind of job for which they are qualified” (Polling Report, n.d.). In another poll, a total of 72 percent agreed that “women and men have equal trouble finding good-paying jobs” (64 percent) or that men have more trouble (8 percent) (Ms. Foundation for Women, 2015). However, when broken down by racial and ethnic categories, the polls tell a different narrative. A recent survey revealed that 70 percent of African Americans, compared with 36 percent of whites, believe that racial discrimination is a major reason that African Americans have a harder time getting ahead than whites (Pew Research Center, 2016). Furthermore, African Americans (66 percent) and Hispanics (64 percent) are more likely than whites (43 percent) to say that racism is a big problem (DiJulio et al., 2015). Here, perceptions among African Americans and whites have not changed substantially; however, Hispanics are much more likely to now say that racism is a big problem (46 percent in 1995 versus 64 percent in 2015) (DiJulio et al., 2015).Diversity in the Context of Health Disparities Essay

Perceptions are confirmed by the persistence of disparities along the lines of socioeconomic position, gender, race, ethnicity, immigration status, geography, and the like has been well documented. Why? For one, historical inequities continue to ramify into the present. To understand how historical patterns continue to affect life chances for certain groups, historians and economists have attempted to calculate the amount of wealth transmitted from one generation to the next (Margo, 1990). They find that the baseline inequities contribute to intergenerational transfers of disadvantage and advantage for African Americans and whites, respectively (Chetty et al., 2014; Darity et al., 2001). The inequities also reproduce the conditions in which disparities develop (Rodriguez et al., 2015).

Racism

Though inequities may occur on the basis of socioeconomic status, gender, and other factors, we illustrate these points through the lens of racism, in part because disparities based on race and ethnicity remain the most persistent and difficult to address (Williams and Mohammed, 2009). Racial factors play an important role in structuring socioeconomic disparities (Farmer and Ferraro, 2005); therefore, addressing socioeconomic factors without addressing racism is unlikely to remedy these inequities (Kaufman et al., 1997).Diversity in the Context of Health Disparities Essay

Racism is an umbrella concept that encompasses specific mechanisms that operate at the intrapersonal, interpersonal, institutional, and systemic

Finally, systemic mechanisms, which may operate at the community level or higher (e.g., through policy), are those whose effects are interactive, rather than singular, in nature. For example, racial segregation of neighborhoods might well be due in part to personal preferences and behavior of landlords, renters, buyers, and sellers. However, historically, segregation was created by legislation, which was reinforced by the policies and practices of economic institutions and housing agencies (e.g., discriminatory banking practices and redlining), as well as enforced by the judicial system and legitimized by churches and other cultural institutions (Charles, 2003; Gee and Ford, 2011; Williams and Collins, 2001). In other words, segregation was, and remains, an interaction and cumulative “product,” one not easily located in any one actor or institution. Residential segregation remains a root cause of racial disparities in health today (Williams and Collins, 2001).

Racism is not an attribute of minority groups; rather, it is an aspect of the social context and is linked with the differential power relations among racial and ethnic groups (Guess, 2006). Consider the location of environmental hazards in or near minority communities. Placing a hazard in a minority community not only increases the risk of adverse exposures for the residents of that community, it also ensures the reduction of risk for residents of the nonminority community (Cushing et al., 2015; Taylor, 2014). Recognizing this, the two communities could work together toward an alternative that precludes having the hazard in the first place, an alternative that disadvantages neither group. Diversity in the Context of Health Disparities Essay