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.
Gail Henderson, Ph.D.
Department of Social Medicine
“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
“Inequality itself constitutes our modern plague.”
(Infections and Inequalities, 1999)
Pappas et al. (1993) Comparing 1960-1986
Rogers et al. (1992)
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)
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)
Mexican, Mexican-American, or Chicano;
…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?
Central and South American 5.3
Puerto Rican 7.8
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)
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
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)
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
5-YR SURVIVAL RATE:
blacks 26.4%, whites 34.1%
12.7% lower for blacks (64% vs. 77% P < 0.001)
SURGICAL SURVIVAL RATE: similar
NON-SURGICAL SURVIVAL RATE: similar
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)
“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)
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.
“It is possible in America to be pretty much who you want to be.”
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
SOCIAL STRUCTURE, INCLUDING INSTITUTIONAL RACISM
HEALTH BEHAVIOR/ LIFESTYLE
INNATE GENETIC/ BIOLOGICAL DIFFERENCES
Social structure, including institutional racism
Health behavior, including lifestyle
Innate genetic/ biological 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)