17 February 2009
To remedy these woes, the Obama administration will seek to expand insurance coverage, harness information technology to increase efficiency and reduce errors, and expand quality-improvement initiatives. All well and good.
But to really improve the nation’s health and keep people from getting sick in the first place, Obama will need to look for solutions outside of health care. This is particularly true if he hopes to improve the health of the many millions of Americans who – by virtue of their race or ethnicity – face poorer health, often from birth to death.
Unequal health opportunities serve as a stark reminder of the distance that remains on America’s road to equality. African-Americans, American-Indians, Alaska-Natives, and Pacific Islanders live shorter lives and have poorer health than Whites across a host of maladies, including higher rates of infant mortality, cardiovascular disease, diabetes, cancer, HIV/AIDS, as well as many other chronic and infectious diseases.
New Latino immigrants have better overall health than native-born people who have similar incomes and education, but their health (as well as that of other immigrants) tends to get worse the longer they live in the United States.
By the second generation, they too lag behind whites in many indicators. And while Asian Americans as a whole also fare better than whites, that’s not true for some Asian-American sub-populations. For example, Vietnamese-American women have the highest rates of cervical cancer in the nation.
Solving these health inequities will be critical to improving the nation’s overall health.
In the process, Obama will need to confront two persistent myths about health inequality that are shared by many policymakers and the general public.
One is that some racial and ethnic groups are prone to poor health because of inherent differences, such as genetic or biologic weaknesses. This myth often finds its way into media reporting on health disparities, such as the fact that African- Americans have nearly 50 percent higher rates of hypertension than U.S. whites.
The sexiest explanations for this phenomenon on TV are that the genes passed on by African-Americans’ ancestors favored salt retention, which in turn can cause high blood pressure.
This “salt-slavery” hypothesis has been debunked by scientists, but still receives prominent attention in popular media, even making an appearance on an Oprah segment with Dr. Oz last year.
(In fact, hypertension rates among West Africans are about half that of African Americans, and rates of hypertension in several European nations are higher than among African Americans.)
Another is that poor health among some minorities is due to “bad behavior,” such as sedentary lifestyles, poor diet, and weak compliance with doctors’ recommendations.
Without question, healthy lifestyles are important to help prevent poor health and to effectively manage illness. But the “bad behavior” explanation ignores the fact that minorities are more likely than whites to live in communities where healthy eating and active lifestyles are difficult to achieve.
These are communities where grocery stores or markets selling fresh fruits and vegetables are few and far between; where fast-food outlets and take-out stands dominate neighborhood food options; where safe parks and recreational facilities are uncommon, if non-existent; and where doctors and good primary care are hard to find. And these problems are too often coupled with other neighborhood pathogens, including disproportionate liquor and tobacco advertising, unwalkable streets, and environmental health risks such as engine exhaust and commercial and industrial wastes.
The health challenges posed by these conditions are profound and can overwhelm even the most ardent attempts to stay healthy.
And they’re fundamentally unfair, often posing the greatest challenges to children and youth before they have an opportunity for a healthy beginning in life.
What’s needed is a comprehensive strategy for improving community resources for health and reducing environmental health risks. The federal government has an important role to play, but state and local governments also possess a great deal of power to address the problem.
The Obama Administration has committed to expanding federal support for community-based prevention in the context of the economic stimulus bill.
State and local governments can address health inequality by using their power to regulate land use, promote healthier and more effective public transportation, and improve housing options.
For example, states can improve the retail food environment by creating incentives for major grocery chains to establish stores in underserved communities, as the Commonwealth of Pennsylvania has done with its Fresh Foods Financing Initiative, or by encouraging the establishment of farmer’s markets.
Or they can limit the proliferation of fast-food restaurants in poor communities, as the Los Angeles County Council did when it imposed a moratorium on the establishment of new fast-food restaurants in South Central L.A.
To be sure, government alone can’t fully address health inequality. Other stakeholders, including business, faith groups, civic organizations, and others must also join the effort.
But the President can lead the charge, and in the process help America become a land where skin color doesn’t limit people’s opportunities for good health.
Brian Smedley is vice president and director of its Health Policy Institute of the Joint Center for Political and Economic Studies.
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