Report: Health disparities not well understood
Report: Health disparities not well understood
While a global movement has stimulated a substantial effort to reduce health disparities by increasing apparent equity among disparate sub-populations, a recent report from the Public Health Policy Advisory Board, an independent public health advocacy group founded and chaired by former Health and Human Services secretary Louis Sullivan, raises questions about the level of understanding about possible risk factors, causal agents, biological factors, or statistical or data anomalies that lead to health disparities, as well as the efficacy of interventions often used in trying to reduce disparities.
Mr. Sullivan and his colleagues said health disparity statistics can be misleading and confusing since they reflect neither an understanding of the reasons for baseline differences between particular subpopulations nor an indication of why the differences fluctuate. "In fact," the report said, "the intransigence of health disparities in the U.S., given the amount of effort and resources expended so far, would seem to be reason enough to question exactly what is really known about the phenomenon of U.S. health disparities."
What the Public Health Policy Advisory Board recommends is that the health disparity movement identify and prioritize specifically those health disparities that are amenable to prevention and that available data show to be significant from a public health perspective. For those that are identified, the report said, intense scientific effort should be made to understand the degree of an association of a health disparity with specific risk factors and potential causes, followed by development of scientifically evaluated interventions.
"A scientific approach is essential because little is known, and much remains to be learned, about the dynamic interaction of complex biological, behavioral, and environmental factors that are believed to create health disparities," the report said. "This understanding is crucial to the development and use of effective interventions."
PHPAB executive director John Cohrssen tells State Health Watch we are learning there are a number of different reasons for differences in health outcomes and it can be difficult to identify specific causes. "It can be misleading to conclude that the United States isn't doing as well as other countries," he says, "because such a statement doesn't account for the diversity in populations in different countries and also the different ways in which health is measured."
Examples of U.S. health disparities cited in the report include: women outliving men by an average of six years; people from households with an annual income of at least $25,000 living an average of three to seven years longer, depending on sex and race, than do people from households with annual incomes less than $10,000; Americans in different geographic regions of the U.S. having dissimilar rates of death and disease. Internationally, disparities occur among, as well as within, countries.
Reasons poorly understood
"Although much has been said and written about the phenomenon of health disparities, the reasons for particular disparities remain poorly understood," the report declared. "For example, in 2002, the leading cause of death, heart disease, killed 26.8% of black, non-Hispanic Americans, whereas it killed 29.2% of white, non-Hispanic Americans. This statistic says nothing about the real reason for the difference. Indeed, there could be many possible reasons for the disparity, including differences in treatments received for heart disease by these subpopulations, differences in the way death certificates are filled out, differences in the geography where they live, and biological differences.
"Some causes of health disparities are obvious, such as malnutrition, unsanitary conditions, and epidemic diseases that ravage parts of the world. For these conditions, more often found in developing countries, effective interventions are well known. There the challenge is to get the resources and manpower to put these interventions into effect. In modern industrialized countries, however, insufficient information may be known about what leads to population differences in morbidity or mortality, beyond obvious causes such as smoking, other high-risk behaviors, and exposure to infection and other identified hazards."
Mr. Sullivan's team pointed out that health disparities address risk factors, which lead to overall differences in a population's susceptibility to death or disease, but said that caution must be exercised in characterizing risk factors as causes. For example, they said, obesity and tobacco use are well-known risk factors associated with a greater risk of premature mortality and increased susceptibility to disease. But public health prevention efforts may oversimplify those concepts by equating "risk" with "cause" as a way to encourage less risk-taking behavior and presumably reduce disease frequency. "Media reports often misleadingly imply that a correlation between a factor and increased disease prevalence means that the factor caused the increase," the report said. "These oversimplifications and misleading conclusions can lead to public confusion and inefficient interventions."
The Public Health Policy Advisory Board said health experts are able to identify today causes of health disparities with reasonable confidence from well-understood threats to health such as high lead levels in the environment. However, the board said, the level of confidence becomes less and less for the validity of a proposed cause of a health disparity or a proposed intervention to address it as the complexity of the interplay of different possible causes increases.
Factors identified by the group as potentially having a bearing on health disparities include disparities in treatment, behavioral factors, biological causes, effects of population and immigration, and data factors.
Disparity/diversity correlate
Board Distinguished Fellow J. Donald Millar, former director of the National Institute for Occupational Safety and Health and former director of the Centers for Disease Control and Prevention's National Center for Environmental Health, said health disparity data indicate that "disparity correlates directly with diversity," and led him to observe that 1) greater diversity among subpopulations will be reflected in greater disparity on health status measures; and 2) reduction of health disparities may be limited or more difficult to address comprehensively by the extent to which the overall population is characterized by subpopulation diversity.
"The U.S. government has established a worthwhile goal of improving health for Americans," the report said. "However, the national thematic approach to improve health based on the elimination of health disparities is based on a view that different subpopulations can or should experience similar if not identical rates of morbidity and mortality. Indeed, health disparity data show that subpopulations, which by definition have different attributes, also experience varying patterns of death and illness…. This does not mean, however, that every effort should not be made to provide interventions that work for those who suffer ill health and death unnecessarily from correctable conditions…. (But) more serious work needs to be done to better understand the phenomenon of health disparities. Fundamental research could look at disparities that arise when environmental and ethnic diversity variables are controlled.
The Public Health Advisory Board made nine far-reaching recommendations:
1. Public health goals need to be driven by science rather than by politics and personal agendas.
2. Public health leaders must be willing to set priorities that make best use of scarce resources, even if it means changing popular but ineffective efforts.
3. While comparisons among subpopulations may point out discrete health disparities, effective public health efforts need to target the particular unmet needs of vulnerable populations.
4. Because harmful behavior causes poor health and increased medical costs, particular attention must be given to reducing those behaviors that not only make individuals sick, but also burden society with their costs.
5. To establish the prerequisite solid foundation for public health, government must ensure availability of adequate numbers of well-trained health scientists, such as epidemiologists and ecology-versed health professionals, who can better identify and determine the significance, if any, of differing health indicators in subpopulations.
6. To gain a fundamental understanding of complex phenomena such as health disparities, government needs to make appropriate investments in both basic genetic research that can reveal the biological bases of differences and similarities among subpopulations in susceptibility to disease and amenability to treatment, and in other research that can assess the contribution of nongenetic factors to disease's distribution and impact.
7. Government should critically evaluate the cost and effectiveness of interventions to eliminate or reduce health disparities.
8. Public health leaders should exercise restraint in use of politically correct formulistic demands such as "health equity" and "health justice," since these concepts, although useful in characterizing the plight of the disadvantaged, are polarizing and inexact for setting priorities to meet specific public health needs.
9. To better understand and address health disparities, health professionals need to work close to the community level of the affected population to benefit from, for example, community-driven priority setting and community-based participatory research.
Mr. Cohrssen tells State Health Watch the board is now looking at other studies it can do to advance some of the most important areas covered in this report.
[Download the report from www.phpab.org/health disparity/health disparity.pdf. Contact Mr. Cohrssen at (202) 775-1110 or e-mail: [email protected].]
While a global movement has stimulated a substantial effort to reduce health disparities by increasing apparent equity among disparate sub-populations, a recent report from the Public Health Policy Advisory Board, ... raises questions ...Subscribe Now for Access
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