The importance of health disparities has never been so apparent. Numerous studies over the last decade have raised concern over the frequently lower quantity of life and the lack of better quality of life that many minority populations in the United States face. These findings confirm a growing concern that American society is one in which health is unequal. Because of the widening gulf between those who are healthy and those who are not, the terms “health disparities” and “health inequalities” are the leading catchphrases today among those who are concerned about health. To begin to address the underlying causes of ill health in our society, it is necessary to increase understanding of the consequences of these disparities. This essay explains how disparities impact society and proposes strategies such as enforceable collaboration as a means to bridge these gaps and create a healthier society. This message is applicable to numerous health-related social advocacy groups and professional organizations. It is important to articulate these principles slowly and distinctly to the larger population because only once the populace grasps their significance can action be taken. U.S. demographics are changing, and health disparities and health literacy can no longer be isolated from the many internal and external forces that are integral to overall societal health. The outer environment, because of its impact on health, requires advocates.
Definition of Health Disparities
A health disparity is a difference in health outcome that is closely linked with social, economic, or environmental disadvantage. Essentially, these are measurable differences in health outcomes for different groups of people. This is why some scholars prefer the term health inequalities while others prefer health disparities. The most important factors in health disparities include economic and social conditions that are reflected in social determinants of health, such as food, housing, public safety, discrimination, unemployment, and social support. These differences can come from a variety of factors, including specific population race, ethnicity, gender, age, income, language spoken, education, disability, location, or sexual orientation. Some populations are vulnerable to poverty and poor access to resources like transportation and healthcare, while others are at higher risk of chronic health conditions based on environmental factors. Health disparities should not be confused with equal treatment. Everyone may have unfair access to healthcare at baseline, but the presence of health disparities means that people also experience unequal treatment in treatment and care. Health disparities usually cause some groups to experience a higher disease burden and thus higher disability and premature death rates. Health inequities, on the other hand, are health disparities that are the result of systemic injustices. In other words, they are health disparities that are avoidable and therefore considered fundamentally unfair and unjust. The occurrence of health disparities in a community or region is shaped by historical factors and ongoing social and economic structures of the area. Even people in similar living conditions will experience different health outcomes based on the shape of their local context. All of this means that understanding and addressing health disparities is a core function of public health.
Understanding the Root Causes
Among the many complex problems in health care, none may be as multifaceted as health disparities. Often brought to light by the unequal ripples of pandemics, disparities underline the misunderstandings that made a health crisis worse. But just as health disparities are often the canary in the inequality coal mine, they are also fundamentally born of similar issues: systematic, systemic causes. The foundational impetus of health disparities in the United States—specifically, but not limited to, those disparities that disproportionately affect Black, Indigenous, and other communities of color—can simply be put: the broader social, environmental, and economic characteristics that influence overall health.
Part of the complexity of health disparities is that they are products of “upstream” issues, meaning systemic changes are likely fundamental to truly address them. Again, another comparison between pandemics makes the point: the issues that lie at the heart of health disparities were long-seated, and they made their sufferers more likely to suffer from the pandemic. Individuals’ health is a product of their comprehensive state of living, and few just “medical” interventions affect all areas of living in the same way. An evidence-based conclusion: when it comes to health disparities, we ought to think holistically whenever we can. From national policymaking to locally focused programming, it is imperative to concentrate attention on health determinants. We have very intentionally characterized many “health inequities” as “disparate,” noting as well that certain disparities were not driven by culture or “genetic pathologies.”
Social Determinants of Health
The social determinants of health (SDOH) include the conditions in which people are born, grow, live, work, and age, as well as systems and policies in place that influence health outcomes. These determinants are shaped by social, political, and economic structures and processes. SDOH include factors such as economic stability, neighborhood physical environment, education, food access, transportation options, public safety, social support systems, access to quality healthcare, preventive services, and government programs. At the core of understanding and addressing health disparities is an understanding and recognition of social determinants of health. This breadth of factors helps provide context to the vast array of issues that impact the field of medical care. The key factor in understanding SDOH is that these social factors do not act in a silo. At any given time, patients exist in a multitude of social spaces. When taken in isolation, any one factor may explain only a part of an individual’s health outcomes, if that. However, due to the influence and interactive nature of these social factors, these determinants can converge and compound, leading to increased inequalities and creating cumulative disadvantages for certain populations, which further impacts access to resources. For example, individuals with limited access to healthcare may be less likely to receive regular check-ups, and if diagnosed with a condition or disease, will be less likely to have access to timely, effective treatment. They may also be less likely to receive sub-specialty care because they present at an advanced stage, ultimately leading to poorer health outcomes. Simultaneously, preventive screenings become less routine for some populations, leading to later diagnoses.
Impacts of Health Disparities
To illustrate the impact of health disparities, it is important to note the consequences of poor health. Apart from impeding individuals’ overall quality of life, chronic poor health will at some point require intervention and treatment, straining the healthcare system and burdening the economy. For individuals, this may translate to increased healthcare costs, while for society at large, it means fewer people contributing to the workforce and, consequently, decreased productivity. Hardship wrought by inaccessibility to affordable care can also manifest in poor school performance, job loss, and, in general, family instability. From a social standpoint, high rates of community members experiencing poorer health outcomes ultimately tug on the overall well-being of an entire neighborhood; mainly, morale suffers when it is clear that a high proportion of a population is systematically oppressed.
Though more difficult to measure than economic costs, some research asserts that factors like social cohesion and other sense of community attributes may suffer in socioeconomically disadvantaged health outcome areas; scholars suggest that health disparities lead to further holistically weakened communities that are becoming more inward-oriented. Others argue that there would be no society without the health of individuals and thus focus on improving public health, regardless of social cohesiveness criticisms. In previous centuries, researchers have found that poorer health status of different minority communities can encourage further ‘blaming’ and ‘othering’ by the general public in an attempt to explain why they face these higher rates of health problems. In turn, feeling blamed for health disparities can lead to greater discrimination and lack of opportunity, which only serves to strengthen the problem of health disparities.
Economic Costs
Attributable costs. Health disparities and inequities create direct costs, creating burdens on uninsured and underinsured individuals and indirectly increasing national healthcare expenditures. Roughly 30% of direct medical costs associated with health inequities can be attributed to the clinical care sector. There is a positive association between health inequities and inefficiencies in national economic productivity, concluding that political stability, public expenditure control, investment in education and infrastructure, and ethical behavior with respect to income disparities, all factors in achieving health equity, can generate economic prosperity and efficiency. Some employers perceive a loss in productivity due to poor worker health. The links between health inequities, job performance, and worker productivity continue to be explored. Furthermore, the costs of health disparities extend beyond those of clinical care—such disparities in health create significant indirect costs through social welfare, school loans, and a society’s social, educational, workforce, and criminal justice systems.
Potential economic benefits of investing in health equity. The financial benefits of investing in progressive health interventions and policies can result in significant returns on investment for society as a whole. Health systems function as a mechanism that amplifies pre-existing social inequalities in both health and healthcare access. Arguments that underscore the financial benefits of investments in proactive health interventions have the potential to inform social justice policies that promote health equity.
Current Efforts and Interventions
At every level, local, regional, and national organizations are working earnestly to address health disparities. These targeted interventions are achieving results. As an example, the Kansas Department of Health and Environment has reduced the prevalence of new childhood cases of lead poisoning in three communities around the state by significant amounts. The company and community of Spartanburg, South Carolina, in partnership with a health program, have reduced the obesity rate in a second-grade cohort from 33% to 26%. In North Carolina, the KidSCope program illustrates that an innovative model can help identify children at risk for dropping out of school. The Durham Healthy Carolinians project has increased the percentage of Durham residents who have health insurance from 86% in 1998 to 94% in 2015. This work didn’t happen overnight. It took more than 10 years of trial and error, constitutional and financial struggles to increase insurance for people facing disadvantages. It took immersion in the community by participants in this “faith and health collaboration”; new ways of thinking about the institutional church and its relationships to the larger community by a largely professional group of participants; and new ways of thinking about each other’s health and well-being as residents and members of distinct religious groups who know each other “when not in worship” to create the Durham Congregations in Action.
There is a growing literature on what works. A systematic review has concluded that programs and policies developed by local governments and community-based organizations were effective in increasing physical activity and healthy eating among kids about 50% of the time. Efforts to provide accessible health care that is culturally and linguistically competent to build block social and emotional well-being and hopeful family and community legacies demonstrate promise. Five systemic interventions to address health disparities have been evaluated for robustness: community-based prevention programs; policy interventions to support wages and incomes; socio-economic and community determinants of health; community-based and policy interventions for global health; and social services and other systems necessary to support positive human development. The work in cross-national health care communications produced no robust findings, and results varied across papers for unconventional and novel care programs, including national centers of excellence for persons with barriers to interpersonal functioning. Even within the successful evidence-based interventions, passage of programs and policies at multiple levels of government, including the creation of funding that could improve coordination and prioritize needs within increasingly constrained funding, requires much leadership capacity-building and community mobilization, as efforts to increase independent financing or seek flexibility have not worked.
There is plenty of good news about a growing number of successful interventions and areas of research that are helping to understand, to develop interventions, and to lower the gap. It is more difficult to find resources to increase the number of well-qualified professionals who can conduct and sustain the research required to end the disparities, or to build the population’s understanding of the magnitude of philanthropic, volunteer, and other resources required to change trajectory and increase understanding and decrease the gap in social determinants of health alone — healthy neighborhoods, with supports for healthy behavior, families, and minds that equal healthy economic contributions to healthy businesses and educational research, as well as to the health system, are essential.
Community Health Programs
Programs designed to bridge the access to care gap and reach people where they live, work, play, and pray have flourished. In Boston, Massachusetts, community programs director of the South End Community Health Center offers free cooking and exercise programs, mobile markets, and healthy holiday baskets. Operated by a community-based initiative with several member agencies, the South Central Healthy Lifestyles Center in Des Moines, Iowa, also serves as a one-stop shop for those in need. Begun in 1989, the Backyard Initiative works with the broader community and includes open spaces like a futon factory, a youth café, and a Good Neighbor club, an employment service for people returning to community life from prison. These and other programs throughout the more than 50 years of community health work, old and new, are vitally important for a number of reasons. First, community-based programs help people get the health care they need, as well as the information and tools to improve their health and to navigate a complex system.
Community-based delivery of health care and health information can create linkages and referrals to the traditional health system and can overcome the suspicion and fear that keep some people from seeing a medical doctor or getting preventive care. The work of a community health initiative is not a ‘program’ in the sense so often used with charitable, social service, and even some public health ‘work.’ The founder of a drop-in center and cooking school calls it “a campaign.” In public health, we talk about campaigns to prevent or cure diseases. This campaign targets something much trickier than pneumonia or sugar levels. Our campaigns target despair, isolation, and cynicism. They can challenge public apathy and the shockingly low standards of both government and private sector support for community organizations. We can prove that it is feasible to put hope into action and invest in activities that build community wellness. The experience in Nashville, however, is key. Not only is the community health program tailored specifically to meet the needs of state workers; it is run by several organizations working together to break down the trust barriers that often isolate the poor. After all, the roots of health disparities are the same whether people work in Welcome Centers or in Walmart.
Future Directions and Recommendations
Despite many recent achievements in the reduction of health disparities, a number of improved practices and tools are required to turn deficiencies into opportunities and issues into solutions. First, there is an urgent need to invest in programs and practices aimed at reducing disparities in vulnerable communities. New approaches are needed and must include practitioners as members of research teams to ensure pragmatic and translatable strategies that reflect real-world conditions. Innovative initiatives need to be supported in conjunction with practical pilots with industry and governmental partners. Second, the evidence base must be improved to further our understanding of what works. This means advocating for the deepening and broadening of research agendas while ensuring that the translation of these efforts occurs in tandem.
Given the fact that evidence favors integrated responses across the sectors of health and social services, a strategy with impact in addressing several disparities and improving upstream issues is crucial. Rather than focusing solely on health care, broader collaborations beyond the health care continuum are vital. These collaborations should also incorporate schools of public health, public health departments, education organizations, and criminal justice organizations. Another area of focused effort will be ensuring that community members, particularly people of color, are regularly and systematically engaged in the development of policies and practices. Innovative approaches will also be needed. For example, leveraging technology to not only bring health services, such as telemedicine, but also other services, such as educational services and vocational training, into targeted communities. Electronic health data can be used to more systematically identify health disparities and monitor disparities in real time, and research on the uses of big data that includes traditionally underrepresented populations will also be important in the years ahead. Key strategies will also include dissemination of and training in cultural proficiency for all staff working across a variety of sectors. Most importantly, a series of topics of the year would be identified, focusing on emerging health disparities that cross multiple domains and might negatively impact an increasingly large proportion of the population. Participants from a variety of sectors would help to build a body of knowledge on these topics for use in confronting these emerging challenges.
Given the anticipated demographic shifts expected, it is important to address disparities in the near term. Looking just within the numbers of people of working age, the percentage of the working population with dark skin will outnumber light skin members of the working population by 2040. It is imperative that we develop a roadmap for addressing disparities that involve age where the population most vulnerable to disparities grows in size. Longer-term research programs should combine public and private funding to concentrate on the social determinants of health, with a focus on upstream activities such as maternal education and its impact on subsequent outcomes. Programs should also focus on health disparities across the lifespan, with a heavy emphasis on the design and development of pediatric interventions aimed at achieving health equity beginning early in life. Ongoing research to better understand the basic nature of emerging disparities and the role that technology and medicine will play in disparity reduction will be critical over the long term.
Policy Changes
Introduction
Policymakers have the power to create a society that is more equitable and healthier in numerous ways, including creating laws and regulations that govern industry. Specifically, regulating aspects of the food and beverage industry, such as limiting sugar-sweetened beverages and prohibiting advertising to children, is essential. These are called lifestyle regulations or laws and have the ultimate goal of improving the social determinants of health. Other changes can be made to the healthcare system to enable everyone to access the care and treatment they need. Additionally, to address health disparities, some areas of public policy need to be modified to mitigate harms in communities already affected by polluting industries. Having clean, renewable energy, built using responsible land ethics, is a way to ensure our communities are healthy and safe.
Policy Changes
• Many policy initiatives are designed to address fundamental social determinants of health, as well as reduce or remove barriers that people face in accessing healthcare, so that health is truly achievable for all. For example, raising the minimum wage, enacting paid sick and family leave, making good quality affordable housing available to all, and guaranteeing access to clean water and air are some of the ways local and tribal communities launch these efforts. Since we know that there is a strong, well-documented relationship between income and health, raising the minimum wage helps directly reduce health disparities, as people have more resources to cover their everyday needs. Additionally, research finds that higher wages are linked to lower rates of diabetes, heart attacks, and stress, while poverty and demands related to low-wage work are tied to weathering and early aging in people of color.
