Challenges and Successes in Reducing Health Disparities Workshop Summary (2008) / Chapter Skim
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2 The Impact of Geography on Health Disparities in the United States: Different Perspectives
2 The Impact of Geography on Health Disparities in the United States: Different Perspectives
Pages 7-46
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EIGHT AMERICAS The Eight Americas presentation is based on analyses of county-level mortality data from the National Center for Health Statistics (NCHS) , collected between 1960 and 2001, explained Dr.
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According to the U.S. national average, and as seen in data from counties that have historically had the highest life expectancies, male life expectancy has been increasing faster than female life expectancy.
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THE IMPACT OF GEOGRAPHY ON HEALTH DISPARITIES Males Females FIGURE 2-1 County life expectancy 1997–2001. 2-01.eps bitmap images
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The Eight Americas are defined in Table 2-1 and represented in Figures 2-4 and 2-5. Mortality and Cause of Death: Comparisons of the Eight Americas Using statistical analyses, it is possible to explore life expectancy and causes of death in the Eight Americas.
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75 70 65 60 1960 1970 1980 1990 2000 Year FIGURE 2-3 Life expectancy for top and bottom 2.5 percent of counties.
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8 High-risk 7.5 $14,800 Urban populations of more than urban black 150,000 blacks living in counties with cumulative probability of homicide death between 15 and 74 years greater than 1.0% SOURCE: Adapted from Murray et al.
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America One, comprised of Asian Americans living in communities in which Pacific Islanders make up fewer than 40 percent of the total Asian population, has a high life expectancy that continues to increase. America Two shows a dwindling advantage over America Three (Middle America)
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80 70 60 2000 1990 1996 1984 1986 1988 1998 1994 1992 1982 Year FIGURE 2-6 Life expectancy at birth in the Eight Americas.
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Overall, comparing the graphs for men and women in Americas One through Eight shows that there is very little change in the net effect between the early 1980s and 2000. County Trends in Life Expectancy The Eight Americas mortality database contains county-level data d ating back to 1960, and an analysis of those data shows a pattern of growing inequalities since 1983.
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16 CHALLENGES AND SUCCESSES IN REDUCING HEALTH DISPARITIES A 2-07a.eps B bitmap image 2-07a.eps bitmap image 2-07b.eps bitmap image FIGURE 2-7 Change in male life expectancy: (a)
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THE IMPACT OF GEOGRAPHY ON HEALTH DISPARITIES 17 A 2-08a.eps B bitmap image 2-08a.eps bitmap image 2-08b.eps FIGURE 2-8 Change in female life expectancy: (a)
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Income information gleaned from the 2000 census, together with county-level data from the tax return database of the Internal Revenue Service, revealed that while life expectancy in several counties is dropping, the counties with decreasing life expectancies are not getting markedly poorer. Global Perspective of the Eight Americas An alternate way to examine the U.S.
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Another way to examine these data is to compare mortality rates across the Eight Americas with the range found in high-income countries
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, typically the best source for biomedical measurements and biomarkers, did not yield sample sizes large enough for the data to be analyzed at the level of the Eight Americas. The Behavioral Risk Factor In-depth survey compiled by the Centers for Disease Control and Prevention's NCHS that combines in-person interviews with standardized physical examinations, diagnostic procedures, and lab tests with national rather than state representation (NCHS, 2008)
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Several interesting observations were made using this method. BRFSS data were used to examine health plan coverage across the Eight Americas (Figure 2-11)
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Considerably more work must be done to determine what the net effect of addressing each of those risk factors would have on the differences that are seen across the Eight Americas. Policy Focus When considering potential policy implications related to reducing health disparities, it is important to speculate beyond the health insurance debate.
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Murray noted that while disparities are increasing in the United States, infant, child, and adult mortality and life expectancy are consistently dropping the ranking of the United States among other countries when health outcomes are compared. Over the last 30 years, the U.S.
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For women there is a marked gradient across the Eight Americas in obesity, going up such that Americas 5–8 are greater than 45 percent obese for women and over 30 percent obese for men. Future work will use attributable mortality calculations to examine what the reduction in disparities and life expectancy would be if obesity could be reduced.
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THE IMPACT OF GEOGRAPHY ON HEALTH DISPARITIES 25 C Obesity Corrected for Self-Report Bias 60% 50% 40% 30% 20% 10% 0% 1 2 3 4 5 6 7 8 America Male Female 2-12c.eps D Uncontrolled Hypertension 35% 30% 25% 20% 15% 10% 5% 0% 1 2 3 4 5 6 7 8 America Male Female E 2-12d.eps Blood Sugar 110 108 106 104 Mean FPG 102 100 98 96 94 92 90 1 2 3 4 5 6 7 8 America Male Female 2-12e.eps are markedly higher in Native Americans which may be caused in part by a genetic component. Again, the pattern resembles the gradient seen in outcomes across the Eight Americas.
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He explained that Hispanic Americans were not represented because county-level life expectancy data comparing death certificates and census reports for Hispanic are unreliable; recorded life expectancies in some counties were found to be as high as 190 to 250 years of age. Fundamental differences exist between how Hispanic status gets reported by physicians or relatives on death certificates and self-reported data on the census, and there has been little success in finding a way to reconcile these data sources.
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. Consistent with the findings of the Eight Americas, research suggests that health and social determinants show large geographic variations in absolute terms and in the level of disparities.
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According to Healthy People 2010 objectives, the nation should strive for a low-birth-weight rate of 5 percent. In over 90 percent of metropolitan areas, white children have low-birth weight rates between 3 and 6 percent, a rate very similar to the distribution of low-birth-weight children among Hispanics.
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When the poverty composition of neighborhoods is analyzed by comparing nonpoor black children to poor white children, the distribution of poor white children remains more favorable than the distribution for nonpoor black children (Figure 2-14d)
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30 CHALLENGES AND SUCCESSES IN REDUCING HEALTH DISPARITIES A Pyramid Graph: Theoretical Equal Neighborhood Environment for 2 Groups: A Mirror Image Over 40% Black White Neighborhood Poverty Rate 30.1-40% 20.1-30% 10.1-20% 0-10% 100 75 50 25 0 25 50 75 100 Share of Children in Neighborhoods with Specified Poverty Rates 2-14a.eps B Metro Chicago Poverty Composition of Neighborhoods of Black v. White Children Over 40% Black White Neighborhood Poverty Rate 30.1-40% 20.1-30% 10.1-20% 0-10% 100 75 50 25 0 25 50 75 100 Share of Children in Neighborhoods with Specified Poverty Rates FIGURE 2-14a–d Distribution of poverty rates for neighborhoods in a metropoli tan area.
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Poor White Children Over 40% All Black Poor White Neighborhood Poverty Rate 30.1-40% 20.1-30% 10.1-20% 0-10% 100 75 50 25 0 25 50 75 100 Share of Children in Neighborhoods with Specified Poverty Rates 2-14d.eps
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metropolitan areas in 2000, it was evident that black and Hispanic children consistently live in neighborhoods with much higher poverty rates than white children. In fact, the socioeconomic profile for Hispanic children at the family, neighborhood, and school levels is similar to the profile of black children.
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One example of this was recently seen during discussions of the State Children's Health Insurance Program reauthorization, when coverage for illegal immigrant children was highly debated and eventually defeated. Policies such as these restrict access to health care for immigrant children, a group among which Hispanic children are the majority.
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The majority of public health professionals have traditionally favored approaches that focus on improving disadvantaged neighborhoods, rather than moving people to new neighborhoods, but it is extremely challenging to try to improve neighborhoods with high poverty rates. Some economic interventions can make a difference, but the problems that exist in these neighborhoods are deeply entrenched and interconnected.
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Acevedo-Garcia's own data would show that the vast majority of white children who are poor do not live in communities in which a lot of people are poor. Even if one could decrease racial segregation and give more minority children better opportunities, the number of children who could be affected would be quite limited.
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Murray, GAVI was created as a public–private partnership through a grant from the Bill and Melinda Gates Foundation, to find a way to increase immunization rates using local innovation. The Global Alliance asked countries to apply and propose how they were going to raise childhood immunization; it did not say how they should do it.
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Having power and wealth concentrated among a few industries, such as the pharmaceutical industry and the professional health care industry, can make it difficult to try to enact the reforms necessary to alleviate health disparities in the United States. Medical advancements have increased life expectancies and led to medical interventions that save lives.
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The health industry in the United States should be based on a foundation of ensuring good health rather than administering sick care as it does now. True health care would take up issues like housing, healthy environments, employment, and income disparities.
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Although that is a component of the problem, the entire issue is much more complex. The solution to framing issues related to health disparities is to shift from benchmarking health problems to benchmarking the coverage or by tracking care, continued Dr.
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Most of us were motivated to come here because we view access to quality health care as a human right, commented Dr.
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Clinical workers and public health professionals must talk about these issues
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Had blacks and poor whites been able to come together in the 1960s and form an effective political coalition, the course of this nation may have changed. Today there is a similar opportunity.
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Her group, Latino Health Access, collects data from census tracts and from communities. She argues that these data need to be revised for public health environments, so that health disparities affecting young communities, which may not be evident in life expectancy data, can be identified with data that use smaller numbers of cases as the unit of analysis.
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Life expectancy has gone up, mortality from HIV/AIDS has declined, and more women have taken advantage of first trimester care. There have been improvements, but they are small.
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2006. Eight Americas: Investigating mortality disparities across races, counties, and race-counties in the United States.
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