Research has amply demonstrated that social and economic forces are important determinants of health. They affect where and how people live, work, learn and play; their patterns of social engagement; and the financial and social resources available to them. They thereby shape their health and length and quality of life.
The World Health Organization’s Commission on Social Determinants of Health suggested four strategies in which policy can be deployed to address health inequalities:
- decreasing social stratification (e.g., power, prestige, wealth, human capital, etc.);
- decreasing exposure to risk;
- lessening the vulnerability or improving the ability of disadvantaged persons to cope with risk; or
- intervening through health care to reduce the unequal consequences of social determinants.
Eliminating social stratification would likely be the most impactful of these strategies, yet seems the least likely remedy to be adopted. Several studies have documented better health in countries with less income inequality. There is also evidence that decreasing exposure to health risks can eliminate disparities. A study of black and white persons living together in an integrated community found no race disparities in diabetes or obesity among women, and a greatly reduced disparity in blood pressure. In this study, race differences in health risks exposures were controlled because both race groups lived in similar social conditions. That disparities were mostly not present in this community indicates that race/ethnic disparities are not immutable, and that when people are exposed to similar health risks they have similar health outcomes.
Adopting a “health in all policies” (HiAP) approach can decrease exposure to health risks for disadvantaged populations. HiAP is based on the realization that policies in virtually every sector, i.e. education, housing, and criminal justice, can have an impact on health. The HiAP approach is to conduct an assessment of all proposed policies for their potential health impact. By conducting a health impact assessment, the differential health impacts of a potential policy decision are understood, public health is included in the policy discourse, and policymakers are able to see how their decisions can maximize positive health impacts, minimize negative health impacts, and ensure that health impacts are distributed in an equitable manner.
The Centers for Disease Control and Prevention (CDC) established the Racial and Ethnic Approaches to Community Health (REACH) in 1999 to address CDC’s Healthy People 2010 goals of improving minority health and eliminating health disparities. The REACH program empowers community-based-organizations to mitigate health risks in their communities. Evaluations of REACH found that it was effective in addressing cholesterol screening and diabetes-related amputations, suggesting that community-based approaches can be effective for improving the health of minority populations.
Perhaps the most common (and likely least effective) approach to addressing race/ethnic disparities is to intervene through health care. The expansion of Medicaid as part of the Patient Protection and Affordable Care Act attempts to address health inequalities by increasing access to care to millions of uninsured Americans. This is a necessary and appropriate step. However, there is overwhelming evidence that expanding access to health care alone will not solve the health inequalities problem. This is precisely what the Institute of Medicine’s report Unequal Treatment documented.
The elimination of health disparities, it seems, will likely be achieved through multi-sectored approaches, bringing together stakeholders from multiple sectors (including health care) with community members empowered with resources to find solutions. Broad partnerships and collaboration are essential to eliminating risks, transforming communities, and ending health inequality.