Disparate Disparities

I'll be at a statewide conference on health disparities all day, so just this quick hit post. Disparities are differences in health status, morbidity and mortality among "population groups." "Groups" means categories like race, ethnicity, gender, sexual orientation, age, and disability. Obviously differences according to age, gender and disability are inherent, but disparities in those cases refers to avoidable differences resulting from correctable inequalities.

This is a major form of discourse in public health these days, inspired in part by the Clinton Administration establishing a national goal to "eliminate" health disparities by 2010. Of course it isn't going to happen. Although I strongly support health equity and structure much of my work around that principle, this discourse says a lot about our politics.

In fact, the most important and best established health disparities are between rich and poor, the well educated and less well educated, people with high occupational status and people with low occupational status. In the health disparities discourse, these factors -- which are closely associated with each other but not really identical -- are usually thought of as exogenous variables that we control for. "Disparities" are what is left over. Such left over disparities are still important and it's well within the egalitarian tradition to study and combat them. But it is noteable that we marginalize socio-economic status.

There seems to be a tacit assumption in the U.S. that class inequality is a force of nature, something we just have to accept as background. We can't do anything about it so why bother to talk about it?

In fact, overall population health status correlates with inequality at the level of the state and nation. More egalitarian countries -- such as the nations of Western Europe -- have healthier populations than the U.S., in spite of lower total wealth. Even a very poor country such as Cuba, which also has low inequality, actually compares favorably to the U.S. on some health status indicators. Social policy - including the structure of the tax system, corporate regulation, and social programs such as universal access to higher education, child care, public transit, job-creating investment and, oh yeah, universal, comprehensive health care -- can powerfully affect the level of inequality in capitalist countries. (Note that health care per se has less effect than most people expect on individual health and longevity. However, providing health care without requiring low income people to pay more than they can afford contributes powerfully to economic equality.)

In research and policy advocacy to combat health disparities, we need to put economic and social equality front and center, not on the sidelines.