Chapter 1_ Vulnerable Populations, Health Disparities, and Health Equity_ An Overview.pdf

Mount Saint Vincent College Access Provided by: Medical Management of Vulnerable and Underserved Patients: Principles, Practice, and Populations, 2e Chapter 1: Vulnerable Populations, Health Disparities, and Health Equity: An Overview Kevin Grumbach; Paula Braveman; Nancy Adler; Andrew B. Bindman O...

Mount Saint Vincent College Access Provided by: Medical Management of Vulnerable and Underserved Patients: Principles, Practice, and Populations, 2e Chapter 1: Vulnerable Populations, Health Disparities, and Health Equity: An Overview Kevin Grumbach; Paula Braveman; Nancy Adler; Andrew B. Bindman OBJECTIVES Objectives Define the terms vulnerable populations, health disparities, and health equity. Distinguish among differences in health, health disparities, and health­care disparities. Understand the relationship between social vulnerability and health disparities, and the pathways mediating this association. Recognize the ethical and human rights principles underlying efforts to achieve health equity Identify actions health professionals may take to change the social conditions that create vulnerability and produce health disparities. INTRODUCTION “Vulnerable” derives from the Latin word for wounded. Populations can be vulnerable for a variety of reasons. In this chapter, we focus on populations that are wounded by social forces that place them at a disadvantage with respect to their health. Vulnerability is visible in the variation across social groups in levels of resources and social influence and acceptance, as well as in the incidence, prevalence, severity, and consequences of health conditions. This chapter provides an overview of the concept of vulnerability. It begins by introducing the notion of health disparities, distinguishing it from simple differences in health, and defining the closely related concept of health equity. It describes evidence of health disparities, particularly by socioeconomic status (SES) and race/ethnicity. It then discusses conceptual models for understanding the pathways between social vulnerability and poor health status. It concludes by suggesting that health professionals have a responsibility not only to develop their skills to respond effectively to the health­care needs of vulnerable patients but also to take action to change the fundamental social conditions that produce vulnerability. WHAT ARE HEALTH AND HEALTH­CARE DISPARITIES? Webster’s dictionary defines disparity as a difference. “Difference” sounds like a neutral concept. It may seem logical that different people have different states of health, requiring different kinds and quantities of care. For example, elderly people are expected to be less healthy than young adults. People who ski are more likely to suffer leg fractures than people who do not. Concern for health disparities is not about all differences in health, but rather about a subset of differences that are avoidable and suggest social injustice. Although few readers of this book probably were moved to righteous indignation by the health differences cited in the example of skiers and more frequent broken bones, the following observations are likely to prompt qualitatively different reactions: A baby born to an African­American mother in the United States is more than twice as likely to die before reaching her or his first birthday as is a baby born to a white mother.1 A World Bank study of 56 countries revealed that, overall and within virtually every country, infant and child mortality were highest among the poorest 20% of the population and lowest among the best­off 20% of the population; the disparities were large in absolute as well as relative terms.2 HEALTH DISPARITIES Downloaded 2024­1­25 11:44 A Your IP is 63.247.224.45 Page 1 / 15 Chapter 1: Vulnerable Populations, Health Disparities, and Health Equity: An Overview, Kevin Grumbach; Paula Braveman; Nancy Adler; Andrew “Health disparities” is a shorthand term denoting a specific kind of health difference between more and less privileged social groups. It refers to B. Bindman ©2024 McGraw Hill. All Rights Terms of Use Privacy Policy and Notice Accessibility differences that adversely affectReserved. disadvantaged groups that are systematic persistent, not random or occasional, and that are at least theoretically amenable to social intervention. The social groups being compared are differentiated by their underlying social position, that is, by their relative more frequent broken bones, the following observations are likely to prompt qualitatively different reactions: A baby born to an African­American Mount Saint Vincent College mother in the United States is more than twice as likely to die before reaching her or his first birthday as is a baby born to a white mother.1 A World Access Provided by: Bank study of 56 countries revealed that, overall and within virtually every country, infant and child mortality were highest among the poorest 20% of the population and lowest among the best­off 20% of the population; the disparities were large in absolute as well as relative terms.2 HEALTH DISPARITIES “Health disparities” is a shorthand term denoting a specific kind of health difference between more and less privileged social groups. It refers to differences that adversely affect disadvantaged groups that are systematic and persistent, not random or occasional, and that are at least theoretically amenable to social intervention. The social groups being compared are differentiated by their underlying social position, that is, by their relative position in social hierarchies defined by wealth, power, and/or prestige; this includes socioeconomic, racial/ethnic, gender, and age groups and groups defined by disability, sexual orientation or identity, or other characteristics reflecting social privilege or acceptance.3,4,5 HEALTH­CARE DISPARITIES Disparities in health care, as opposed to disparities in health, refer to systematic differences in health care received by people based on these same social characteristics. Although disparities in health care account for only a relatively small proportion of disparities in health, they are of particular importance to health­care providers and are discussed in detail in the next chapter. HEALTH EQUITY For individuals concerned about vulnerable and underserved populations, one overarching objective is eliminating health disparities. A slightly different way of framing this aspiration is to state that the goal is to achieve health equity. This frames the objective as a positive one (achieving equity) rather than a negative one (eliminating disparities). This approach mirrors defining health as a positive state of well­being and not just the absence of disease. Health equity may be understood as a desired state of social justice in the domain of health, and health disparities as the metric used to measure progress toward this state. A reduction in health disparities is evidence of making progress toward greater health equity.6 ROLE OF SOCIOECONOMIC CLASS AND RACE/ETHNICITY IN HEALTH DISPARITIES Profound and pervasive disparities in health associated with a range of socioeconomic factors such as income or wealth, education, and occupation have repeatedly been documented in the United States and globally.2,7,8,9 Despite ongoing debates about whether causation has been definitively established, considerable evidence has accumulated demonstrating, at a minimum, the biological plausibility of those associations.10,11 Similarly, virtually wherever data on health according to race or ethnic group have been measured, racial or ethnic disparities in health also have often been observed; these disparities sometimes, but not always, have disappeared or been markedly reduced once socioeconomic and other contextual differences have been accounted for.12,13,14 SOCIOECONOMIC STATUS Social class shows a strong association with health and longevity. Higher SES provides individuals with more material, psychological, and social resources, which can benefit their health. There is no standardized method for defining or measuring social class in the clinical setting, and this information is not routinely collected as a part of health­care encounters. Some of the typical dimensions of social class used in research studies include occupation, income, and education level, which are all components of what is generally referred to as socioeconomic status. Some of the most compelling evidence about the association between SES and health comes from the Whitehall study in the United Kingdom. This research on British civil servants demonstrated a linear association of higher occupational grade with lower 10­year mortality.15 This was a striking finding because significant differences in mortality occurred in a population in which all participants were employed and had health­care coverage. Despite the relative homogeneity of the group, those in higher occupational grades had significantly lower rates of a number of diseases as well as lower mortality. These differences remained 25 years later, even after some of the civil servants had retired from their jobs.16 A similar SES and health gradient has been observed in the United States. A 2010 study using national data observed stepwise incremental gradients of health improving as either income or educational level rose, for scores of indicators across the life course.8 INCOME AND HEALTH Analyses of the SES gradient generally reveal a sharp drop in mortality as income increases from the most extreme categories of poverty toward more moderate poverty, and a continued but more gradual drop in mortality as incomes rises above this moderate poverty level. The National Longitudinal Mortality Survey in the United States showed a difference of more than 6 years of life expectancy at age 25, between those who were poor and those Downloaded 2024­1­25 11:44 A Your IP is 63.247.224.45 with incomes more than four times the poverty level; there was a 2­year difference in life expectancy at age 25 between those with intermediate­level Page 2 / 15 Chapter 1: Vulnerable Populations, Health Disparities, and Health Equity: An Overview, Kevin Grumbach; Paula Braveman; Nancy Adler; Andrew incomes (200–399% of poverty) and the higher­income group (Figure 1­1).8 B. Bindman ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Figure 1­1. INCOME AND HEALTH Mount Saint Vincent College Access Provided by: Analyses of the SES gradient generally reveal a sharp drop in mortality as income increases from the most extreme categories of poverty toward more moderate poverty, and a continued but more gradual drop in mortality as incomes rises above this moderate poverty level. The National Longitudinal Mortality Survey in the United States showed a difference of more than 6 years of life expectancy at age 25, between those who were poor and those with incomes more than four times the poverty level; there was a 2­year difference in life expectancy at age 25 between those with intermediate­level incomes (200–399% of poverty) and the higher­income group (Figure 1­1).8 Figure 1­1. Family income and life expectancy at age 25 in the United States. This figure describes the number of years that adults in different income groups can expect to live beyond age 25. For example, a 25­year­old man with a family income below 100% of the federal poverty level can expect to live 49.2 additional years and reach an age of 74.2 years. (Source: CDC/NCHS, National Health Interview Survey Linked Mortality File, 2006. National Center for Health Statistics. Health, United States 2011: With Special Feature on Socioeconomic Status and Health. Hyattsville, MD: 2012. http://www.cdc.gov/nchs/data/hus/2011/fig32.pdf.) Above and beyond one’s own economic status, there is some evidence that the distribution of income across a population makes a difference. Although still being debated, income inequality itself may be bad for people’s health, irrespective of the average overall standard of living in a society. As discussed in Chapter 7, cross­national comparisons indicate that nations with less income inequality have better overall health indicators than nations at a comparable level of economic development with more unequal income distribution.17 Wealth is another measure of economic status. Wealth includes not just income, but also the value of assets such as home ownership, real estate, and investments—assets that often accumulate among families over generations. Wealth tends to have an even more inequitable distribution across a population than does income. EDUCATION AND HEALTH In contrast to the relationship between income and health, which demonstrates a continued drop in mortality as income increases (albeit with a sharper drop in the lower portion of the distribution), the association between mortality and education is more discontinuous. For all­cause mortality and each of the specific causes, the death rates are lower for those with more education (Figure 1­2). To the extent that education provides information, knowledge, and skills that improve health, each additional year of education should contribute somewhat equally to improved health. However, educational attainment also serves a credentialing function. As a result, there is a greater benefit of achieving years of schooling that result in a degree or credential than of additional years that do not. Thus, the benefit of completing the 12th year of schooling, which results in a high school degree, is greater than the benefit of completing any other single year of high school (referred to as the “sheepskin” effect). Figure 1­2. Educational attainment and life expectancy at age 25 in the United States. This figure describes the number of years that adults in different education groups can expect to live 11:44 beyond 25.IP For a 25­year­old man with a high school diploma can expect to live 51.4 additional years and reach Downloaded 2024­1­25 A age Your is example, 63.247.224.45 Page 3 / 15 Chapter Vulnerable Populations, Health Disparities, and Health Survey Equity: Linked An Overview, Kevin Paula Braveman; Nancy Adler; Andrew an age of1: 76.4 years. (Source : CDC/NCHS, National Health Interview Mortality File, Grumbach; 2006. National Center for Health Statistics. Health, B. Bindman United States 2011: With Special Feature on Socioeconomic Status and Health. Hyattsville, MD: 2012. ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility http://www.cdc.gov/nchs/data/hus/2011/fig32.pdf.) a degree or credential than of additional years that do not. Thus, the benefit of completing the 12th year of schooling, which results in a high school degree, is greater than the benefit of completing any other single year of high school (referred to as the “sheepskin” effect). Mount Saint Vincent College Figure 1­2. Access Provided by: Educational attainment and life expectancy at age 25 in the United States. This figure describes the number of years that adults in different education groups can expect to live beyond age 25. For example, a 25­year­old man with a high school diploma can expect to live 51.4 additional years and reach an age of 76.4 years. (Source: CDC/NCHS, National Health Interview Survey Linked Mortality File, 2006. National Center for Health Statistics. Health, United States 2011: With Special Feature on Socioeconomic Status and Health. Hyattsville, MD: 2012. http://www.cdc.gov/nchs/data/hus/2011/fig32.pdf.) The data linking education and health can more clearly be interpreted as a causal effect of education and health than is the case for income and health. While poor health can reduce one’s income,18 education occurs earlier in life than do most serious diseases, and this temporal ordering provides a strong rationale for attributing the association to the impact of education on health. Data in the United States on SES and health have been limited. While public health monitoring and epidemiologic surveys frequently collect information on race and ethnicity, they less often include information on income or education. Until recently, death certificates had only data on race and ethnicity, but now include information on education but not occupation, income, wealth, or other SES variables. RACE/ETHNICITY Race and ethnicity often are combined and referred to as one concept. Nevertheless, the concept of race as commonly used tends to evoke differences in skin color and other superficial secondary characteristics, whereas ethnicity incorporates the concept of culture.19 The health implications of classification of both racial and ethnic groups derive primarily from the social construction and impact of being labeled as belonging to one or another group. Apart from a small number of genes that code for skin color and other superficial secondary characteristics, and a few genes that are linked to geographic origin which confer risk for specific diseases, there is little biologic basis for health disparities among racial and ethnic groups. Advances in genomics have exposed the concept of race as predominantly a social construct, rooted in historical biases and social stratification based on ancestry and superficial phenotype rather than emanating from fundamental genetic differences among populations perceived to be of different “races.” There is no gene or set of genes that are exclusive to one race and that can be used to define those belonging to a race. Stated another way, one cannot look at a person’s DNA and tell definitively that she or he is Asian, African American, Latino, or white. The genetic variation among people within a racial and ethnic group is much greater than the variation across groups.20 Despite the lack of definitive genetic determinants, race and ethnicity have important influences on health. Based on historical conventions, US federal agencies use a two­item approach to classification. The first item is considered to represent race, and includes five major groups: African American or black, American Indian or Alaska native, Asian, native Hawaiian or other Pacific Islander, and white. The second item is considered to measure ethnicity, and consists solely of a dichotomous categorization of Hispanic or non­Hispanic. In our view, such categorical distinctions between the concept of race and ethnicity are an oversimplification of this socially defined construct, and we use the term “race–ethnicity” to communicate a more holistic notion of this concept. Disparities by race–ethnicity are present in the United States for such diverse health indicators as infant mortality, cancer mortality, coronary heart disease mortality, and the prevalence of diabetes, HIV infection, or stroke (Table 1­1). Two clear observations can be made about these health outcomes categorized by race and ethnicity. First, African Americans experience the greatest morbidity and mortality on every reported indicator, and Downloaded 2024­1­25 11:44 A Your IP is 63.247.224.45 the gap often is substantial. For example, African Americans experience 12.7An deaths for every 1000 live births,Paula compared with Asian or Pacific Islanders, Page 4 / 15 Chapter 1: Vulnerable Populations, Health Disparities, and Health Equity: Overview, Kevin Grumbach; Braveman; Nancy Adler; Andrew who experience 4.5 deaths. Second, no other group shows consistently poor health outcomes across all indicators. Whites show poorer outcomes B. Bindman ©2024 McGraw Hill. AllAfrican Rights Americans Reserved.onTerms Privacyhealth Policyindicators Notice (e.g., Accessibility than groups other than many of of Use the reported overall cancer mortality). American Indians and Alaska natives have the second highest rates of infant mortality, and Hispanics or Latinos have the second highest prevalence of diabetes. Asian Americans concept of race and ethnicity are an oversimplification of this socially defined construct, and we use the term “race–ethnicity” to communicate a more Mount Saint Vincent College holistic notion of this concept. Access Provided by: Disparities by race–ethnicity are present in the United States for such diverse health indicators as infant mortality, cancer mortality, coronary heart disease mortality, and the prevalence of diabetes, HIV infection, or stroke (Table 1­1). Two clear observations can be made about these health outcomes categorized by race and ethnicity. First, African Americans experience the greatest morbidity and mortality on every reported indicator, and the gap often is substantial. For example, African Americans experience 12.7 deaths for every 1000 live births, compared with Asian or Pacific Islanders, who experience 4.5 deaths. Second, no other group shows consistently poor health outcomes across all indicators. Whites show poorer outcomes than groups other than African Americans on many of the reported health indicators (e.g., overall cancer mortality). American Indians and Alaska natives have the second highest rates of infant mortality, and Hispanics or Latinos have the second highest prevalence of diabetes. Asian Americans and Pacific Islanders show the most favorable profile. Table 1­1. Health Disparities by Condition and Race–Ethnicity Race/Ethnicity Health Condition and Specific Example White Black/African American Hispanic/Latino Asian and Pacific American Indian and Islander Alaska Native Infant mortality: rate per 1000 live births 5.5 12.7 5.6 4.5 8.4 Cancer mortality: rate per 100,000 173 206 120 108 158 Lung cancer mortality: rate per 100,000 49 52 21 25 40 Female breast cancer mortality: rate per 22 31 15 11 15 118 141 87 67 92 Stroke: mortality rate per 100,000 38 56 30 32 30 Homicides, per 100,000 2.6 19.9 6.6 2.2 9.0 HIV infection: prevalence per 100,000 17 128 50 15 32 6.8 11.3 11.5 10.2 DSU 100,000 Coronary heart disease: mortality rate per 100,000 adults Diabetes: prevalence per 100 adults DSU, data are statistically unreliable. Source: CDC Health Disparities and Inequalities Report, United States, 2013. MMWR 2013;62(Suppl), No. 3; National Cancer Institute, SEER Cancer Statistics Review 1975–2011. One limitation of these conclusions is that they are based on large groupings by race–ethnicity. These broad categories may obscure substantial variation in health within some of the groups. Members of the same major racial–ethnic group from different countries and areas of origin have different degrees of disadvantage and health risk. For example, among Latinos and Hispanics in the United States, the infant mortality rate is 4.9 among Cubans and 7.3 among Puerto Ricans. The importance of looking at subgroups also may differ by disease. For example, Asian Indians have the lowest rates of all­cause mortality, yet they have relatively high rates of coronary heart disease compared with other Asian groups.21 DUAL EFFECT OF SOCIOECONOMIC STATUS AND RACE/ETHNICITY The overlap between race/ethnicity and SES makes it difficult to disentangle the relative contributions of each of these factors toward health.22 Both African Americans and Hispanics are overrepresented in lower SES categories. Data from the 2010 census reveal that 30.3% of whites 25 years of age Downloaded 11:44 Acompared Your IP iswith 63.247.224.45 and older are 2024­1­25 college graduates, 19.8% of African Americans and 13.9% of Hispanics. Similarly, there are large differences in income by Page 5 / 15 Chapter 1: Vulnerable Populations, Health Disparities, and Health Equity: An Overview, Kevin Grumbach; Paula Braveman; Nancy Adler; Andrew race/ethnicity. For example, in 2009 the median family income was $38,409 for African Americans, whereas it was $62,545 for whites. If one uses a B. Bindman measureMcGraw of net worth (wealth) of income, differences race/ethnicity are even more dramatic. ©2024 Hill. All Rightsinstead Reserved. Termsthe of economic Use Privacy Policy by Notice Accessibility lowest rates of all­cause mortality, yet they have relatively high rates of coronary heart disease compared with other Asian groups.21 Mount Saint Vincent College DUAL EFFECT OF SOCIOECONOMIC STATUS AND RACE/ETHNICITY Access Provided by: The overlap between race/ethnicity and SES makes it difficult to disentangle the relative contributions of each of these factors toward health.22 Both African Americans and Hispanics are overrepresented in lower SES categories. Data from the 2010 census reveal that 30.3% of whites 25 years of age and older are college graduates, compared with 19.8% of African Americans and 13.9% of Hispanics. Similarly, there are large differences in income by race/ethnicity. For example, in 2009 the median family income was $38,409 for African Americans, whereas it was $62,545 for whites. If one uses a measure of net worth (wealth) instead of income, the economic differences by race/ethnicity are even more dramatic. For some health outcomes, differences in the United States between African Americans and whites become much less significant once analyses control for income and/or education. For other health outcomes there ​continue to be differences associated with race/​ethnicity that are not explained by socioeconomic class alone23 (Figure 1­3). Figure 1­3. Self­rated health status according to race–ethnicity and income in the United States. (Source: CDC/NCHS, National Health Interview Survey 2010, Family Core and Sample Adult Questionnaire. National Center for Health Statistics. Health, United States 2011: With Special Feature on Socioeconomic Status and Health. Hyattsville, MD: 2012. www.cdc.gov/nchs/data/hus/2011/056.pdf.) The relative emphasis on disparities according to race–ethnicity and SES varies in nations across the globe, reflecting differences in both demographic characteristics and social history. A comparative analysis of US and EU approaches to health equity observed, “With a history marked by the legacy of slavery and discrimination, the United States has adopted a racially oriented perspective on certain social concerns to ensure equitable treatment under the law and safeguard civil rights. In Europe, by contrast, experience with ethnic group genocide during World War II has caused great reluctance to segment or even identify populations on racial or ethnic grounds. Consequently, authorities in many European countries have made a deliberate decision not to collect data on race and ethnicity.”24 As social scientists continue to investigate the complex interplay among race–ethnicity, social statuses, and health status, the prevailing wisdom is that both race–ethnicity and SES matter.7 Race–ethnicity can confer a vulnerability rooted in experiences of racism and social oppression that is not completely reducible to socioeconomic disadvantage. At the same time, focusing exclusively on disparities by racial and ethnic groups overlooks the contribution of socioeconomic inequalities to these disparities. The following section examines in detail the pathways through which social vulnerabilities such as minority race–ethnicity or low SES translate into poor health status. HEALTH DISPARITIES AND PATHWAYS OF VULNERABILITY Phyllis Gripman has been driving a bus for 22 years. The stress of keeping on schedule despite traffic congestion and impatient commuters contributes to her poorly controlled blood pressure. She often skips taking her diuretic medication when working to avoid the need for bathroom stops, which could put her behind schedule. Frequently, passenger complaints about the bus service are coupled with derogatory comments about the fact that she is a woman and African American. Downloaded 2024­1­25 11:44 A Your IP is 63.247.224.45 Page 6 / 15 Chapter Vulnerable Health An Overview, Kevin Grumbach; Paulabeing Braveman; Adler; Andrew Tho Van1:fled his nativePopulations, Cambodia toHealth escapeDisparities, the Pol Potand regime. HeEquity: has nightmares reliving watching his brother torturedNancy to death. He often B.must Bindman rely on his daughter to translate during his medical visits. He avoids discussing his nightmares in front of his daughter. He worries about his ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility teenage son, who has joined a gang and is truant from school. contribution of socioeconomic inequalities to these disparities. The following section examines in detail the pathways through which social Mount Saint Vincent College vulnerabilities such as minority race–ethnicity or low SES translate into poor health status. Access Provided by: HEALTH DISPARITIES AND PATHWAYS OF VULNERABILITY Phyllis Gripman has been driving a bus for 22 years. The stress of keeping on schedule despite traffic congestion and impatient commuters contributes to her poorly controlled blood pressure. She often skips taking her diuretic medication when working to avoid the need for bathroom stops, which could put her behind schedule. Frequently, passenger complaints about the bus service are coupled with derogatory comments about the fact that she is a woman and African American. Tho Van fled his native Cambodia to escape the Pol Pot regime. He has nightmares reliving watching his brother being tortured to death. He often must rely on his daughter to translate during his medical visits. He avoids discussing his nightmares in front of his daughter. He worries about his teenage son, who has joined a gang and is truant from school. Walter Jones has been homeless since his discharge from the army following the Iraq War. He has been in and out of rehabilitation programs for his heroin addiction. He is managing to stay clean while in a methadone maintenance program. He initiated evaluation for other medical problems at the Veteran’s Administration medical center, but did not follow up for treatment after he overheard a physician refer to him as “that noncompliant homeless drug addict who’s wasting our time and money.” These three examples identify individuals with social characteristics that make them vulnerable to experiencing health disparities. Viewed within the framework of health disparities, defined in the preceding as health differences between more and less privileged groups, “vulnerability” consists of those social characteristics, such as minority race–ethnicity and low SES, that are associated with health disparities. How do these characteristics ultimately result in inferior health status? PATHWAYS BETWEEN DEMOGRAPHIC CHARACTERISTICS AND HEALTH STATUS The conceptual model displayed in Figure 1­4 synthesizes ideas from a variety of models that have been proposed to explain the pathways between demographic characteristics and health status.25,26,27,28,29 Figure 1­4. A conceptual model that synthesizes ideas from a variety of models proposed to explain the pathways between demographic characteristics and health status. This model proposes that poor health culminates from several major forces. Downloaded 2024­1­25 A Yourculminates IP is 63.247.224.45 This model proposes that11:44 poor health from several major forces: Page 7 / 15 Chapter 1: Vulnerable Populations, Health Disparities, and Health Equity: An Overview, Kevin Grumbach; Paula Braveman; Nancy Adler; Andrew B. Bindman 1. Genetic endowment and epigenetic processes. Everyone is born with a genetic endowment that offers relative protection against, or vulnerability ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility to, certain conditions. Ms. Gripman, the bus driver, may have inherited a disposition to develop essential hypertension. Mr. Jones, the homeless Figure 1­4. Mount Saint Vincent College Access Provided by: A conceptual model that synthesizes ideas from a variety of models proposed to explain the pathways between demographic characteristics and health status. This model proposes that poor health culminates from several major forces. This model proposes that poor health culminates from several major forces: 1. Genetic endowment and epigenetic processes. Everyone is born with a genetic endowment that offers relative protection against, or vulnerability to, certain conditions. Ms. Gripman, the bus driver, may have inherited a disposition to develop essential hypertension. Mr. Jones, the homeless veteran, may have a genetic susceptibility to opiates that abetted his addiction to heroin. However, health and illness are determined not just by one’s genetic makeup but by “epigenetic” processes. Exposures and experiences across one’s life can determine whether specific genes are activated or are suppressed. The occurrence of disease thus depends not just on the “hardwiring” of genetics but also on the “software” of epigenetics. 2. Physical environment. The air, water, food, toxins, and physical dangers to which one is exposed may have a profound impact on health. Minorities and the poor are more likely to reside in neighborhoods and work settings with unhealthful physical environments; therefore, this is a socially mediated influence on their health (see Chapter 25). For example, housing is often crowded, noise is pervasive, pollutants and toxins are prevalent, and facilities for exercise are sparse. Mr. Jones’ lack of housing is a particularly glaring example of vulnerability in his physical environment. 3. Social environment. Vulnerable populations also often face an oppressive social environment, including factors such as institutional and other forms of racism, housing segregation, and low levels of social capital (generally defined as the resources that come from strong community and interpersonal relationships). Communities with greater social capital and collective efficacy (i.e., more able to organize and garner resources) have lower morbidity and mortality.30,31 Mr. Van’s experience of political violence and social disruption as a refugee from Cambodia poignantly represents a social environment that has adverse effects on health and the receipt of health care (see Chapter 29 and 36). 4. Behavior and lifestyle. Unhealthful behaviors such as smoking and substance use are more prevalent among people with less education, and sedentary lifestyles and high­fat diets are more common among African Americans and those with low SES.32 The reasons for these high rates of prevalence are complex and also are heavily influenced by differences in physical and social environments, chronic stress, and delivery of health care (see Part 3: Populations). 5. Chronic stress. Researchers have begun to identify the toxic effects of chronic stress related to lack of economic and social resources or experiences of discrimination. McEwen33 developed the concept of “allostatic load” to describe the biological processes involved in responses to chronic stress. Allostatic load scores have been found to be higher among African Americans than among whites and greater among those with less education.34 Allostatic load scores, in turn, have been shown in a sample of older adults to predict physical and cognitive decline, the onset of new cardiovascular disease, and mortality over a 7­year period.35,36 The types of occupational stresses experienced by Ms. Gripman have also been 37 associated2024­1­25 with unfavorable Downloaded 11:44 Ahealth Youroutcomes. IP is 63.247.224.45 Page 8 / 15 Chapter 1: Vulnerable Populations, Health Disparities, and Health Equity: An Overview, Kevin Grumbach; Paula Braveman; Nancy Adler; Andrew B. 6. Bindman Health care. Inadequate access to and quality of health care is a final pathway to health disparities. Structural inequalities in the distribution of ©2024 McGrawresources, Hill. All Rights Reserved. of Use Privacy Policy Notice Accessibility health­care such as physiciansTerms and hospitals, across communities, may lead to inequity in access to and quality of care. The interpersonal process of delivering care may be deficient because of factors such as discrimination or lack of cultural or non­English language 5. Chronic stress. Researchers have begun to identify the toxic effects of chronic stress related to lack of economic and social resources or experiences of discrimination. McEwen33 developed the concept of “allostatic load” to describe the biological processes involved responses to Mount SaintinVincent College chronic stress. Allostatic load scores have been found to be higher among African Americans than among whites and greater among Access Provided by: those with less education.34 Allostatic load scores, in turn, have been shown in a sample of older adults to predict physical and cognitive decline, the onset of new cardiovascular disease, and mortality over a 7­year period.35,36 The types of occupational stresses experienced by Ms. Gripman have also been associated with unfavorable health outcomes.37 6. Health care. Inadequate access to and quality of health care is a final pathway to health disparities. Structural inequalities in the distribution of health­care resources, such as physicians and hospitals, across communities, may lead to inequity in access to and quality of care. The interpersonal process of delivering care may be deficient because of factors such as discrimination or lack of cultural or non­English language competence among health­care workers. For example, a clinic with greater availability of interpreters and culturally appropriate mental health services might afford Mr. Van greater opportunity for effective treatment of his posttraumatic stress disorder, resulting in better health status and well­being (see Chapters 14, 29, 31, 33). Although Figure 1­4 presents this model in a relatively linear form, it is important to recognize that the forces producing health disparities function in a more dynamic, multidirectional manner involving interactions and feedback loops among all the elements displayed. For example, chronic stress from war trauma may have contributed to Mr. Jones’ adoption of unhealthful behaviors such as alcohol and drug use as a mechanism to cope with stress. Poor health or a chronic medical condition, such as Ms. Gripman’s hypertension, may increase stress levels. Moreover, these factors all operate at multiple levels, ranging from the individual to the broader community and social institutions. The cumulative negative force of these pathways may be viewed as representing the social vulnerability that produces health disparities. Most analyses have concluded that health care explains only about 10–20% of population health outcomes, with social, environmental, and behavioral factors being the most powerful determinants. As one leading public health advocate in the United States concluded about the powerful effect of social and environmental conditions, “Your ZIP code may be more important to your health than your genetic code.”38 RESILIENCE In contrast, individual and collective resilience—the capacity to develop positively despite harmful environments and experiences—represents the positive vector of these pathways that may act as a countervailing force and produce better health outcomes. One example of the positive effects that can result from individual and collective resiliency is reflected in the finding that first­generation immigrants appear to have a health advantage across virtually every group.39 This may partially result from the “healthy immigrant” effect, in which there is differential selection for those who have the characteristics (including better health) that allow them to emigrate to the United States.40 It may also reflect protective effects of traditional diets, supportive social networks, or other health practices of first­generation immigrants. The finding of lower mortality among older Mexican Americans living in neighborhoods with a higher density of Mexican Americans supports this view.41 The researchers attributed this difference to the protective effects of the concentration, which may buffer Mexican Americans from the “unhealthful aspects of US culture.” ETHICAL AND HUMAN RIGHTS PRINCIPLES Ethical and human rights principles underlie the notion of health equity. “Distributive justice,” that is, normative ethical principles designed to allocate resources in limited supply relative to demand, is especially relevant to health disparities.42 DISTRIBUTIVE JUSTICE The ethicist John Rawls has provided a framework for considering the principle of distributive justice and its application to health equity. In defining how one would know what was just an allocation of resources to different groups in a society, Rawls43 introduced the notion of “the veil of ignorance.” In his view, policies allocating resources should be made as if one were operating behind a “veil of ignorance” about the social group into which one had been born. If I did not know whether I would be born rich or poor, black or white, male or female, into a family living in a rural area or one in an urban area, how would I recommend allocating resources? Rawls believed that, under those circumstances, most people would prefer that resources be allocated according to need. HUMAN RIGHTS AND THE RIGHT TO HEALTH Human rights frameworks and principles provide a universally recognized frame of reference for initiatives to reduce health disparities between more and less advantaged social groups. When the term “human rights” is encountered, most people think of civil and political rights, such as freedom of speech and freedom from cruel or arbitrary punishment. However, human rights also encompass economic, social, and cultural rights, such as the right to a decent standard of living, which in turn includes rights to adequate food, water, shelter, and clothing requisite for health as well as the right Downloaded 2024­1­25 11:44 A Your IP is 63.247.224.45 to health itself. Page 9 / 15 Chapter 1: Vulnerable Populations, Health Disparities, and Health Equity: An Overview, Kevin Grumbach; Paula Braveman; Nancy Adler; Andrew B. Bindman Almost every country in the world has signed agreements that include health­related rights. The right to health is a cornerstone underlying efforts to ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility achieve health equity. The World Health Organization’s constitution44 defined the right to health as the right of everyone to enjoy the highest possible HUMAN RIGHTS AND THE RIGHT TO HEALTH Mount Saint Vincent College Access Provided by:between more Human rights frameworks and principles provide a universally recognized frame of reference for initiatives to reduce health disparities and less advantaged social groups. When the term “human rights” is encountered, most people think of civil and political rights, such as freedom of speech and freedom from cruel or arbitrary punishment. However, human rights also encompass economic, social, and cultural rights, such as the right to a decent standard of living, which in turn includes rights to adequate food, water, shelter, and clothing requisite for health as well as the right to health itself. Almost every country in the world has signed agreements that include health­related rights. The right to health is a cornerstone underlying efforts to achieve health equity. The World Health Organization’s constitution44 defined the right to health as the right of everyone to enjoy the highest possible level of health. The right to health can be operationalized as the right of all social groups (defined by social position) to attain the level of health enjoyed by the most privileged group in society. The right to health thus provides the basis for comparing the health experienced by different social groups, always using as the reference group the most privileged group in a given category.4 RACISM AND HEALTH One final conceptual framework useful for understanding vulnerability derives from a model developed by Jones for understanding racism and its impact on health.45 Jones proposes that racism operates at three levels: institutionalized, personally mediated, and internalized. Institutionalized racism refers to the structural elements of racism that are “codified in our institutions of customs, practice and law so there need not be an identifiable perpetrator.” Examples are housing segregation, school inequality, and the history of Jim Crow laws in the United States. Personally mediated racism is the prejudice and discrimination experienced in daily encounters, ranging from overt racial slurs to the less explicit racism of the prejudicial judgments made by teachers, clinicians, shopkeepers, and other social contacts. Internalized racism is defined as “acceptance by members of the stigmatized races of negative messages about their own abilities and intrinsic worth.” Internalized racism manifests itself as lack of self­esteem and devaluing of the sense of self­worth. These types of racism may interact: for example, one study found that the impact of reported experiences of discrimination on risk of cardiovascular disease of African­American men was moderated by internalized racial group attitudes.46 Although developed for understanding racism, Jones’ model is applicable to all the “­isms” that create social vulnerability. For example, the levels proposed by Jones apply to sexism. Sexism operates at an institutional level (e.g., objectification of women by mass media and entertainment, inadequate laws, and lax enforcement to protect women against violence and sexual abuse), interpersonal level (e.g., prejudice in hiring and promotion decisions), and internalized level (e.g., victimization, lowered expectations for achievement). The same principles apply to ​vulnerabilities based on social class, sexual orientation, gender identity, immigrant status, and other characteristics.7 TREATING VULNERABILITY: ADDRESSING THE ROOT CAUSES For health professionals to successfully attend to the health needs of vulnerable populations, they must recognize how vulnerability manifests itself at each of these levels for each patient’s particular constellation of vulnerabilities. Social consciousness is required to identify the factors that perpetuate vulnerability at the institutional level, whether in health­care organizations or other community institutions; to change these conditions requires translating awareness into social advocacy. Insight and reflection are necessary to enhance awareness of the biases and misassumptions—both obvious and subtle—that reinforce vulnerability at the personally mediated level. Finally, for clinicians to effectively care for vulnerable populations also require healing of patients’ internalized wounds—the despair and devaluation of self­worth that thwart healthful living and healthy relationships. What health­care providers can do to promote health equity by improving health care for socially vulnerable and underserved patients is addressed throughout this book. Subsequent chapters comprehensively discuss approaches to delivering more accessible, effective, and responsive health care and social services to vulnerable patients. However, the most effective treatment for the problems of vulnerable patients would be to change the fundamental social conditions that are the sources of vulnerability and primary determinants of health disparities. Is it appropriate to expect health­care professionals to engage in arenas (e.g., health­care policy making) for which they are not trained? Without becoming policy makers themselves, health professionals have made major contributions to health­care policy debates by speaking out in diverse forums, contributing their time to support other activities of groups advocating for policies to reduce health­care disparities, and/or providing financial support for such groups. At some time, nearly every health­care provider has experienced the frustration of providing an effective treatment for a patient’s health problem, only to send the patient back to the same circumstances in the physical or social environment that caused or triggered the illness. An example is treating an asthma attack and then discharging the patient to the same substandard housing permeated with allergens. Virtually every clinician knows the frustration of prescribing regimens of medications, diet, and/or exercise to patients whose life circumstances make the successful implementation of those care plans very unlikely. For example, people who live in neighborhoods without stores that sell affordable fresh produce or in which outdoor exercise is unsafe or infeasible have same opportunities to follow recommended regimens as those who live in more health­promoting Downloaded 2024­1­25 11:44do A not Your IP isthe 63.247.224.45 Page 10 / 15 Chapter 1: Vulnerable Populations, Health Disparities, and Health Equity: An Overview, Kevin Grumbach; Paula Braveman; Nancy Adler; Andrew neighborhoods. B. Bindman ©2024 McGraw Hill. All Rights Reserved.probably Terms of Use Privacy Notice Accessibility However, most health­care professionals feel that fulfillingPolicy their own personal professional expectations as providers of high­quality health care, informed by the latest evidence, is difficult enough without adding expectations that they change their patients’ life circumstances as well. In Mount Saint Vincent College At some time, nearly every health­care provider has experienced the frustration of providing an effective treatment for a patient’s health problem, only Access Provided by: to send the patient back to the same circumstances in the physical or social environment that caused or triggered the illness. An example is treating an asthma attack and then discharging the patient to the same substandard housing permeated with allergens. Virtually every clinician knows the frustration of prescribing regimens of medications, diet, and/or exercise to patients whose life circumstances make the successful implementation of those care plans very unlikely. For example, people who live in neighborhoods without stores that sell affordable fresh produce or in which outdoor exercise is unsafe or infeasible do not have the same opportunities to follow recommended regimens as those who live in more health­promoting neighborhoods. However, most health­care professionals probably feel that fulfilling their own personal professional expectations as providers of high­quality health care, informed by the latest evidence, is difficult enough without adding expectations that they change their patients’ life circumstances as well. In addition, health­care professionals feel ill equipped to change circumstances outside of the realm of health care that they are trained and experienced to provide. However, there are many feasible ways in which health­care providers can contribute to health equity, beyond their influence on reducing disparities in health care. Pragmatic strategies for engaging in advocacy to address social and environmental determinants of health are discussed in Chapter 8. Methods for integrating interventions to address social determinants into routine ​clinical practice are discussed in Chapter 9. Health­care organizations as diverse as Kaiser Permanente in the United States and the Cuban National Health Service are finding common ground on a shared focus on the goal of population health, not just the health of individual patients. This focus is providing motivation and incentives for health professionals to address the social and environmental determinants that influence the health of the populations they serve. CONCLUSION Patients like Ms. Gripman, Mr. Van, and Mr. Jones need excellent health professionals who understand the needs and circumstances of vulnerable populations and can deliver high­quality care to vulnerable patients. A public health perspective compels health professionals to not only heal the wounds of vulnerability but also eradicate the primary causes of those wounds. Health professionals committed to health equity do not need to become policy makers, or abandon health­care delivery, to make significant contributions to efforts to alter the fundamental conditions breeding vulnerability and producing health disparities. KEY CONCEPTS Vulnerable populations are those with a disadvantaged position in social hierarchies defined by wealth, power, and/or prestige, placing them at risk for poor health. Health disparities are potentially avoidable, systematic differences in health status that are associated with social vulnerability and are at least theoretically amenable to social intervention. Several different pathways mediate the association between social vulnerability and health disparities, including genetic endowment, physical environment, social environment, behavior and lifestyle, chronic stress, and health care. Health equity refers to the absence of disparities in controllable or remediable aspects of health. A reduction in health disparities is evidence of making progress toward greater health equity. The ethical principle of distributive justice and international human rights principles provide a universally recognized frame of reference for initiatives to achieve health equity. In addition to promoting health equity by delivering high­quality health care to vulnerable populations, health professionals also can make meaningful contributions to improving the fundamental social conditions that create vulnerability and produce health disparities. ACKNOWLEDGMENT The authors acknowledge the contributions of Sofia Gruskin, JD, MIA, of the Francois Xavier Bagnoud Center for Human Rights, Harvard University School of Public Health, to the development of the concepts of the relationships among human rights and health equity presented in this chapter. DISCUSSION QUESTIONS 1. Review the data on health disparities shown in Table 1­1. Downloaded 2024­1­25 11:44 A Your IP is 63.247.224.45 Page 11 / 15 a. What are some of the reasonsHealth that African Americans as a group haveAn such poor health relativePaula to whites? Consider the different Chapter 1: Vulnerable Populations, Disparities, and Health Equity: Overview, Kevinstatus Grumbach; Braveman; Nancy Adler; Andrew B. Bindman pathways mediating vulnerability and health status (e.g., social environment, physical environment) in suggesting the various mechanisms ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility possibly mediating the association between African American race/ethnicity and poor health. The authors acknowledge the contributions of Sofia Gruskin, JD, MIA, of the Francois Xavier Bagnoud Center for Human Rights, Harvard University Mount Saint Vincent College School of Public Health, to the development of the concepts of the relationships among human rights and health equity presented in this chapter. Access Provided by: DISCUSSION QUESTIONS 1. Review the data on health disparities shown in Table 1­1. a. What are some of the reasons that African Americans as a group have such poor health status relative to whites? Consider the different pathways mediating vulnerability and health status (e.g., social environment, physical environment) in suggesting the various mechanisms possibly mediating the association between African American race/ethnicity and poor health. b. The infant mortality rates for Latinos and non­Latino whites are nearly identical, despite Latinos as a group having much lower incomes and educational status than whites. What might be the factors that confer a “protective effect” for Latino birth outcomes and infant health in the face of socioeconomic disadvantage? 2. Many public health advocates call for the complete elimination of health disparities in the United States. Is this goal reasonable and feasible, or will societies always have inequities in health because of differences in income, education, occupation, and related aspects of SES among different members of a society? 3. Try to locate some data on public health measures in your own county, city, or community. (Your local or state health department may be a source of information comparing neighborhoods or social groups on health indicators such as infant mortality rates, age­adjusted mortality rates, cancer deaths, and preventable hospitalizations.) Use these data to identify a vulnerable social group (e.g., homeless persons, minorities) or a vulnerable neighborhood that appears to experience a health disparity. What are the most important factors in your local community contributing to this health disparity? Develop an action plan for how you and your colleagues could address these factors and improve the health of the identified vulnerable population. Make sure to consider interventions outside of the formal health­care system in developing your action plan. RESOURCES http://www.cdc.gov/omh/AboutUs/disparities.htm. Centers for Disease Control. Healthy People 2010: Goal of Eliminating Racial and Ethnic Health Disparities. http://www.kaiseredu.org/topics_reflib.asp?id=329&parentid=67&rID=1. Kaiser Family Foundation. Race, Ethnicity and Health Care: The Basics. http://www.macses.ucsf.edu/. MacArthur Foundation Research Network on Socioeconomic Status and Health. http://www.sph.umich.edu/miih/index2.html. The Michigan Initiative on Inequalities in Health. http://www.ucsf.edu/csdh/. The UCSF Center on Social Disparities in Health. REFERENCES 1. Mathews TJ, MacDorman MF. Infant mortality statistics from the 2010 period linked birth/infant death data set. National Vital Statistics Reports , vol 62, no 8. Hyattsville, MD: National Center for Health Statistics, 2013. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_08.pdf. 2. 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World Health Organization Constitution of the World Health Organization; as adopted by the International Health Conference. June 19–22, 1946. Accessed August 21, 2005. Available at http://www.ldb.org/iphw/whoconst.htm. 45. Jones C. Levels of racism: A theoretic framework and a gardener’s tale. Am J Public Health 2000;90(8):1212. [PubMed: 10936998] 46. Chae DH, Lincoln KD, Adler NA, Syme LS. Do experiences of racial discrimination predict cardiovascular disease among African American Men? Soc Sci Med 2010;71(6):1182–1188. [PubMed: 20659782] Downloaded 2024­1­25 11:44 A Your IP is 63.247.224.45 Page 14 / 15 Chapter 1: Vulnerable Populations, Health Disparities, and Health Equity: An Overview, Kevin Grumbach; Paula Braveman; Nancy Adler; Andrew B. Bindman ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility 44. World Health Organization Constitution of the World Health Organization; as adopted by the International Health Conference. June 19–22, 1946. Mount Saint Vincent College Accessed August 21, 2005. Available at http://www.ldb.org/iphw/whoconst.htm. Access Provided by: 45. Jones C. Levels of racism: A theoretic framework and a gardener’s tale. Am J Public Health 2000;90(8):1212. [PubMed: 10936998] 46. Chae DH, Lincoln KD, Adler NA, Syme LS. Do experiences of racial discrimination predict cardiovascular disease among African American Men? Soc Sci Med 2010;71(6):1182–1188. [PubMed: 20659782] Downloaded 2024­1­25 11:44 A Your IP is 63.247.224.45 Page 15 / 15 Chapter 1: Vulnerable Populations, Health Disparities, and Health Equity: An Overview, Kevin Grumbach; Paula Braveman; Nancy Adler; Andrew B. Bindman ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility