The Consequences of Health Disparities

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The Consequences of Health Disparities

• 2007 Social Equity Leadership Conference
• February 16, 2007
• Steven H. Woolf, MD, MPH
• Departments of Family Medicine, Epidemiology and
  Community Health
• Virginia Commonwealth University

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• Injustice anywhere is a threat to justice
  everywhere.
• Martin Luther King Jr., Letter from Birmingham
  Jail, April 16, 1963

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June 11, 1963
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• The Negro baby born in America today,
  regardless of the section of the Nation in which
  he is born, has about one-half as much chance of
  completing a high school as a white baby born in
  the same place on the same day, one-third as much
  chance of completing college, one-third as much
  chance of becoming a professional man, twice as
  much chance of becoming unemployed, about
  one-seventh as much chance of earning 10,000 a
  year, a life expectancy which is 7 years shorter,
  and the prospects of earning only half as much

Televised address on civil rights June 11, 1963
Oval Office address, John F. Kennedy
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HealthUS, National Center for Health Statistics
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From Satcher et al. Health Affairs
200524459-64.
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County Life Expectancies by Race
Murray CJL, Kulkarni SC, Michaud C, Tomijima N,
Bulzacchelli MT, et al. PLoS Medicine Vol. 3, No.
9, e260 doi10.1371/journal.pmed.0030260
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Murray CJ, Kulkarni S, Ezzati M. Eight Americas
new perspectives on U.S. health disparities.Am J
Prev Med 200529(5 Suppl 1)4-10.
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Health Care Disparity

• A race disparity in recommendation for coronary
  revascularization was found among patients in the
  Veteran Affairs health system, where there are no
  race differences in ability to pay and providers
  are paid a salary.

Percent of patients receiving procedure
Source Ibrahim SA, Whittle J, Bean-Mayberry B,
Kelley ME, Good C, Conigliaro J. Racial/ethnic
variations in physician recommendations for
cardiac revascularization. Am J Public Health.
2003 Oct93(10)1689-93. Statistically
significant difference between African Americans
and whites.
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A Tale of Two Choices

• Effectiveness
• Equity

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Age-Adjusted Mortality (1991-2000)Disparity of
24-29
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Study Question

• Decade of 1991-2000
• Comparison of lives saved by
• generic improvements in health care vs.
• correction of racial disparities in mortality
  rates
• Reduction in population all-cause mortality
  attributed entirely to improvements in medical
  care

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From Woolf SH, Johnson RE. Am J Public Health
2004942078-81
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From Woolf SH, Johnson RE. Am J Public Health
2004942078-81
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Societal Preference
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To improve health, scientific discoveries must
be translated into practical applications. Such
discoveries typically begin at the bench with
basic researchin which scientists study disease
at a molecular or cellular levelthen progress to
the clinical level, or the patients bedside.
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Determinants of Population Health
Social determinants of health
Secondary prevention
Primary prevention
Tertiary prevention
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Educational attainment, by race and ethnicity
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Mortality rates, by educational attainment
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From Woolf and Johnson, Woolf SH, Johnson RE,
Geiger HJ. The rising prevalence of severe
poverty in America a growing threat to public
health. Am J Prev Med 200631332-341.
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The Washington PostMay 7, 2006 Sunday

• While the income of the families in the middle
  fifth of society has grown 12 percent since 1980,
  the income of the top tenth has grown 67 percent,
  and the income of the top 1 percent has more than
  doubled. In short, the rich have grown a whole
  lot richer.

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A Matter of Framing
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• We must recognize the full human equality of all
  of our people before God, before the law, and in
  the councils of government. We must do this, not
  because it is economically advantageous, although
  it is not because of the laws of God command it,
  although they do not because people in other
  lands wish it so. We must do it for the single
  and fundamental reason that it is the right thing
  to do.

Robert F. Kennedy, University of Cape Town Cape
Town, South Africa June 6, 1966
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• In the end, we will remember not the words of
  our enemies, but the silence of our friends.
• Martin Luther King Jr.