Moving Forward and Looking Back: The Intersection of Race and Dentistry

1
Moving Forward and Looking Back The
Intersection of Race and Dentistry
Presentation to the College of
DentistrySeptember 23, 2004

• john a. powell
• Williams Chair in Civil Rights Civil Liberties,
  Moritz College of Law
• Executive Director, Kirwan Institute for the
  Study of Race and Ethnicity
• The Ohio State University
• http//www.kirwaninstitute.org/

2
Presentation Overview

• The Construction of Race the Framing of
  Disparities
• Disparities in Dentistry
• Diversity in Education
• Diversity in Dentistry
• Developing Cultural Competence
• The Need for Research
• Moving Forward Progress

3
The Construction of Race and Framing of
Disparities

• Health is the place where all the social forces
  converge.
• -Reed Tuckson, M.D., Vice President, American
  Medical Association

4
The Construction of Race and Framing of
Disparities

• We overestimate our civil rights gains racial
  disparities still exist on many levels.
• We will examine the concept of race in our
  society, how it was constructed and the
  historical framing of disparities.

5
Disparities Civil Rights Era Today

• The typical Black family had 60 as much income
  as a white family in 1968, but only 58 as much
  in 2002.
• Black infants are almost two-and-a-half-times as
  likely as white infants to die before age one a
  greater gap than in 1970.
• At the slow rate that the Black-white poverty gap
  has been narrowing since 1968, it would take
  until 2152, to close.
• For every dollar held by Whites in 1968, Blacks
  had only 55 cents. By 2001, Blacks had only 57
  cents for every dollar held by Whites. At this
  pace, it would take Blacks 581 years to get the
  remaining 43 cents.
• While white homeownership has jumped from 65 to
  75 since 1970, Black homeownership has only
  risen from 42 to 48. At this rate, it would
  take 1,664 years to close the homeownership gap
  about 55 generations.

Source State Of The Dream 2004 (United for a
Fair Economy)
6
The Construction of Race Biological

• Race was once considered biological
• The common 19th century theory of racial ethnic,
  and gender inferiority.
• Blacks were considered to be intellectually,
  culturally, morally and physically inferior to
  whites.
• Physicians claimed that African-Americans had
  unique physiological and anatomical features such
  as small brains, thick skin, high tolerance for
  heat, sun and pain, etc.
• This rationalized slavery and the unethical use
  of African-American men and women as medical
  research subjects.
• Tuskegee syphilis study
• Genetic testing/sickle cell screenings in the
  1970s
• Forced sterilization of Black women in the 1970s

Source Eliminating African-American Health
Disparity via History-based Policy. Harvard
Health Policy Review, 2002.
7
The Construction of Race Biological

• Although countless studies have documented that
  race is not biological, researchers in 2001 found
  that most citizens believe that race is a
  biological construct.
• If race is not biological, then what is it?

Source Eliminating African-American Health
Disparity via History-based Policy. Harvard
Health Policy Review, 2002.
8
The Construction of Race Deficit Perspective

• Disparities have more recently been attributed to
  individuals and culture the idea that
  individuals alone can (and should) rise above
  their conditions of poverty, and the idea of a
  defective culture of poverty.
• This illustrates our deep beliefs about success
  and failure.
• Personal responsibility
• Meritocracy (basketball/gym analogy)
• Where to these beliefs come from?

9
The Construction of Race Personal Racism

• This approach leads to focusing on personal
  racism and explicit legal discrimination.
• Diversity training
• Neutralizing the language in laws
• Focus on intent
• Research has shown that personal prejudice and
  racial attitudes are improving steadily (maybe),
  yet racial disparities persist on every level.
• Disparities also continue despite the seemingly
  neutral language in policies and laws.
• What does this suggest about this approach to
  alleviating racism and remedying disparities?

10
Model for Disparate Outcomes
Historically
Today
Biased Structures
De Jure Neutral Structures
What is occurring here to replicate the outcomes
today?
Disparate Outcomes
Disparate Outcomes
Individuals/ Culture
Structures/ Opportunity
11
Model for Disparate Outcomes

• In order to understand disparities that are not
  explained by personal discrimination or explicit
  laws and policies, we must look at the
  relationship between individual attitudes,
  structures, and outcomes, as they are all
  interrelated.
• Institutional and public arrangements influence
  our private choices and resources.
• People usually make reasonable choices given
  their constraints and opportunities, but these
  constraints are not necessarily rational.
• We need to examine those constraints in order to
  understand the limitations placed on individual
  choices.

12
The Construction of Race Social Hierarchy

• Although Individual attitudes towards race have
  improved over the past decade, there has been
  less institutional change.
• Race is an expression of social structuring.
  Social structuring cannot arise from personal
  feelings alone.1
• We often fail to acknowledge the ways that race
  has been a fundamental axis of social
  organization in the US, and how structures have
  historically been organized to establish and
  maintain racial hierarchy.
• Even within neutral arrangements and without
  racist actors, disparities can still exist.
• Therefore to eliminate disparities, we must
  address the social structures institutions that
  have created and perpetuated them.

Source 1. Martinot, S. (2003). The Rule of
Racialization.
13
Structural Racism (SR)

• A structural racism approach examines how
  history, public policies, norms, institutional
  practices and arrangements can interact to
  maintain racial hierarchies and inequitable
  racial group outcomes.
• What are the inequality generating processes?
• How do we make meaning of durable inequality?

14
Structural Racism (SR)

• Racialized outcomes do not require racist actors,
  theoretically neutral policies and practices can
  function in racist ways.
• These policies and practices are not neutral
  however, and as a result the burdens are
  distributed unevenly.
• These burdens, or disparities are the symptoms of
  structural racism.

15
Disparities in Dentistry

• Of all the forms of inequality, injustice in
  health is the most shocking and the most
  inhuman.
• -The Rev. Martin Luther King, at the Second
  National Convention of the Medical Committee for
  Human Rights, Chicago, March 25,1966

16
Disparities in Dentistry

• Craniofacial, oral, and dental diseases and
  disorders are among the most common health
  problems affecting all people at all stages of
  life.
• Blacks, Hispanics, American Indians and Alaskan
  Natives have the poorest oral health of any
  population group.
• Poor oral health has significant long-term
  impacts on individuals life opportunities and
  quality of life.
• Many of the existing problems are treatable and
  preventable.
• We will examine these disparities, considering
  both the cause and the long-term impacts of them.

Sources A Plan to Eliminate Craniofacial, Oral,
and Dental Health Disparities. The National
Institute of Dental and Craniofacial Research,
February, 2002.
17
Disparities in Dentistry

• Many American suffer from oral pain and disease,
  but racial and ethnic minorities, low-income
  populations, and special care groups suffer
  disproportionately.
• Access to basic oral healthcare is a human right.
• Although 43 million Americans have no private
  health insurance, more than 150 million Americans
  have no dental insurance.
• This has significant impacts on the attainment of
  oral care for low-income populations,
  particularly people of color.

Source The Disparity Cavity Filling Americas
Oral Healthcare Gap. Oral Health America The
Kellogg Foundation, 2000.
18
Percent Who Visited a Dentist or Clinic in the
Past Year by Income
Disparities in Dentistry
Data source Behavioral Risk Factor Surveillance
Survey, 2002
19
Disparities in Dentistry
Percent Who Needed Dental Care, Including
Checkups, During the Past 12 Months But Could Not
Afford It
Data source National Health Interview Survey
(NHIS), 2001
20
Disparities in Dentistry Children

• According to the National Institute of Dental
  Research, dental caries is the most common,
  preventable disease in children.
• Professional care is necessary for maintaining
  oral health, yet 25 of poor children have not
  seen a dentist before entering kindergarten.1
• Poor children have 5 times more unfilled, decayed
  teeth than children above 300 of the poverty
  line.2
• 80 of tooth decay is found in 25 of children,
  concentrated in minority populations.2
• Mexican and African American children have twice
  the number of untreated cavities as white
  children.

Sources 1. Oral Health in America A Report of
the Surgeon General. Executive Summary, 2000.
2. The Disparity Cavity Filling Americas Oral
Healthcare Gap. Oral Health America The Kellogg
Foundation, 2000.
21
Disparities in Dentistry Children

• Routine dental care for children is also
  important for diagnostic reasons
• Examination of the teeth and mouth can detect
  signs of abuse and neglect.
• A dental exam also picks up on poor nutrition and
  hygiene, and growth and development problems.

22
Disparities in Dentistry Children

• The social impacts of oral disease in children is
  substantial.
• More than 51 million school hours are lost each
  year to dental-related illness, an average of
  1.17 hours per child.1
• Poor children suffer nearly 12 times more
  restricted-activity days than children from
  higher-income families.2
• Pain and suffering due to untreated diseases can
  lead to problems in eating, speaking and
  attention to learning. This interference with a
  childs normal development will have significant
  long-term effects on that childs future.
• With early preventative dentistry, cavities in
  children could be avoided entirely.

1. The Disparity Cavity Filling Americas Oral
Healthcare Gap. Oral Health America The Kellogg
Foundation, 2000. 2. Oral Health in America A
Report of the Surgeon General. Executive Summary,
2000.
23
Disparities in Dentistry Adults

• Regarding access to dental care, there is a
  four-fold difference between high- and low-income
  groups.
• Less than two thirds of adults report having
  visited a dentist in the past 12 months. Those
  with incomes at or above the poverty level are
  twice as likely to report a dental visit in the
  past 12 months as those who are below the poverty
  level.
• The percentage of African Americans who have
  untreated caries is twice that of whites.
• For adults in low income groups, half of the
  teeth that have decayed have never been filled.
• Among low-income people over the age of 35, 1/3
  have no teeth. The difference between lowest and
  highest socioeconomic groups is eight-fold.

Sources 1. The Big Cavity Decreasing Enrollment
in Minority Dental Schools. The Kellogg
Foundation, March 2001. 2. Oral Health in
America A Report of the Surgeon General. 2000.

24
Disparities in Dentistry Adults

• The mouth is considered the laboratory of the
  body. An oral examination of the mouth can
  detect early signs of diabetes, bone and joint
  disease, and cancer as well as general infection
  and stress.
• Sores and ulcerations can also diagnose herpes,
  mononucleosis, or HIV infection.
• A number of recent studies suggest that there may
  be links between improper oral hygiene and
  several diseases and conditions such as heart
  disease, stroke, diabetes, and premature
  delivery.
• We have the potential to have a major impact on
  health through a minor investment in dental care.

Source A Plan to Eliminate Craniofacial, Oral,
and Dental Health Disparities. The National
Institute of Dental and Craniofacial Research,
February, 2002.
25
Disparities in Dentistry

• A number of preventative measures have been
  implemented within recent years, overall lowering
  the percentage of Americans who get cavities.
• This success does not translate to all groups,
  however. Statistics show that for those who do
  get cavities, the percentage of those who have
  them repaired is declining.
• Preventative measures have been incomplete, and
  not universally available to all.
• Although it was introduced almost 60 years ago,
  approximately 40 of the public still does not
  have community water fluoridation.
• Dental sealants are found in only 23 of youth
  under age 8 and in less than 10 of low-income
  minority children.

Source Nation Brings Home a Lackluster C on Oral
Health Report Card. Oral Health America. April
23, 2003.
26
Disparities in Dentistry

• Oral diseases and disorders affect health and
  well-being throughout life.
• Healthy People 2000 found that more than 2/5, or
  93 million American had limited their activities
  because of dental problems.
• In one year, 164 million work hours were lost, an
  average of 1.48 hours per worker.
• Dental problems may
• Undermine self-image and self-esteem.
• Discourage normal social interaction, and lead to
  chronic stress and depression.
• Interfere with vital functions such as breathing,
  eating, swallowing, speaking and sleeping.
• Impact economic productivity, making it difficult
  to get and keep a job.

Source The Disparity Cavity Filling Americas
Oral Healthcare Gap. Oral Health America The
Kellogg Foundation, 2000.
27
Opportunity Structures
28
Disparities in Dentistry

• A web of structures exists in which individuals
  live and operate.
• This web helps us conceptualize the interaction
  among these structures and the impact disparities
  may have on a variety of levels.
• For example, Medicaid recipients have less
  disposable time, yet wait almost 40 longer for
  their first appointment than persons with private
  insurance. They also have on average less
  transportation options and less disposable
  income, yet must travel much further to reach a
  dentists who will treat them.1

Source 1. Berthold, M.. Dental Medicaid Studied.
American Dental Association. April 5, 2005.
29
Disparities in Dentistry

• What else might affect an individuals overall
  oral health?
• Neighborhood Resources
• Grocery stores as opposed to convenient stores
• Availability of dentists in the area
• Employment
• Health Insurance
• Ability for an individual to take time off work
  to visit a dentist
• Childcare
• Whether that person has childcare available so
  they may attend a dental appointment

30
Disparities In/Out Cause/Effect

• Disparities are often the result of inadequate
  sets of inputs/developments.
• Disparities can generate new disparate outcome.

31
Disparities in Dentistry

• Because of this complex web, disparities in
  dentistry have far greater implications than just
  oral health oral health ultimately affects a
  multitude of life opportunities.
• Inequality matters group inequalities matter
  more. Why?
• When disparities are durable and cumulatively
  visited on certain groups, this bring into
  question the fairness of larger structures and
  arrangements.
• Structures in society can start off fair, but
  because of their interaction and changes in the
  environment, become unfair.

32
Disparities in Dentistry Healthcare

• In examining structural arrangements, consider
  healthcare. How accessible is our healthcare
  system in America, and to whom?
• Oral health care in America is financed
  principally through private sources.
• Studies have demonstrated that insurance is a
  major determinant to dental utilization 70 of
  those with insurance reported having seen a
  dentist in the past year as opposed to 51 of
  those without insurance.1
• Uninsured children are 2.5 times less likely than
  insured children to receive dental care children
  from families without dental insurance are 3
  times more likely to have dental needs.2
• A growing number of adults are facing
  difficulties in accessing care, as states cut
  Medicaid dental benefits and unemployment
  continues to rise.
• Elderly individuals also face unique challenges
  to accessing dental care. Many lose their dental
  insurance when they retire, particularly older
  women who have on average lower incomes and may
  never have had insurance.

Source 1. A Plan to Eliminate Craniofacial,
Oral, and Dental Health Disparities. The National
Institute of Dental and Craniofacial Research,
2002. 2. Oral Health in America A Report of the
Surgeon General. Executive Summary, 2000.
33
Disparities in Dentistry Healthcare

• In the US, the healthcare system is least
  accessible to low-income individuals and
  families. The organization of our society is such
  that healthcare is only truly accessible to the
  middle and upper classes (work-based healthcare
  insurance, etc.).
• Black men in the United States, as compared to
  individuals in third world countries, are
  financially richer. Despite this, African
  Americans have an absolutely lower chance of
  reaching mature ages than people of many third
  world countries such as China, Sri Lanka, and
  parts of India.1
• Can we translate our resources into capacity
  enhancing outcomes/utilities?
• Europe, for example, considers healthcare a basic
  right of citizenship. Countries such as the
  United Kingdom, France, Spain, and Japan provide
  universal healthcare.1

Source 1. Sen, A. (1999). Development as Freedom.
34
Disparities in Dentistry Healthcare

• Roberto Unger argues that the state and
  government have a civic responsibility to address
  persistent disparities in a meaningful way the
  role of society is to make up the social capital
  that the parent or family is unable to provide.
• This organization of civil society is lead by
  what can be described as the caring economy or
  the practical organization of social solidarity.
  This includes the practices by which we care for
  the very young, the very old, the infirm or the
  disabled.
• If we are arranged as a middle-class society, how
  do we reach those who are being left behind?

Source Alternative Law Forum, Public talk on
Innovation and Inclusion in the World Economy by
R. Unger.
35
Diversity

• What is it?
• Is it important and if so why?

36
Diversity in Education

• Student body diversity promotes learning
  outcomes, and 'better prepares students for an
  increasingly diverse workforce and society, and
  better prepares them as professionals.
• Grutter v Bollinger Et. Al., 2002
• Brief for American Educational Research
  Association et al. as Amici Curiae 3

37
Diversity in Education

• In order to address some of these disparities,
  the pursuit of increased racial and ethnic
  diversity in dentistry has been suggested.
• How does a diverse dental class and
  administration lead to reduced disparities?
• Diversity should not be thought of just in terms
  of numbers.
• We need what is called structural diversity or
  transformative action.

38
Diversity in Education

• It is probable that no other area in American
  higher education is so severely segregated by
  race as professional schools of dentistry.
• Nearly 40 of all black students enrolled in
  dental programs are enrolled at the two
  historically black universities (Howard and
  Meharry).
• Blacks make up only 3 of the students at
  predominantly white dental schools In the U. S.,
  blacks constitute 12 of the total population.

Source Racial Segregation Persists in American
Schools of Dentistry. Journal of Blacks in Higher
Education, 2002.
39
Diversity in Education
Dental School Graduates by Race/Ethnicity
2000-2001
Race and Ethnicity in the U.S., 2000
Data Source American Dental Education Association
Data Source US Census Bureau
40
Diversity in Education

• In 1995, there were 951 black dental students in
  the United States. In 2002 there were 832, a
  reduction of 12.5.
• During the same period, overall enrollment was up
  by 6. What contributed to this decline?
• Lack of academic preparation
• Decline of affirmative action programs
• Why be concerned with those who didnt make it
  in? If the admissions process is colorblind, does
  that means it is fair?

Source Racial Segregation Persists in American
Schools of Dentistry. Journal of Blacks in Higher
Education, 2002.
41
Diversity in Education

• Consider for a moment those factors which you
  attribute your admission into dental school to
• Education, Family Influences, Hard Work, etc.
• Now consider the quality of your primary and
  secondary education. Did you have textbooks
  available, was the building safe, were the
  teachers qualified?
• Should an applicant get special consideration if
  they succeeded in the face of adverse
  circumstances such as these but may not have
  scored as high on the DAT?
• Where does this leave us with those who are shut
  out of higher education as a result of such
  failing schools? And why should we be concerned
  with pursuing racial and ethnic diversity in
  dentistry?

42
Diversity in Education
The representation of African American and
Hispanic Students gradually decreases from
undergraduate enrollment, to dental school
enrollment, and finally as dental school faculty.
Data Sources US Census Bureau, American Dental
Education Association
43
Diversity in Education

• The 2002 Affirmative Action case Grutter v
  Bollinger Et. Al. asserted that integrated,
  equitable education
• Is needed for individuals to function in a
  multi-racial society.
• Leads to better citizenship.
• Is necessity for the American economic system and
  even national security.
• In the field of healthcare, integrated education
  is even more crucial in order to train and
  prepare students to serve diverse populations.
• A diverse and culturally competent workforce is
  necessary to meet the oral health needs of the
  nation.

44
Diversity in Education

• Studies have shown that students of color are
  more likely than white doctors to serve in
  communities where there is a shortage of
  physicians, and to treat minority, sicker and
  poorer patients.
• These doctors more often serve as a community
  spokespersons, addressing key health problems and
  service needs. 
• If given a choice, people also tend to select
  health providers from their own racial group one
  survey found that 60 of African American
  dentists patients are African American 45.4 of
  Hispanic American dentists patients are Hispanic
  American.1
• Because of both patient preferences and the
  tendency of dentists of color to work in
  underserved communities, increasing the number of
  minority dentists is critical to serving our
  countrys oral health needs.

Source 1. The Big Cavity Decreasing Enrollment
in Minority Dental Schools. The Kellogg
Foundation, March 2001.
45
Diversity in Dentistry
There is a lack of racial and ethnic diversity
in the oral health workforce. Efforts to recruit
members of minority groups to positions in health
education, research, and practice in numbers that
at least match their representation in the
general population not only would enrich the
talent pool, but also might result in a more
equitable geographic distribution of care
providers. -Oral Health in America A Report
from the Surgeon General, 2000.
46
Diversity in Dentistry Shifting Demographics

• Each year more dentists will leave the profession
  than graduate from dental school, and there are
  already not enough future practitioners of color
  in the pipeline to replace those currently in
  practice.
• This projection does not take into consideration
  the changing demographics of our country. Over
  the next fifty years, the white population is
  expected to decline from 73 to 53, while
  Hispanics and African American populations will
  increase from 10.8 to 25, and 12.1 to 13.6,
  respectively.1
• These shifts have important implications not only
  for the recruitment of African American and
  Hispanic dentists, but for the training of all
  dentists.

Source 1. Statement on the Roles and
Responsibilities of Academic Dental Institutions
In Improving the Oral Health Status of All
Americans. ADEA House of Delegates Manual. Feb5,
2003.
47
Diversity in Dentistry Cultural Competency

• Certain racial and ethnic groups face unique
  obstacles to accessing healthcare, such as
  language barriers.
• Other cultural factors impact care as well, such
  as African Americans mistrust of the healthcare
  system and providers.
• Healthcare professionals may also need to serve
  as change agents, bring care into communities
  through mobile clinics and reaching minority
  patients through churches and community groups.
• In order to provide and serve these diverse
  communities with effective and competent care, it
  is imperative that healthcare professionals
  undergo culturally competency training.

48
Diversity in Dentistry Cultural Competency

• This acquisition of knowledge, awareness and
  skills begins in institutions of higher learning.
• Programs across the country are recognizing this
  need and are implementing cultural competency
  curriculums.
• Cultural competency training can work towards
  eliminating disparities through the infusion of
  culturally competent principles into the policies
  and practices of organizations providing dental
  services.

49
Diversity in Dentistry Research

• The field of dentistry also faces significant
  research challenges
• Need comprehensive data on health, disease and
  health practices and care use, especially for
  racial and ethnic minorities.
• Need consistent data on patient provider race,
  ethnicity and language, as well as how these
  might affect the process, structure and outcomes
  of care.
• In order to achieve statistically valid results,
  we need to make sure that all racial and ethnic
  groups are adequately represented in research.
• Cultural quality assessments of patient care
  should be collected by race and ethnicity.
• We need to not only better document race-related
  differences in health outcomes, but to also
  vigorously investigating the cause of these
  disparities.

50
Diversity in Dentistry Incentives

• Despite the growing list of research needed,
  there is a shortage of qualified researchers.
• One impediment to this, as well as the lack of
  dentists in low-income communities, is the great
  financial burden students face following dental
  school.
• With debt from anywhere between 100-150k, it is
  difficult for graduates to accept lower paying
  positions at a university or in a community.
• Loan Repayment Programs are one effort to address
  this.
• Faculty loan repayment programs Funds are used
  to repay qualifying health professionals
  educational loans in return for serving at least
  2 years as a full-time faculty member.
• Loan repayment programs also exist to incentivize
  students to work in underserved communities.

51
Structural Diversity

• What would this look like in higher ed?
• What does this look like in dentistry?

52
Summary
We are all caught up in an inescapable network
of mutuality, tied in a single garment of
destiny. Whatever effects one directly effects
all indirectly. -The Rev. Dr. Martin Luther
King, Jr.
53
Moving Forward

• How does a structural racism approach differ from
  other approaches to addressing oral health
  disparities?
• Continue pursuing initiatives designed at
  alleviating inequities in healthcare.
• But,
• Instead of viewing them individual and
  independent, work from a more cohesive approach.
• For example,
• When providing care to low-income patients,
  consider the impediments they face such as
  transportation, childcare, etc.
• How are other institutions and structures
  pursuing the outcome you are seeking? Is there
  room for collaboration (i.e. medical
  practitioners)

54
Progress and Next Steps

• We have and can make progress.
• Our efforts in the past have been transactional,
  we are making small changes- incremental gains
  within existing arrangements.
• Including people where they once were excluded is
  a step in the right direction, but it is not
  enough.
• For low-income, African American and Hispanic
  patients, we need to examine where the healthcare
  system is failing and seek change at that level.
• We need to consider ways to bring more students
  and administrators of color into dentistry.
  Instead of focusing on this goal when they reach
  the doors of the university, we need to extend
  our efforts into middle schools and high schools.
  

55
Next Steps

• We need transformative thinking to combat
  structural racism.
• For example, all of our efforts at reaching
  underserved populations are within the current
  medical model. We have seen for decades the
  failure of this model for this nations poor and
  people of color.
• Instead of continuing to try to make incremental
  changes within this structure, we need to
  challenge it and reshape it.
• The separation of oral health from systemic
  health in the U.S. health care system has
  resulted in a disciplinary chasm between oral
  health providers and the rest of medical care to
  the detriment of the patient, especially the
  underserved.
• -2003 ADEA House of Delegates Manual

56
Next Steps

• Unless we work towards large-scale change we will
  continue only making adjustments which are all
  too often negated by other impacting factors.
• Our focus should be outcome-oriented, not just
  simple process or input focused. We must identify
  our goals, then align our institutional
  arrangements to produce those desired outcomes.
• If we are seeking a diverse workforce in the
  field of dentistry, we must start with this goal
  and adjust our institutions and structures to
  achieve this.

57
Next Steps

• We cannot issues or marginality without
  disturbing the center.
• Because of the multidimensional nature of our
  laws and policies, progress in one area can cause
  retrenchment in another.
• We must examine the social forces that are
  compounding healthcare disparities and remedy
  them through the pursuit of specific racial- and
  ethnic-targeted health policies.

58
Next Steps

• In order to improve disparities, there have been
  several initiatives suggested
• Identify and inequality producing processes that
  impact healthcare
• Design better means of care delivery, including
  the location of health care facilities
• Elucidate risk factors and facilitate means of
  risk reduction
• Enhance health-promoting and care-seeking
  behaviors
• Pursue a diverse study body and faculty in higher
  education.
• Public education is one key component that we
  must include.
• One 2001 study found that most middle-class white
  citizens believe that health status is negotiated
  by self-determination, choice and individual
  responsibility. This undoubtedly has effects on
  contemporary epidemiology and health policy
  development.1
• We need public support and for that we need
  public education, to begin working on a policy
  agenda that will address healthcare inequities.

Source Eliminating African-American Health
Disparity via History-based Policy. Harvard
Health Policy Review, 2002.
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Summary

• We must expand our notion of what equality means,
  taking into account access to opportunity. We
  must offer solutions that do not seek to affect
  transactional change, but transformational change
  and stop pursuing avenues which arent yielding
  measurable results.
• At the same time, we must understand that it is
  often important to work on many levels at once to
  create change, and that it is impossible to know
  concretely whether a change can be
  transformational. Coalition building and
  community rather than simply criticism.

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Why do this?

• Or why would those who are doing well disturb the
  current arrangements?
• Why would you or me?

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www.KirwanInstitute.org