by Fall Ferguson, JD, MA
I recently listened to a panel that took place in February 2014 at AcademyHealth’s National Health Policy Conference. The panel was entitled “Community Health & Disparity: Moving Beyond Description.” As the title suggests, the panelists addressed the idea that we need to shift our policy focus from describing health inequities to finding solutions. I recommend the panel to anyone interested in understanding current trends in policy approaches to health inequities.
One aspect of the panel troubled me greatly. Specifically, I have a problem with the self-satisfied notion that we pretty much know what we need to know about this issue. I am all for working on solutions, but let’s not assume that we’re anywhere close to understanding all the sources and the entire impact of health inequities. There are at least two areas in which we need to expand our awareness.
First of all, we can’t find a solution for a health inequity if our current health paradigm blinds us to its very existence. The “health inequities” lens has been and continues to be extremely important to expanding our understanding of the ongoing impact of race and ethnicity on health and well-being. However, we are not yet effectively using this lens to examine health differences based on other key identities and characteristics.
Second, and just as important, our public health systems and health researchers have an extremely poor understanding of the intersectional nature of oppressions and stigma. Our lived experience is complex and nuanced, and few are taking this complexity into account yet.
What Are Health Inequities?
The World Health Organization defines health inequities as “avoidable inequalities in health between groups of people” resulting from social and economic conditions. Health inequities are most often categorized in terms of race/ethnicity, socio-economic status, gender, and geography (e.g., urban/rural or different countries). The social determinants of health that generate health inequities are defined as “the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness.” Health inequities are understood to be unjust and preventable, though how to prevent them continues to elude us in many cases.
The concept of health inequities is a relatively recent development in the field of public health and has occasioned a significant reframe for the development of research, programming, and policy. In the U.S., the publication of Unequal Treatment in 2002 was a pivotal moment for the medical and public health professions. Based upon a study commissioned by Congress with the Institute of Medicine, the book presented overwhelming and irrefutable evidence of health disparities among different racial and ethnic populations within the U.S. based on social determinants of health.
Using the Health Inequities Lens with Additional Forms of Oppression
There are at least three categories or identities that I believe are a significant source of health inequities in many societies but which are virtually ignored by public health policy makers: disability, LGBTQ, and weight/size. This list isn’t meant to be exclusive; I recognize that my own cultural blinders may be preventing me from seeing the existence of other similarly situated groups. In any case, it is by now well established that weight, sexual orientation, gender expression, and disability status are all significant sources of stigma and oppression, and that stigma and oppression are in and of themselves health risks. Unfortunately, we have not yet begun to apply a health inequities lens to the health disparities experienced by these groups.
The U.S. Centers for Disease Control and Prevention (CDC) website acknowledges the existence of health disparities for those who identify as LGBTQ, stating: “Differences in sexual behavior account for some of these disparities, but others are associated with social and structural inequities, such as the stigma and discrimination that LGBT populations experience.” However, there has been no real attempt to understand or remediate these disparities through a health inequities approach. Indeed, a February 2014 article in the American Journal of Public Health bemoaned the lack of research into LGBTQ health issues as “contribut[ing] to the perpetuation of health inequities.”
In a position statement on its website, the U.S. National Council on Disability (an “independent federal agency committed to disability policy leadership”) has pointed out the lack of research and attention to disabilities as a source of health inequities:
“People with disabilities experience significant health disparities compared with people who do not have disabilities, yet they are not included in major Federal health disparities research, as mandated by the Minority Health and Health Disparities Research and Education Act of 2000 and undertaken by the National Center on Minority Health and Health Disparities (NCMHD) and other centers and institutes of NIH.”
The health differences in morbidity and mortality between people of different weights is well known. Those differences have generally been exaggerated and misunderstood, with the general rules about correlation not equaling causation being nearly universally ignored. Perhaps reframing weight/size as a source of health inequities rather than as a cause of disease offers us a better way of thinking about all this. It has proven to be so for health disparities observed in other groups that used to be “blamed” for their own health predicaments.
At least two articles have recently made a case for weight-inclusive public health approaches: “Obesity, Health At Every Size, and Public Health Policy” published in February 2014 in the American Journal of Public Health, and “The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss,” published in August 2014 in the Journal of Obesity. These articles marshal significant evidence supporting the idea that weight stigma and size bias are deeply affecting our health. Now it’s time to take the next step and argue for including weight/size – along with disability and LGBTQ – in the “health inequities” lens.
Any attempts to broaden our health inequities lens must account for intersectionality. (See this earlier piece for an explanation and useful graphic on intersectionality.) Current public health analyses of racial and ethnic disparities are incomplete at best – and possibly even inaccurate – because there is usually no attempt to account for the lived experience of those who experience multiple forms of oppression and stigma that affect health and well-being. As we move forward, our understanding of how social determinants affect our health, and how we can best address these social determinants, must be informed by the nuance and complexity of an intersectional approach.
I plan to talk more about this in future posts, including some of the obstacles and opportunities for these ideas. In the meantime, I look forward to feedback – positive and negative – about the concept of using a health inequities lens with respect to analyzing health disparities related to weight/size, LGBTQ, and disabilities.
One concern I had in writing this piece was the potential for inadvertently putting different oppressed identities into competition with each other in a world of scarce resources. I am not arguing for less attention to health inequities that impact groups defined by race or ethnicity. There is no acceptable form of health inequity. Ethically, we have to find a way to support health for all, rather than only some. From a strategic point of view, I would also argue that staying in our issue-based or identity-based silos, and only addressing those health issues that directly address our own constituencies, will hamper true reform of our broken systems. Emerging from our silos will take more than just words, but perhaps the process can begin with the stated intention to seek health justice for all.