A colleague of mine once joked that after he completed an African-American health course at a university, he half-expected every African-American he saw to be walking around coughing, wearing crutches with a portable dialysis machine.
The dark humor in the comment highlights the difference between perception and reality in the health of African-Americans. While African-Americans are a highly visible ethnic group whose problems are well documented (perhaps hyper-documented), it is difficult to form a realistic grasp on their overall health status.
How might one go about doing so?
If I wanted to summarize the state of health of African-Americans, I might choose to go the heavy handed statistical route. Unfortunately, creating a statistical indicator “soup” (with graphs and figures depicting the differences in health outcomes by race) would put me (the author) to sleep just as fast as it would you, the reader.
Not because the statistics are unimportant (of course they are important).
Not because the statistics are incorrect (most of reported statistics are correct).
Rote statistical expositions of health inequities lack vision; the statistical picture of the health of African-Americans needs to be transfigured into a coordinated conceptual/intellectual movement which aggregates the mountains of evidence of health inequities into a cohesive understanding.
This is especially necessary because discussions of health equity have become increasingly polarized:
Progressive academics or activists in the health equity movement search for innovative ways to discover and document health inequities. The ideological underpinnings of this approach tend to focus on structural violence: change the social structures that impede social mobility and discourage healthy lifestyles, and you effectively undermine the forces crafting health inequity.
Conservatives and other critics of the modern health inequity movement (e.g. Sally Satel), suggest that such a focus undervalues the role of individual responsibility and behavior in the improvement of the health of the public.
The Need for a Model
The reason such polarity exists is because there is no general framework on which these discussions can take place. Right now, ‘health inequity’ is a nebulous concept comprised of a collection of micro-phenomena.
Health inequities might benefit from a model population whose historical plight is understood, whose health status is well documented (statistically) and whose cultural, biological and social conditions are transparent.
The African-American community provides everyone interested in health—politicians, activists, economists, clinicians, epidemiologists and biomedical scientists—with a canonical population through which to study and understand the interaction between social structure, individual behavior and biology (genetics) in the creation of health inequities.
Through the health of African-Americans, we observe a range of phenomenon that allow us to discard the ideological leanings that pit structural overhaul against individual responsibility; improving the health of African-Americans is about both, and is context dependent.
We’ll demonstrate this context dependence in two examples:
Example 1: Sickle Cell Anemia
Sickle cell anemia is a popular focus of health disparities conversations. Even in 2012, discussions involving inequities and sickle cell anemia tend to focus on the prevalence of the disease, which of course, disproportionately affects African-Americans.
This is strange, because the sickle cell anemia prevalence “inequity” (as in, the disparity in the absolute disease burden) is almost entirely genetic in origin.
Investing in social upheaval or behavioral change programs to improve sickle cell disease prevalence statistics would be a miserable waste of time and resources.
Simply implementing low-cost screening into school-aged children (or younger) visits (similar to how blood-type is determined) would be enough. On top of that, breakthroughs in therapies that improve red blood cell integrity and micro circulation can decrease disease morbidity.
The main interventions for sickle cell anemia—screening and better therapies—are far different than those that would affect, for example, the asthma disparity, which is powerfully influenced by environmental racism and city planning policy.
(Oddly enough, the structural violence issues that do relate to sickle cell anemia, such as self-medication, addiction and “pain-seeking” behavior receive very little direct attention in health inequity circles)
Example 2: Violence in African-American Males
The basic social-causation premise is quite simple: social disenfranchisement can create communities that accept or promote illicit and violent behavior. In addition/alternatively, poor economic standing can increase the incentive to do whatever is necessary to attain wealth, even commit acts of violence. Such an understanding fits observations about African-American males, who have been the authors of the US’s highest violent crime rate (offenders and victims) for many years.
That said, far fewer African-American men were the perpetrators and victims of violence in 2008 than in 1980. Despite the fact that social conditions remain, a change in the behavior of individuals, triggered by a likely combination of influences led to fewer African-American men engaging in violent behavior.
And again—economic and structural indicators don’t support the notion that the trigger was societal or economic improvement. For several reasons, African-American men have decided to not engage in as much violent behavior as their demographic did twenty years ago. This supports notions that behavioral change is not off-limits in discussions on how to positively change health inequities; we need not simply wait around for “the social revolution” in order to change unhealthy or dangerous behaviors.
In the sickle cell anemia and youth violence examples, we see how behavior, structural violence and genetics interact to create different inequities in African-American communities. This approach affirms the important role that African-Americans should play in the health inequity movement: African-Americans could provide an archetype for how health inequities are studied, understood and addressed. Such an approach could conceivably be applied to any population or health disparity.
New approaches driven by this model would represent an improvement over the status quo, where experts and activists overemphasize single actors (behavioral intervention, structural violence or genetics) rather than appreciating how interactions between forces create health different inequities.
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