Among the hurdles to attacking disparities in health between ethnic and racial minorities and whites is the confounding reality that some inequities have so far defied explanation and the differing views on what constitutes “fairness.”
That’s the assessment of Dr. Paula Braveman, a national expert who has done extensive work on health issues that disproportionately affect minority and low-income groups.
Speaking in Denver on Thursday, Braveman focused on one reality to make her point: African Americans are at least twice as likely to deliver premature and low birth weight babies as whites, and no one understands why. Expansion of Medicaid beginning in the 1980s dramatically increased pre-natal care for poor, expectant African American women, but there was no corresponding drop in low birth weight and premature babies, Braveman said.
That reality has made it difficult to figure out how to attack the problem – and difficult to muster the kind of public attention that leads to change, she said.
“If you don’t know the cause, how can you say that’s unfair?” Braveman asked.
Braveman, director of the Center for Social Disparities in Health in the School of Medicine at the University of California-San Francisco, made the remarks in a talk at the Colorado Trust.
Braveman’s remarks came in the wake of “Losing Ground,” an 18-month I-News investigation that examined the social, economic and health standings of Colorado’s white, African American and Latino residents. Using six decades of U.S. Census data as well as criminal justice and health statistics, the I-News series showed that by many measures blacks and Latinos in Colorado are worse off today than they were in the years surrounding the civil rights movement.
On health, I-News found that a black baby born in Colorado is three times as likely as a white baby to die before reaching his or her first birthday. And a Latino baby born in Colorado is 63 percent more likely to die in the first year of life than a white child.
In addition, data compiled by the Colorado Department of Health and Environment showed that African Americans and Latinos are more likely to die from a host of diseases and do not live as long as their white counterparts.
Braveman, in both her prepared remarks and in a question-and-answer session afterward, said that the fact that two groups experience different health outcomes does not alone amount to a health disparity.
“Would anyone here be morally outraged if I told you that skiers have more arm or leg fractures than non-skiers?” she asked. “Would anyone here be morally outraged if I told you women live longer than men?
“The men in the room, right?”
Instead, she argued that public policy and attention should be focused on problems that are avoidable, are unfair, and disproportionately affect groups that are disadvantaged – like people in poverty, or ethnic and racial minorities. And, she argued, efforts must be aimed at problems that are “plausibly avoidable.”
It’s unavoidable, for example, “that younger adults have better health than older adults,” Braveman said.
But untangling those complexities is difficult.
Take the issue of babies who are born prematurely or with low birth weight. Those factors are strong predictors of infant mortality, developmental problems and even chronic illness later in life. Cutting the number of premature and low birth weight babies could make a tremendous difference in overall health in the African American community.
But until research pinpoints the causes, it’s difficult to know what to do to improve the statistics.
And while Braveman argued that improving the education system and investing in things like early childhood programs could have dramatic, positive impacts on health, she noted that what she called the “black-white disparity” in premature and low birth weight babies was greatest among college educated, higher-income women.
Solving the disparities, she said, would likely take decades.
So, Braveman was asked, if the problems are so complex, so tangled and, in some cases, so mystifying, what should be done?
That’s easy, she said: Focus on small steps that can make a difference and recognize that it will take a long time to change realities that have taken generations to develop.
“A short answer is to think about intermediate outcomes,” Braveman said. “Don’t set yourself up for failure.”
