The recent COVID-19 pandemic which has infected over 178 million people and killed more than 3 million worldwide (June 2021; WHO) shows regional disparity as well as differences in racial and ethnic populations. The disparities associated with COVID-19 pandemic underscores the need to address health disparities.
Health disparities are well documented in various parts of the world. In European countries such as Britain, where the population is fairly homogenous (i.e., mostly European whites), health disparity has been understood as differences in health outcomes between various socio-economic groups; where the upper-class educated and wealthy professionals are healthy and live longer compared to the lower-class and uneducated poor population. In such settings, disparities between different racial and ethnic groups, such as between the British whites and west African black immigrants has generally received less attention. On the other, the United States health disparities studies have typically been focused on racial and ethnic differences in disease incidence and mortality rates among different racial and ethnic groups of the US population. Unfortunately, in many other parts of the world particularly in developing nations, health disparities studies have received very little attention.
To address health disparities across populations, it is critical to understand what constitutes a disparity. Health inequities are systematic differences in the health status of different population groups. According to Dr. Margaret Whitehead, health disparities is the “differences in health outcomes that are not only unnecessary and avoidable but, in addition, are considered unfair and unjust”. Health disparities are far reaching and can affect a wide range of diverse populations. Race or ethnicity, sex, sexual identity, age, disability, socioeconomic status, and geographic location all contribute to an individual’s ability to achieve good health. Michael Marmot has argued that: ‘Inequalities in health between and within countries are avoidable; and that there is no biological reason why life expectancy should be 48 years longer in Japan than in Sierra Leone or 20 years shorter in Australian Aboriginal and Torres Strait Islander People than in other Australians.
Evidence shows that social factors including education, employment status, income level, gender and racial and ethnicity have a marked influence on a person’s health. In all countries, whether low-income or high-income, there are wide disparities in the health status of different social groups. The lower an individual’s socio-economic status, the higher their risk of poor health.
Studies have shown that people over the age of 60 years old made up over 90 percent of COVID-19 death in the European union. People with disadvantaged backgrounds in Latin America and the Caribbean are more than 43 percent likely to have disability. Two out of three children under the age of 5 who suffer from stunted growth are from Africa and Southeast Asia. Girls aged 15-19 years old in sub-Saharan Africa contract HIV at a rate 3 times higher than boys of the same age. African American babies are 2 times more likely to die as babies compared to other US races and ethnicities. People of low-income countries live 18.1 years fewer than those in high income countries. Even in high income countries such as western Europe and the US, people of African descent are disproportionately affected by high incidence and mortality rates of chronic diseases includingcardiovascular diseases, cancer, diabetes, kidney disease and cerebrovascular disease and hypertension.
Most prominent among the causes of health disparities are social determinants and environmental risk factors, access to healthcare, utilization, and quality of health status or health outcomes. More recent findings from scientific studies that focused on the role of genetics in health disparities has provided additional insight into the complex interactions of gene–environment and social determinants in defining health outcomes. Complex gene–gene and gene–environment interactions may explain differences in disease risk or outcomes among various racial/ethnic groups and the extent to which environmental exposures can affect gene expression to modify disease risk that are differentially distributed across populations.
African Americans and other minorities or low-income groups who live in segregated neighborhoods, such as slums or the poorest parts of urban areas, are disproportionately affected by air pollution and other environmental stresses. Even when social class and other confounding factors are eliminated, belonging to a minority race/ethnicity group alone has been found to be associated with increased risk to toxic exposure as was recently documented for lead poisoning in Flint, Michigan in the US.
There is extensive evidence for the role of social determinants in the origin of premature and low birth-weight infants, and such an early life course is linked to future health outcomes in the African American population, for instance, childhood obesity is directly linked to increased risk of cardiovascular diseases. The accumulating evidence suggests an association of early life exposure, indeed intrauterine conditions such as diet and maternal stress during pregnancy, and susceptibility to diseases such as cardiovascular diseases, hypertension, diabetes, and stroke, which disproportionally affect the African American population. Psychological stress caused by perceived racism has adverse health outcomes, including disproportionally high incidence of depression and high blood pressure in African American and other minority groups.
The roles of diet, physical activity, tobacco use, and alcohol consumption are widely recognized as determinants for poor health outcomes. However, some of the choices are themselves determined by availability such that heavy marketing of unhealthy foods, alcohol, and cigarettes, especially targeting children, is commonplace in low-income neighborhoods along with limited access to stores selling healthy foods. Many of the behavioral factors are complicated by psychological and emotional issues, such as depression.
The prevailing observation points to intervention at different angles to bridge health disparities. For instance, behavioral intervention is one option to reduce health disparities. Reports indicate that behavioral interventions for smoking, physical inactivity, poor diet, and alcohol abuse showed an overall favorable cost effectiveness for multiple behavioral interventions. Other evidence indicates that the greatest return on investment will come from interventions that simultaneously target multiple risk behaviors in various populations. A landmark behavioral intervention study named the Diabetes Prevention Program (DPP) was established with the overarching objective to reduce diabetes’ risk. The goals set out in the DPP was the total reduction of body weight by 7% and a minimum of 150 min of physical activity per week (Diabetes Prevention Program). The study used dietary modification focused on reducing total fat and a minimum of 150 min’ walk (similar to brisk walk) and equivalent to 700 K Cal/week of total calorie expenditure, with participants instructed to self-monitor fat and calories. Also, interventions targeted at high-risk groups may achieve efficiency through the greater available risk to be reduced. For instance, interventions to diet change were found to be especially cost effective when applied to groups with 3–4 combined risk factors, such as smoking, hypertension, and elevated LDL cholesterol.
Culture denotes the ways of life that are normally transmitted from one generation to another, and these are associated with various ethnic and racial groups. The culture of African or US Hispanics and other low–socioeconomic (SES) minority populations may influence health behaviors and practices and interactions with the health-care system. Minority populations are likely to seek alternative approaches to the Westernized health-care system for disease treatment. Some of these alternative treatments, including the use of chamomile tea to induce sleep and relaxation, are effective, while other alternative treatments, such as breaking an egg on the stomach to treat susto (a belief about a form of spiritually induced depression in the Hispanic community) has no effect, and yet other alternative treatments, such as the use of lead-based remedies for treating empacho (obstruction of the stomach; indigestion, diarrhea, constipation) among populations of Mexican origins, can be dangerous. Latino populations may use various diets and herbal treatment to treat diseases, instead of taken Western medicines. Conversely, the cultural assumptions on which the health/care systems, policies, and interventions are based may impact health behaviors and outcomes for minority and low-SES populations. Health disparities can be alleviated in part by creating and maintaining a culturally competent health-care system
Stress and psychological distress caused by perceived racial discrimination or other social factors may elicit negative emotional responses. These, in turn, can trigger adverse biological responses and negative health behaviors, and eventually lead to adverse health outcomes. The concept of “allostatic load” is used to demonstrate how environmental stresses including psychosocial ones can culminate in health disparities.
In order to effectively reduce and/or eliminate health disparities, scientifically based remedies have to be implemented in broad/based behavioral interventions that are focused on changing conditions at the community, state, and governmental levels, in addition to the individual level. Infrastructure, such as social networks involving community-health representatives, peer-outreach workers, community-health aides, and peer educators and their interactions with health-care professionals needs to be established.
Some reports suggests that social determinants are the root causes of health disparities, noting that factors such as economic hardship, psychosocial stress, and racial discrimination are causes of bad health. These social determinants derive from the environments and communities in which people are born, live, grow, work, and age. These circumstances are further shaped by the distribution of wealth, power, and resources at the global, national, and local levels, which can themselves be influenced by government policy.
We face a mammoth challenge in health disparities, and there is no single element or factor to explain all the incidence and mortality rates associated with disparities. Interventions to reduce or eliminate health disparities must be approached from multiple angles. While some believed that universal care would resolve disparities, this model has not worked in some countries, such as the United Kingdom, because health care alone does not solve problems, such as residential segregation and employment opportunities which are important determinants for heath. Addressing health disparities requires concerted efforts at the individual, family, community, local, and state levels, as well as government policies and international organization including the World Health Organization, the World Bank and Global Commission on the Social Determinants of Health with strategic interventions directed towards communities or populations at great risk.
Poverty is clearly a major determinant of health differentials everywhere. Poor countries have worse health indicators than rich ones and the poor within a country have worse indicators than the rich. That health is an important condition for poverty reduction and economic development of nations was one of the conclusions of the report of the 2001 WHO Commission on ‘Macroeconomics and Health: Investing in Health for Economic Development’. The reduction of social inequalities in health, and thus meeting human needs, is an issue of social justice.
(Read more: Health Outcomes in a Foreign Land- A Role for Epigenomic and Environmental Interaction; Springer 2017).