Graph via cdc.gov
By Emily Tiry, Staff Editor
The October issue of Health Affairs focuses on health disparities, which are prevalent in the U.S. They stem from several different causes, and solving them may therefore require several different strategies. A major theme running through many of the articles is that the amount and quality of medical care people receive, while important, are not the only determinants of health. Many social factors, like education and income, also contribute to health disparities. For example, Steven H. Woolf and Paula Braveman report that “adults without a high school diploma or equivalent are three times as likely as those with a college education to die before age sixty-five.”
So what is being done to eliminate these disparities? The Department of Health and Human Services recently released its Action Plan to Reduce Racial and Ethnic Disparities, which attempts to address health disparities mainly through increasing awareness of the problem as well as through increasing access to health care.
While these strategies are essential steps toward reducing health disparities, I think the HHS Action Plan doesn’t go far enough in dealing with their root causes. The Woolf and Braveman article explains the difference between “downstream” determinants of health (access to medical care, exposure to pollution, health behaviors such as smoking, etc.) and “upstream” determinants (education, income, social environment, etc.). For example, many poor neighborhoods are “food deserts” where healthy foods are hard to come by. Promoting good health behaviors like eating a healthy diet is important, but before that can happen, we need to make sure people everywhere actually have access to fresh produce.
The HHS plan is mainly focused on changing downstream determinants, but upstream determinants are equally important. Some organizations have stepped in to tackle the upstream determinants of health. In an op-ed for The New York Times, David Bornstein describes how the non-profit organization Health Leads is helping people find resources like food assistance or heating fuel subsidies to combat these problems. However, many of the resources they find are government programs, and many are likely to be subject to budget cuts in the continuing economic hard times.
I think any effort to truly reduce health disparities has to address both downstream and upstream determinants. Not only is it important to increase access to health care and to encourage good health behaviors, but it is also important to minimize obstacles that may hinder those goals.
This way of thinking widens the scope of health policy. Policy decisions in areas ranging from the environment to taxation to education may indirectly affect health and health disparities. In a way, maybe all policy is health policy.