As the United States once again considers the possibilities for health systems reform, no problem seems more enduring and worthy of attention than the existence of major health disparities and inequities along the lines of race and socioeconomic class. Throughout the United States, there are enormous gaps in health access, quality, and outcomes between racial and ethnic minorities, as well as the poor of all races, and the rest of America. Authors in this issue of this journal represent a wide range of professions and many sectors of society, including some directly impacted by this problem. The articles capitalize on this diversity by providing observations on the magnitude of the health disparity and inequity problems and offer unique observations on what might be done to eliminate them.
In the opening commentaries, the Reverend Desmond Tutu, who has fought hard for equality on all fronts in South Africa and elsewhere in the world, makes the important point that health equity will not be attained without active and effective partnerships among government, healthcare, the private sector, and other social and community groups. Most Americans know General Russel L. Honoré as the Commander of Joint Task Force Katrina, who symbolized the return of order and the beginning of recovery in New Orleans after it was hit by Hurricane Katrina. In his commentary, General Honoré passionately describes how health disparities put the entire population at risk by inhibiting the nation from building a “culture of preparedness.”
A joint commentary issued by the National Association of County and City Health Officials, National Association of Local Boards of Health, and Association of State and Territorial Health Officials highlights the importance of tackling the causes of health disparities, as well as the consequences, and moving toward health equity through a comprehensive approach that targets social and economic inequalities. This viewpoint is echoed by Boyce and Smith in the commentary from the National Association of State Office of Minority Health. The commentary by Honoré et al reinforces the work documented in another article in this issue by calling for partnerships between public health and the nation's community college systems. A call to action is made for expanding current educational opportunities to embrace community colleges as a means of building the public health workforce while also positively impacting health and socioeconomic equity for students. Finally, in their commentary, Henry and colleagues discuss the potential benefits of public health agency accreditation and public health systems and services research to eliminating health disparities.
The authors of this issue's articles describe and analyze various efforts to combat health disparities at the national, state, and community levels. David R. Williams and colleagues make the essential point that any attempts to reduce or eliminate health disparities must involve factors outside the healthcare system that are major determinants of health. Reviewing the research literature, Dr Williams demonstrates that because health status is related to these other factors, the United States can move closer to health equality for all by improving housing, neighborhoods, and socioeconomic opportunities for those who are currently disadvantaged.
In the second article, Robert M. Goodman outlines a construct for capacity building in public health initiatives in minority communities. Using data collected in a qualitative cross-case study, he documents the importance of leadership, organizing capacity, developed operational procedures, effective oversight, and careful activity formation in attaining success in minority community health efforts.
The focus shifts to clinical disparities in the article by Margarita Alegria. In “How Missing Information in Diagnosis Can Lead to Disparities in the Clinical Encounter,” the author describes a study of contributions to clinician bias during assessments of ethnic/racial minority patients. The research findings suggest that racial and ethnic factors can lead to significant differences and bias in patient diagnoses. To work toward ending this problem, diagnostic practices will have to be thoroughly examined and modified.
The development of effective databases for measurement is critically important in any public health effort to reduce disparities and improve health outcomes. In “Measuring Disparities in Leading Health Indicators at the State and Local Levels,” Marsha Gold and colleagues analyze the availability of state and local data to support activities to reduce disparities as part of Healthy People 2010. Looking at data availability for the 10 leading health indicators, Dr Gold concludes that significant state data gaps remain.
Dr Leiyu Shi, in “Rethinking Vulnerable Populations in the United States: A New Way to Look at Health Disparities,” describes the growing number and level of analytic sophisticated reports that monitor health disparities, including those produced by the Agency for Healthcare Quality and Research and the Institute of Medicine. As the authors note, these reports are indispensable aids in developing recommendations to reduce and/or eliminate health disparities, as called for in Healthy People 2010.
Providing an article showing the relevance of data to monitoring health status, Evelyn Cruz and colleagues outline the development of the Healthy Birth Outcomes Initiative in Wisconsin, where African American infants have historically had a mortality rate three times that of White infants. Although it faces some challenges, the Wisconsin Minority Health Program, including the Healthy Birth Outcomes Initiative, promises to turn this situation around with evidence-based solutions.
In the article, “Something Old Is New Again: Mutual Aid and the Tennessee Office of Minority Health,” Elizabeth A. Williams and colleagues analyze the activities of the Tennessee Office of Minority Health over a 15-year period and discuss the meaning and history of “mutual aid” in African American communities. As Dr Williams and colleagues note, the task of the Office of Minority Health has been to build on this tradition of “mutual aid” by developing innovative minority health programs for the state.
In the final article, Barbara Pullen-Smith and colleagues describe the Community Health Ambassadors Program (CHAP). This training, education, and service learning demonstration program was developed in partnership with community colleges to involve a wide range of community leaders in efforts to eliminate health disparities in North Carolina. The authors provide evaluation data, suggesting that the program has provided considerable training and education across the state with benefits leading to cost-effective activities aimed at reducing health disparities with respect to diabetes and other diseases.
Taken as a whole, the commentaries and articles in this issue show that although health disparities and inequities have many causes, it is an immense problem all too common across America. Elimination will require determined efforts in diverse areas of healthcare and society at large. As editors, we hope that you as readers can learn from the information provided here and make your own contributions toward achieving health equity in America.