Health Disparities
J. Michael Oakes, PhD
McKnight Presidential Fellow
Associate Professor
Division of Epidemiology & Community Health
Minnesota Population Center
University of Minnesota
oakes007@umn.edu
As a biological process, we should expect differences (ie,
variation) in health across individuals and groups.
Pick (most) any health outcome and you’ll find differences in
incidence and impact by race and class.
The rub is in “why” the differences exist?
What’s the difference b/w a “difference” and a “disparity”?
Should we be concerned with outcomes or processes?
Is strict equality Good?
To what extent should research offer/propose remedies?
Provocative, motivating documentary
that should get our public health
activist and research juices flowing!
Major Themes
• Poor are less healthy
• Society is making us sick
• Chronic stress without control is
mechanism if illnesses
• We must reduce economic inequality to
mitigate if not eliminate health disparities
• Immigrants suffer by coming here
This stuff is too important to be
sloppy in our thinking…
What are facts?
Source: Coleman, W. (1982). Death is a Social Disease: Public Health and
Political Economy in Early Industrial France. Madison, WI, University of
Wisconsin Press.
Percentage of Poor Families over Time
50
% Poor Families
40
30
20
10
0
1960
1970
1980
1990
2000
Year (CPS data)
All Families
Female Headed
2010
Health Disparities?
Socioeconomic status
Rich
Poor
White
Black
Health Disparity = 3
Excellent
Socioeconomic status
Rich
Health Disparity = 7
Poor
Poor
Rich
Excellent
Health Disparity = 2
Poor2
Poor1
Poor
Rich
Excellent
Health Disparity = 2
Poor
Poor
Rich
Socioeconomic status
Health Loss = 5
Health Disparity = 3
Poor
Poor
Rich
Poor
Excellent
Health Loss = 7
Health Disparity = 2
Health Loss = 1
Excel1
Health Loss = 2
Rich
Excel2
Health Disparity = 6
Poor2
Poor
Health Gain = 2
Poor1
Rich
Excel2
Health Gain = 5
Excel1
Health Disparity = 11
Poor2
Health Gain = 4
Poor1
Poor
Income Inequality?
Lynch, J., et al. 2004. "Is income inequality a determinant of
population health? Part 1. A systematic review." Milbank Q 82:5-99.
Lynch, J., et al. 2004. "Is income inequality a determinant of population health? Part
2. U.S. National and regional trends in income inequality and age- and causespecific mortality." Milbank Q 82:355-400.
Culter, David, Angus Deaton, and Adriana Lleras-Muney. 2006. "The
determinants of Mortality." Journal of Economic Perspectives 20:97-120.
Lee, Roland. 2003. "The demographic transition" Journal of Economic
Perspectives 17
350
Deaths per 1000 livebirths
300
250
200
Non-White
150
100
50
White
0
00 04 08 12 16 20 24 28 32 36 40 44 48 52 56 60 64 68 72 76 80 84 88 92 96
19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19
Infant Mortality Rates by Race, US 1900 - 1998
Culter, David, Angus Deaton, and Adriana Lleras-Muney. 2005. "The
determinants of Mortality." White paper
Risk of Death by Race/Ethnicity
White is reference
NDI-linked NHIS data, persons 18+ in 1986-1995 samples
1.40
Puerto Rican
1.30
1.20
Adjusted Odds Ratio
African American
Cuban American
1.10
1.00
Mexican American*
0.90
Other Hispanic
0.80
Asian American
0.70
Rogers RG, RA Hummer, CB Nam. 2000. Living and Dying in the USA: Behavioral, Health, and Social
Differentials of Adult Mortality. New York: Academic Press. Figure 4.1, page 64
What is the effect of neighborhood poverty on
American Indian infant death in Minnesota?
Neighborhood Poverty
All-cause infant death
Endogenous-cause death
Exogenous-cause death
<5%
5-19%
20-39%
40-100%
7.5
3.8
3.8
16.2
7.8
8.4
17.4
10.1
7.3
23.3
12.0
13.3
Johnson, Pamela Jo. 2004. "The Effect of Neighborhood Environments on American Indian Mortality
in Minnesota." Unpublished PhD Dissertation. Division of Epidemiology, University of Minnesota.
Lower Life Expectancy?
Life Expectancy at Birth
Low Class
High Class
USA (1980-82)
73.0
75.8
England/Wales (men 1971-76)
66.5
72.0
Brazil (1970)
53.2
62.0
But Cuba!!!
It’s a dictatorship island that you cannot escape.
IRM rates are probably fraudulent, if not surely don’t include
efforts to save preemies or other sick kids.
Maternal mortality is sky high, 4-5 times higher than US.
Sure, you’ll be employed but you have little to no choice in your
career or life plans.
10,000 – 50,000 died trying to get to Miami.
How much more should the
rich have to do?