American Indian Health Through the Lens of Health Equity
Anthony Fleg
Introduction: Health equity is NHI’s framework for how to understand the health of American Indians
(while loving service is our framework for how we address health issues). Health equity is quite different
from health disparities, namely in that health equity views differences in health as UNJUST, UNFAIR,
AND PREVENTABLE. Disparities, meanwhile, takes no moral position on differences in health, and simply
means that differences exist; the term disparities simply means there is a difference between X and Y,
and can be heard describing two teams, two cities, etc.
Three primary reasons why we must begin using a health equity framework in our health policies, in our
thinking about health, and in our health programs
1) Health equity gives us an ethical gold standard for which to work toward, with a goal to achieve
equal health status for all.
2) Health equity requires us to look upstream from health outcomes such as death rates, putting
emphasis on the risk factors and protective factors related to health (e.g. education, socioeconomic status, living conditions, racism, historical trauma). These factors are often known as
social determinents of health.
3) Health equity requires us to take a broader approach to developing solutions. Since this
framework is based on social justice, it follows the Dr. King’s words “injustice anywhere is a
threat to justice anywhere.” Thus, if the issue is low graduation rates is a risk factor for
developing diabetes in a particular population, health equity would require us to look at other
populations that might have similar inequities in graduation rates, prescribing a larger-picture
solution as opposed to a solution just for one population
As an example of how this influences our work toward a more just society that would lead to the
elimination of health inequities, consider this example:
African American males die from prostate cancer at 2-3 times the rate of European Americans.
 Disparities framework: Our goal is to reduce the disparities in death rates from prostate
cancer between African Americans and European Americans.
 Health equity framework: Our goal is to eliminate the inequities in death rates from
prostate cancer in all populations where these inequities exist, beginning with a focus on the
living and working conditions that predispose populations to prostate cancer.
Some questions before you get to the reading:
1) Are all differences in health to be called health inequities
YES and NO. Yes, when hearing about differences in health, our default must be “It is an inequity
until proven otherwise”. A good example is the higher drowning rates for African Americans,
which was assumed to be a biological tendency toward drowning by the scientists and medical
leaders in the 1950s. It was not studied properly, as the leading thought toward this was that
there could be no solution to this. However, had this been approached from a realm of health
equity, we would have found out that there were many societal reasons that explained the
higher drowning rates among African Americans, all of which were able to be
addressed/changed, including this populations lack of access to swimming pools in days of
segregation, not to mention swimming lessons.
 Take home point – differences in health should be assumed to be health inequities until
proven otherwise.
The NO part of this answer relates to the very small percentage of disease where the difference
is explained by un-addressable factors, such as genetics. Examples would include the higher
rates of sickle cell anemia in African Americans and the higher rates of Tay-Sach’s disease in
certain Jewish populations, both of which have direct genetic links.
2) If we are able to lower rates of a particular disease in our country, does this mean that the
health inequities associated with that disease will decrease as well?
NO – lowering rates of a disease is great, but has nothing to do with the inequities of that
disease since the latter is a measure of differences between segments of the population. For
example, over the last 80 years the rates infant mortality (death in the first year of life) have
been decreasing in the U.S.; however, the differences between the rates in European Americans
and African Americans have stayed constant, with African American babies dying at 2-3 times
the rate of European Americans consistently over these decades.
 Take home point – even as medical science may decrease rates of disease, if social inequities
persist, the health inequities may very well persist
3) What is our scope when talking about health inequities?
Quick answer –it varies. We can look at health inequities in life expectancy for a given town and
that Latinos and those living on the west side are faring the worst. We can enlarge the scope to
the state level, and see that it is now American Indians, men, and those living in the inner city
who are faring the worst. Enlarge again to the level of the U.S. and we might find that it is those
in the Southwest doing the worst. Enlarge again to a global scope and we see that it is African
countries far worse than other parts of the world.
 Take home point – health equity requires us to see the bigger picture, and helps make a
connection that at all levels of scope, there is probably similar social determinants of health
causing the inequity (e.g. from the town to state to country to global level, maybe it is lower
socio-economic and educational status that is the constant).