disadvantage inequality and social policy

May 21, 2008 § Leave a comment

So a few months ago I was having a conversation with white mother and daughter about why infant mortality rates are so much higher in the states than in other countries.  The mother said that she thought it was because in the states so many middle class women are having children after 40 years of age.  I said that I thought it was related to the extensive poverty throughout the US.  Ever since then I have been keeping my eyes out for connections between race, poverty, culture, and infant mortality, mother health, etc.

So today a few selections from

Disadvantage, Inequality, And Social Policy

But what if policies that most enhance population health and increase disparities also bring large increments of improved health to those who are most disadvantaged? It is reasonable to accept disparities if the health of all groups is enhanced.

This dilemma is illustrated by examining progress in reducing U.S. infant mortality between 1950 and 1998.9 Black infant mortality in 1950 was 43.9 deaths per thousand live births, 64 percent higher than the white rate of 26.8. By 1998, black infant mortality fell to 13.8 deaths per thousand compared with a white rate of 6.0, a disparity of 130 percent.10 In every five-year period since 1965, more black babies than white babies were saved per thousand live births. A comparison of deaths in 1950 and 1998 indicate a reduction of 20.8 deaths per thousand live births for whites and a 30.1 reduction for blacks, an absolute change that favored blacks 50 percent more than whites. Ironically, this occurred while the magnitude of disparities in infant mortality increased, with the exception (discussed later) of the period 1965–1975, when blacks gained relative to whites.

If the derivation from Link and Phelan is correct, overall efforts to improve population health through new technological changes such as preventive screening, modifying smoking and other substance abuse, increasing exercise, improving nutrition, and many more may well increase disparities. Such initiatives, however, might improve the absolute health of disadvantaged groups more than would initiatives directed specifically at reducing health disparities.

so i guess we should just be grateful that a rising lifts all boats.

in this article David Mechanic makes a false dichotomy.  He posits the question as: Should we aim for overall health improvement or should we put our resources into targeting vulnerable populations even if it at the loss of white or more financially well-off communities.  Yet he does not show us when has targeting vulnerable populations ever led to less healthy communities of privilege.

He goes on to say: Interventions may improve population health without increasing disparities if directed at problems that are much more prevalent among disadvantaged groups and that offer a relatively simply executed and efficacious remedy….

and ends the article by saying:

Reducing health disparities is a complex task involving important considerations as to how to achieve the largest gains for disadvantaged persons from the investments made. The irony is that some of the largest gains possible for disadvantaged persons through population initiatives may have the effect of increasing disparities because of the dynamics of advantage. Health disparities impress many of us as fundamentally wrong and undesirable, but a compelling case could be made for policies that maximize population health at the cost of disparities when they provide large life and health benefits to disadvantaged groups as well as to others.

Strategies to redistribute income to the poor will remain contentious, although there is strong support for policies that help persons to attain health insurance and medical care access and for helping workers achieve a livable wage. Most thoughtful persons also understand the importance of maintaining a reasonable safety net for persons with disabilities and persons who are homeless, sick and uninsured, or temporarily down on their fortunes. Disagreements continue on how to respond to the more long-term welfare population who exhaust their eligibility. However this issue is resolved, there is much to be said for aggressive policy efforts in areas such as education, where positive outcomes can be expected and where there is much public support.

So it looks like  the dynamics of advantage are at work not only in current health care policies.  But also in future visions of US healthcare.  For example health care initiatives are limited by how much public support there is for the initiative.  And the public is not going to support a policy which readjusts these dynamics of advantage toward white folk.  It is easier to get support for initiatives which allow for some improvement in the health of vulnerable communities without changing the fundamental disparity between rich and poor white and colored.

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