By Gail Christopher (Click here to view the entire P&R issue)
This nation has the resources to assure that all of its citizens have an equal opportunity to live healthy lives. If the rights to life, liberty and the pursuit of happiness are inalienable, then surely the right to an equal opportunity for health and well-being is comparable. Persistent health disparities are a result of a lack of leadership and political will to address the well-documented social conditions, inequalities and discriminatory practices that contribute to poor health outcomes. Indeed, our nation’s relatively poor health standing in comparison to many other developed nations is also a consequence of this leadership void. America ranks poorly in several key health indicators, including infant mortality—despite the fact that it has the world’s highest per-person medical expenditures. This conundrum—high investments in medical technology and persistent disappointing outcomes, coupled with seemingly intractable gaps in health between minorities, the poor and the more advantaged—demands fresh new approaches to the most fundamental challenge that our nation faces. The health and well-being of all the people should be the primary concern of leaders in a democratic society.
Healthy People 2010, a set of official HHS health objectives for the nation to achieve over the first decade of the new century, is designed to achieve two overarching goals: 1) increase quality and years of life; 2) eliminate health disparities. This bold government assertion, a goal to eliminate health disparities, recognizes that the right to the equal opportunity to live healthy lives is embodied in the fundamental freedoms of a democratic society. It also reflects a more pragmatic realization of demographic trends. Groups currently experiencing poorer health status—racial and ethnic minorities—are expected to grow as a proportion of the total U.S. population; therefore, the future health of America as a whole will be influenced substantially by success in improving the health of these groups.
Despite these stated public sector goals and demographic imperatives, racial and ethnic health disparities are not being eliminated. In fact, some disparities, such as infant mortality, are increasing. Historically, human and civil rights for minorities have been gained through social action of movements. From civil rights for African Americans to voting rights for women, freedoms required concerted action before fairness or equality became possible.
What would it take to truly eliminate racial and ethnic health disparities? Like all social injustices that have a disproportionate impact on the poor and minorities, health inequalities are a result of a set of laws, practices, policies and discriminations that benefit some while burdening others. The Institute of Medicine study, Unequal Treatment, provides irrefutable documentation of patterns of disparate treatment and service delivery, based on race and ethnicity. While some resist the idea that caregivers’ behaviors and decisions are racially motivated, the evidence of discriminatory pattern —different treatment—is well established.
Is there a right to health? Under international law, there is a right not merely to healthcare but to a much broader concept of health. The 1948 Universal Declaration of Human Rights, proclaimed by the United Nations General Assembly as a common standard for all humanity, provides the legal foundations for the right to health. The right to access the conditions, resources and services conducive to health and well-being is as fundamental in a viable democracy as the right to freedom from bondage and discrimination and the right to vote.
Translating that international legal standard into an actualized reality in this country will require a “Fair Health” movement. Eliminating health disparities requires the same energy that is required for eliminating other outrageous social injustices. Communities must become mobilized and coordinated in countering the laws, policies, conditions, practices and perceptions that encourage health disparities. History has taught us that democratic tenets and assertions of human and/or civil rights is not enough. Realization of equality, or some of its promises, has required persistent, organized, directed action by diverse organizations and like-minded groups. These efforts involved politics, activism, litigation, education, research, national and local mobilization, and perhaps more than anything, vision.
What would constitute a “Fair Health” movement? The “Fair Housing” movement offers some valuable lessons. The Fair Housing movement emerged during a period in U.S. history—1940s and 1950s post-war era—in which minorities had made significant sacrifices for the country and, upon their return home, could more effectively assert their right to equality in voices that the nation’s political elite could not ignore. This movement was based on the assertion of a fundamental right of a democratic society. The right to own and transfer property was considered to be crucial to the political and economic viability of the country. Advocates claimed that to prevent certain groups from acquiring property was to deny them full citizenship. Advocates also argued that it was time that the country abide by the principles established in the Civil Rights Act of 1866, which stated:
They further argued that segregation was wrong, that it had negative social and economic effects, and that America would be a truly democratic society when all races lived in one community.
Proponents of a “Fair Health” movement can make similar assertions concerning the right to equal opportunity for health, and can call for the nation to indeed abide by the levels and principles of the Civil Rights Act of 1964, particularly Title VI. Title VI prohibits discrimination on the basis of race, color or national origin by programs and activities that receive federal financial assistance. Title VI administrative enforcement procedures vest federal agencies with considerable discretion to design, implement and evaluate civil rights enforcement standards and procedures. A complaint must be filed with the appropriate federal agency. Health issues are to be handled by the Department of Health and Human Services’ Office of Civil Rights. However, a 1999 report by the United States Commission on Civil Rights concluded that “the timid and ineffectual enforcement efforts of the Office of Civil Rights have fostered, rather than combated the discrimination that continues to infect the nation’s healthcare system.”
Title VI was silent on the issue of when private individuals who had suffered discrimination could sue, but in Alexander v. Sandoval the Supreme Court, in a 5-4 majority decision, held that individuals who allege disparate impact (de facto) discrimination under Title VI of the Civil Rights Act of 1964 have no private cause of action to enforce their rights. Now only federal agencies can enforce prohibitions against disparate impact discrimination under Title VI. Thus, an effective battle against healthcare discrimination will require creative, new litigation strategies and/or must find ways to mobilize Congress to reverse Sandoval through legislation.
But healthcare parity is just one aspect of a “Fair Health” movement. Researchers estimate that medical care alone constitutes only 10% of the factors that contribute to health. Broader social determinants and community context will have to be addressed. Chronic diseases, excess mortality and morbidity in minority groups are symptoms of deeper underlying social, economic and environmental inequalities like housing, joblessness, crime, pollutants and their associated stress.
A successful “Fair Health” movement will require actions on a continuum that moves from community factors to access and quality of care issues. A possible framework is offered here for goals and specific strategies:
- Identifying and addressing the economic, social, environmental and behavioral determinants that can lead to improved health outcomes.
- Increasing resource allocations for the prevention and effective treatment of chronic illness.
- Informing policy and practice to reduce infant mortality and improve child and maternal health.
- Reducing risk factors and supporting healthy behaviors among children and youth.
- Improving mental health and reducing factors that promote violence.
- Optimizing access to, and the quality of, healthcare.
- Creating conditions for healthy aging and improving the quality of life for seniors.
Where people live determines their risk for and exposure to disease-inducing factors, as well as their access to care. Ultimately, the realization of Fair Health and the elimination of racial and ethnic health disparities will require place-based accountability systems. Coordination and collaboration across several social and human development movements will also be needed. Child welfare, education, regional equity and family support activists will need to work with housing, economic and community development, criminal justice, civil rights, human rights and health and medical care consumer and advocacy groups.
The lessons from the “Fair Housing” movement are transferable. Fair Health activists must work to influence public opinion and perceptions and foster a sense of urgency and outrage, while appealing to deeply held fundamental principles of democracy. The horrific images from the Gulf Coast post-Katrina may have done more to illustrate racial and ethnic health disparities and the social conditions of poverty and neglect than any social marketing campaign could have ever accomplished.
The challenge facing us now is to clarify and implement the strategies and interventions that are so urgently needed. The challenge is to indeed mobilize an effective “Fair Health” movement.
Gail Christopher is Vice President, Office of Health, Woman and Families at the Joint Center for Political & Economic Studies and Director of the Joint Center Health Policy Institute. gchristopher@jointcenter.org
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