The Science of Eliminating Health Disparities: Embracing a New Paradigm

Health disparities in the United States will not be solved by an isolated cadre of public health experts—the problems are complex, and achieving health equity will require a profound transformation of our health care system and our society. Solutions will have to emerge from a large and expanding network of institutional partnerships in which organizations that represent health disparity communities play a preeminent role. This was our thinking when the National Center on Minority Health and Health Disparities (NCMHD) convened the 2008 National Institutes of Health (NIH) Science of Eliminating Health Disparities Summit. With its rich variety of presenters and topics, the Summit exemplified the changing landscape of the field of health disparities. It called for a multipronged approach to action on all determinants of health. It also challenged participants to address and provide recommendations to tackle the complex interplay of factors ranging from access to affordable and quality health care to the social, environmental, political, cultural, and economic influences on determinants of health.

Our focus on health disparities is good news for what it tells us about ourselves. It signals that we are dedicated to equity and justice and to a democratic process in which those previously excluded from the public health dialogue are allowed to voice their concerns and be heard by political leaders and the scientific and medical communities. However, our satisfaction is tempered by the immensity of the task. Disparities in health remain the reality for too many in this country.

THE CHALLENGE OF DIVERSITY IN HEALTH DISPARITIES RESEARCH

As we expand epidemiologic surveillance, we are increasingly aware of the breadth and complexity of health disparities. We are still a nation of immigrants, and each immigrant population has unique health concerns, as do many other communities. American Indian, Alaska Native, African American, Hispanic, Asian, and Pacific Islander are broad categories, each comprising many subpopulations with very different cultures, historical experiences, and health outcomes. Lesbian, gay, bisexual, and transgender groups face numerous forms of discrimination and health problems that are not well understood. As technologically advanced a nation as we are, our rural populations still cannot access quality health care. The growing concerns of health disparities among these groups and other segments of our population, such as prison inmates and veterans, cannot be ignored. Effective translation of scientific knowledge to all of these specific populations and communities will require an intimate understanding of their unique cultures and attitudes.

THE SCIENTIST'S ROLE IN SOCIAL CHANGE AND POLICY

The 19th-century scientist and pathologist Rudolph Virchow gave voice to many of our present-day concerns about disparities and went a long way toward defining the task before us. A socially minded man, he believed that science should speak the language of the common people and that medicine should serve the public's health. He wrote,

If medicine is to fulfill her greatest task, then she must enter the political and social life… . Do we not always find diseases of the populace traceable to defects in society?¹

His view was that because diseases so often result from poverty or disadvantage, scientists and public health advocates need to be leaders in addressing the poor. Virchow stated the need for the medical profession to move beyond the biological causation of disease and appreciate the social and political influences that influence poverty. He suggested that, if disparities in health according to socioeconomic status are to be corrected, they must be better recognized, characterized, understood, and addressed with effective interventions beyond “increased access to cellular medicine” solutions.^2(p396)

Virchow reminds us that health disparities reflect vast divides in the United States—in socioeconomic status, environmental quality, and educational opportunity—that must be addressed if we are to achieve health equity. Thus in planning for the Summit, we challenged participants to formulate recommendations that would link the three often disconnected domains: science—the research into the complex causation of health disparities; practice—the application of scientific knowledge to the delivery and management of health care; and policy—the course of action or system of interventions adopted as a result of scientific and practical knowledge or experience.

A TIME FOR TRANSFORMATION

Addressing the complex nature of health disparities is even more urgent in the era of health reform. It is within the context of this charged and conscious environment that we welcome this supplement on addressing the science of eliminating health disparities.

The summary of the Summit recommendations in this issue will help to inform the programmatic efforts of NCMHD and the continued development and strengthening of partnerships and collaborations involving numerous federal agencies, state governments, universities, the private sector, and community organizations. This issue contains many articles that we believe will help define the future of health disparities research. I particularly want to call your attention to several of them. The analytical essay on translational, transformational, and transdisciplinary approaches defines a paradigm-shifting approach to health disparities, describes important dimensions of these three strategies, and calls on investigators to examine health disparities innovations through a balanced combination of these domains.³ Freudenberg describes how we can integrate primary care practice and targeted regulatory policies to reduce deaths and disparities from chronic disease and injuries.⁴ Two other articles describe the contributions of community-based participatory research to intervention research and its role at the intersections of science and practice and policy.^5,6 Additional articles on research and practice shed light on some of the health disparity diseases and conditions within minority and medically underserved populations and on the application of a social determinants of health framework for devising effective intervention programs.

Overall, the articles in this supplement provide a stimulating and urgently needed perspective on the science of eliminating health disparities. Taken as a whole, they capture the thinking and expertise of many leading experts in the fight against health disparities and add new and important dimensions to the field.

A CALL TO ACTION

Health disparities can no longer prevail in this country. We can no longer be victims of inaction. Our role as scientists is to provide the knowledge and perspectives for effective practice and policies, including the necessary changes in social policies that influence health disparities. In this call to action, we must accelerate the translation and dissemination of discovery from innovative interventions into poor and underserved communities. We must also focus on adopting new partnership and collaboration models such as community-based participatory research and community empowerment in the research process. Community and individual empowerment is important for health and for health disparities research to provide practical solutions. We have a moral obligation in our society to do what is necessary to improve health, and the health disparities research community should be in the vanguard of that movement.