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Abstract

The 2003 Institute of Medicine (IOM) report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (National Research Council, 2003) provides, through comprehensive reviews, strong evidence of health disparities in healthcare in the USA. In the article entitled ‘A life course perspective on how racism may be related to health inequities’, the authors cite the IOM study, in addition to numerous other studies that demonstrate racism’s contribution to health disparities, and describe a number of approaches that have been adopted in an attempt to at best eliminate, and otherwise at least diminish, these disparities. In this paper the authors propose a new approach to the study of health inequities which uses a life-course structure that can be helpful in future health disparities research. This structure has the potential to create new and more comprehensive solutions. They also provide an extensive literature review of various approaches taken to combat racialised inequality, and these form a foundation on which to base further study.

Using a life-course approach

The authors suggest a holistic approach based on a person’s life over the course of a lifetime. This includes an individual’s different roles and responsibilities as well as their circumstances, employment, income and other factors. The authors suggest that studies which cover the course of a lifespan can lead to a richer understanding of the causes and impacts of disparities than past studies that focused on only one or two elements or time periods of a person’s life. They also suggest that a person who experiences discrimination at one time in their life may also have done so in other areas and at other times. Changes in roles over time, together with the potential accumulative effect of racism, may have a greater impact on a person’s health than has previously been realised.

Structure

One of the most useful tools in this article is a table that outlines the proposed structure for future research. This table includes the definitions of what the authors refer to as ‘life-course concepts’, namely age, sensitivity, linked lives, latency periods, stress proliferation, period effect (historical events) and cohort effect. For example, people born in the 1950s in the USA experienced a very different kind of discrimination, one that was legalised, compared with people growing up today under an African-American president. Both birth cohort effects and period effects come into play when evaluating the effect of discrimination on individuals born in each of these time periods. Each section of the table includes a summary of the impact of the concept on an individual’s health status, as well as ideas on future research that could be conducted to include this concept and thus further expand the understanding of the impact of race on health inequities.

Past studies have demonstrated that as individuals age, they enter and exit different social structures within society, within their workplace and within their family and personal lives. As they enter and exit these structures, the impact of racism on their health status varies. It is this variance of impact that accumulates over time which must be studied in order to reach a more complete understanding of health inequities. Taken together, the authors assert that this provides a more realistic and comprehensive picture of a person’s experience of racism and health disparities.

Model

The authors conclude the article with a visualisation of their model. It provides a picture of how racism may shape health outcomes across the lifespan, and the impact that disparities have on individuals. The first and most powerful concept that this model communicates is that the time line for a person who experiences racism is shorter; people who experience racism die at an earlier age than those who do not experience it. If nothing else convinces researchers of the value of studying the effects of racism on health status, this fact alone should be enough.

The time line is further divided into life stages, such as time devoted to education, and time filled with uncertainty (e.g. during unemployment or incarceration). This model demonstrates that those who experience racism spend more time in uncertain or negative time segments, while those who do not experience racism spend more time in positive time segments, such as education and retirement. The simplicity of the timeline highlights the message that it conveys about the impact of racism on a person’s life. The authors recommend that future study should be undertaken to discover what additional life elements are missing from their model that would allow a richer picture to emerge on the life-course perspective.

In discussing the model, the authors acknowledge that all people can potentially experience unequal treatment in healthcare across the course of the lifespan, but that the burden of disparities falls upon minorities. It is important to acknowledge this. As a result of eliminating disparities for minorities, society as a whole will benefit.

Conclusion

This article provides a stepping stone for the development of future research into the impact of race and racism on health inequities. It provides a framework, complete with definitions, concept illustration and potential impacts. The article ends with a comprehensive bibliography of articles with which the authors believe all researchers in health disparities should be familiar. This article might be perceived as overly optimistic and simplistic. The study of health disparities is complex, and one study design alone will not have a major impact on our understanding of those disparities. However, the authors do provide a fresh outlook with their approach, and one that is backed by an evidence-based literature review.