A Public Health of Consequence: Review of the July 2017 Issue of AJPH

Why do we do what we do? We would argue, modeled on the work of many before us, that the study of public health should be concerned with the distribution of health across and within populations and the mechanisms that contribute to these health distributions.¹ This issue of AJPH includes four articles that we find to be sobering reminders of the continued core challenges public health faces, even as they provide hope in the possibilities of improvement in the health of populations.

Health disparities have been a core concern of public health for decades and have been the subject of several efforts aimed at narrowing health disparities, particularly racial/ethnic health disparities. Among these efforts are the US Department of Health and Human Services’s Health and Human Services Action Plan to Reduce Racial and Ethnic Health Disparities and the National Stakeholder Strategy for Achieving Health Equity. The Minority Health and Health Disparities Research and Education Act was passed in 2000; it established the National Institute on Minority Health and Health Disparities. The second goal of Healthy People 2020 is to “achieve health equity and eliminate disparities,” focusing attention on the subject. These and other efforts have borne fruit, with an overall narrowing of racial/ethnic disparities in a variety of health metrics, and yet it is clear that much progress remains to be made.

The final report for Healthy People 2010 (https://www.healthypeople.gov) reported on health disparities for 469 population-based health objectives, showing that although there was some improvement, disparities have either increased or stayed the same as the baseline measures for the majority of objectives, particularly between racial/ethnic groups.

HEALTH DISPARITIES

Two articles tackle the ongoing challenge of US intergroup differences in health. Montez et al.² add to our understanding of disparities, focusing on differences in disability between educational groups. They found that disparities in disability by education vary across states, ranging from a 20–percentage point disparity in Massachusetts to a 12–percentage point disparity in Wyoming. Importantly, they observe that the socioeconomic resources of low-educated adults account for nearly a third of this variation. This article is an important reminder of the role context plays in shaping health differences and highlights the role of social embeddedness in the production of health and attendant intergroup differences in health.

Des Jarlais et al.³ examine racial/ethnic intergroup differences among persons who inject drugs at the end of the HIV epidemic in New York City. Racial/ethnic disparities have been documented throughout the HIV/AIDS epidemic,⁴ and Des Jarlais et al. show that even as these data show that the HIV epidemic has ended among all three major racial/ethnic groups of persons who inject drugs in New York City, racial/ethnic disparities still exist in the prevalence of untreated HIV infection and in estimated HIV incidence. Both of these were lowest among Whites and highest among African Americans. The disparities in HIV prevalence were particularly concentrated among HSV-2–seropositive persons who inject drugs who were at high risk for sexual transmission. This is a remarkable demonstration of the persistence of racial/ethnic disparities, essentially through the end of the HIV/AIDS epidemic, and another echo of the social and structural influences on the production of intergroup differences in health, which Montez et al. also demonstrate well.²

MORBIDITY, MORTALITY, AND FIREARM POLICY

Two other articles tackle a different issue altogether: firearms and their consequences in the United States. Firearms have been a substantial cause of morbidity and mortality in the United States since about the turn of the 20th century. There are now more firearm deaths, including homicides, suicides, and deaths from unintentional shootings, than there are deaths from motor vehicle accidents in the United States. And yet public health action on the issue has been infuriatingly slow despite some recent galvanization of effort among the public health community,⁵ which is informed in no small part by large-scale national tragic mass murders.

Although arguments about gun ownership rights often center on self-protection from other firearms, the evidence is overwhelmingly clear that this argument is not supported by the data. Kivisto et al.,⁶ therefore, advance our understanding by studying whether stricter firearm legislation is associated with rates of fatal police shootings. They found that state-level firearm legislation was significantly associated with lower rates of fatal police shootings and that, importantly, states in the top quartile of legislative strength had a 51% lower incidence rate than did states in the lowest quartile. This work provides hope that state-level action can contribute substantially to reducing what ultimately is a preventable cause of death and disability.

The work of Siegel et al.⁷ sets, we hope, the stage for more work in this area. Siegel et al. describe a new database containing detailed annual information on firearm-related laws that were in place in each of the 50 states from 1991 to 2016. They show that the number of firearm laws doubled during the past quarter century. Importantly, this work also shows variability across states and widening interstate differences. Further work will have to assess whether these differences will contribute to interstate disparities in the consequences of firearms commensurate with the interstate differences that Montez et al. document in disability.²

All four articles discussed tackle important, intractable issues that rightly concern public health today, adding to our existing science and highlighting potential solutions. All four dwell on issues of consequence for public health, setting the groundwork for the research and action that may follow. We look forward to seeing next steps in both these areas.