Making Decisions That Narrow, or Widen, Health Gaps: A Public Health of Consequence, February 2019

We are concerned with improving population health, so our science should guide us on how to do so and public health practice should lead the way in making these efforts. We are also, however, centrally concerned with health gaps between populations and between groups within populations. Insofar as health is a human right, part of our mission is to ensure that we do not create, or support, structures that generate intergroup differences in health that may be amenable to improvement.

In the United States, much of the discussion on this subject has centered on the idea of “health disparities,” and that term has typically been applied to racial/ethnic differences in health. US population health has been characterized by long-standing racial/ethnic differences. Blacks still have higher death rates for all-cause mortality than do Whites in all age groups younger than 65 years, although this gap has narrowed over the past 20 years.¹ Similarly, other ethnic minority groups have poorer health than do White majority groups; Latino/a populations, for example, have higher morbidity than do Whites on a broad range of health indicators.²

UNCOVERING HEALTH DRIVERS

Population health scientists have long understood that the drivers of these differences are principally structural forces that span generations and that accompany us over the life course; these include residential segregation, structural racism, and limited access to resources. The challenge for recognizing the influence of these forces is, not infrequently, that they are omnipresent and may appear to be beyond the scope of those whose remit is health promotion. It is, then, important to remember that the forces that drive health gaps ultimately stem from decisions that we as a society make and that these decisions have as their consequence the creation and propagation of health gaps. Exposing these decisions through our science can help clarify how we can and should act differently to narrow these gaps.

Two articles in this issue of AJPH, tackling dramatically different topics, do just that. Himmelstein and Venkataramani (p. 198) investigate racial and gender inequities in the compensation and benefits of US health care workers and assess the potential impact of a $15 per hour minimum wage on their economic well-being.³ The authors show that a third of women health care workers earned less than $15 an hour, with that proportion rising to 50% for Black and Latina women. Perhaps not surprisingly, this results in 1.7 million women health care workers and their children across the country living in poverty. This article also shows that increasing the minimum wage to $15 per hour could reduce poverty rates in this group by up to 50%.

On a rather different topic, Chakraborty et al. (p.244) explored flooding from Hurricane Harvey in Greater Houston, Texas, and analyzed the extent to which areal flooding was distributed inequitably with respect to race, ethnicity, and socioeconomic status.⁴ They found significantly greater flooding in neighborhoods with a higher proportion of Black, Latino/a, and socioeconomically deprived residents, leading to disproportionate impacts of the flooding on different populations in Houston.

WAGES, POVERTY, AND HEALTH

Both these studies point to causes of poor health that disproportionately fall on minority or low socioeconomic status communities. The relation between low wages, poverty, and health is perhaps one of the best documented relations in population health science.³ Poor wages, and their attendant poverty, for women—particularly minority women—working in the health care sector contribute to poorer health in these groups and to health gaps. Similarly, disasters are well understood to have a wide range of physical and mental health consequences⁴; the socioeconomic patterning of the consequences of these events will therefore—as climate change–related disasters increase in frequency and severity—result in the widening of health gaps.

These articles, then, both point to decisions that we make collectively that, perhaps unintentionally, sustain and widen health gaps.

Society sometimes allows low wages to be paid for doing particular jobs, even ones that are as urgently needed as health care work, which is projected to grow in importance with an aging population.⁵ As Himmelstein et al. note, researchers have paid substantial attention to wage equity in physician and nursing jobs and much less to lower-level health care work, where the bulk of health care workers are employed. The decision to keep wages low is undoubtedly rooted in the structures that privilege profit making in the health care industry. But, as Himmelstein et al. show, wage increases of the size they examined are unlikely to result in a decreased demand for health care.⁶ This, coupled with evidence showing that raising the minimum wage to $15 per hour will result in improved health,⁷ suggests that we are, ultimately, deciding that the profit made by keeping wages low is a reasonable tradeoff with having large groups of the population being left behind on health.

CONSEQUENCES OF DISASTERS

The pattern of disasters having disproportionate consequences on minority and low socioeconomic status populations is perhaps one of the least well understood aspects of the growing threat of global climate change. Although we all stand to be affected by climate change, marginalized populations will bear the brunt of its consequences; thus, climate change will further widen health gaps. If we acknowledge climate change and the conditions in high-risk areas that predispose populations to the risks of climate change and yet do nothing, we are effectively accepting widening health gaps in coming decades.

MINDING THE GAP

These two studies fulfill an important role in population health science by illustrating the choices we make that promote health gaps. In clearly documenting how these gaps are created and linked to avoidable social decisions, they remind us yet again that we must grapple with the values that render health gaps acceptable. As the science matures, providing evidence that the decisions we make promote health gaps, it becomes ever clearer that informing our collective values so that we demand health and narrowing of health gaps is a central role—and should be a goal—of public health practice.