J. Michael Oakes, PhD

McKnight Presidential FellowAssociate Professor

Division of Epidemiology & Community HealthMinnesota Population Center

University of Minnesota

oakes007@umn.edu

Health Disparities

Pick (most) any health outcome and you’ll find differences in incidence and impact by race and class.

As a biological process, we should expect differences (ie, variation) in health across individuals and groups.

The rub is in “why” the differences exist?

To what extent should research offer/propose remedies?

What’s the difference b/w a “difference” and a “disparity”?

Should we be concerned with outcomes or processes?

Is strict equality Good?

Provocative, motivating documentary that should get our public health

activist and research juices flowing!

• Poor are less healthy

• Society is making us sick

• Chronic stress without control is mechanism if illnesses

• We must reduce economic inequality to mitigate if not eliminate health disparities

• Immigrants suffer by coming here

Major Themes

What are facts?

This stuff is too important to be sloppy in our thinking…

Source: Coleman, W. (1982). Death is a Social Disease: Public Health and Political Economy in Early Industrial France. Madison, WI, University of Wisconsin Press.

0

10

20

30

40

50%

Po

or F

am

ilie

s

1960 1970 1980 1990 2000 2010

Year (CPS data)

All Families Female Headed

Percentage of Poor Families over Time

Health Disparities?

Poor

Rich

Health Disparity = 3

So

cio

eco

no

mic

sta

tus

White

Black

Poor

Excellent

Poor

Rich

Health Disparity = 7

So

cio

eco

no

mic

sta

tus

Poor

Excellent

Poor2

Rich

Health Disparity = 2

Poor1

Poor

Excellent

Poor

Rich

Health Disparity = 2

Poor

Poor

Rich

Health Disparity = 3

So

cio

eco

no

mic

sta

tus

Health Loss = 5

Poor

ExcellentRich

Health Disparity = 2

Health Loss = 7

Health Loss = 1

Poor

Excel1

Poor1

Rich

Health Disparity = 6

Excel2

Poor2

Health Loss = 2

Health Gain = 2

Poor

Excel2

Poor1

Rich

Health Disparity = 11

Poor2

Health Gain = 4

Health Gain = 5

Excel1

Income Inequality?

Lynch, J., et al. 2004. "Is income inequality a determinant of population health? Part 1. A systematic review." Milbank Q 82:5-99.

Lynch, J., et al. 2004. "Is income inequality a determinant of population health? Part 2. U.S. National and regional trends in income inequality and age- and cause-specific mortality." Milbank Q 82:355-400.

Culter, David, Angus Deaton, and Adriana Lleras-Muney. 2006. "The determinants of Mortality." Journal of Economic Perspectives 20:97-120.

Lee, Roland. 2003. "The demographic transition" Journal of Economic Perspectives 17

0

50

100

150

200

250

300

350

1900

1904

1908

1912

1916

1920

1924

1928

1932

1936

1940

1944

1948

1952

1956

1960

1964

1968

1972

1976

1980

1984

1988

1992

1996

De

ath

s p

er

10

00

liv

eb

irth

s

Infant Mortality Rates by Race, US 1900 - 1998

Non-White

White

Culter, David, Angus Deaton, and Adriana Lleras-Muney. 2005. "The determinants of Mortality." White paper

Asian American

Mexican American*

Cuban American

Other Hispanic

African American

Puerto Rican

0.70

0.80

0.90

1.00

1.10

1.20

1.30

1.40

Ad

jus

ted

Od

ds

Ra

tio

Risk of Death by Race/Ethnicity

White is reference NDI-linked NHIS data, persons 18+ in 1986-1995 samples

Rogers RG, RA Hummer, CB Nam. 2000. Living and Dying in the USA: Behavioral, Health, and Social Differentials of Adult Mortality. New York: Academic Press. Figure 4.1, page 64

What is the effect of neighborhood poverty on American Indian infant death in Minnesota?

<5% 5-19% 20-39% 40-100%

All-cause infant death 7.5 16.2 17.4 23.3Endogenous-cause death 3.8 7.8 10.1 12.0

Exogenous-cause death 3.8 8.4 7.3 13.3

Neighborhood Poverty

Johnson, Pamela Jo. 2004. "The Effect of Neighborhood Environments on American Indian Mortality in Minnesota." Unpublished PhD Dissertation. Division of Epidemiology, University of Minnesota.

Lower Life Expectancy?

Low Class High Class

USA (1980-82) 73.0 75.8

England/Wales (men 1971-76) 66.5 72.0

Brazil (1970) 53.2 62.0

Life Expectancy at Birth

But Cuba!!!

It’s a dictatorship island that you cannot escape.

IRM rates are probably fraudulent, if not surely don’t include efforts to save preemies or other sick kids.

Maternal mortality is sky high, 4-5 times higher than US.

Sure, you’ll be employed but you have little to no choice in your career or life plans.

10,000 – 50,000 died trying to get to Miami.

How much more should the rich have to do?