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Health Disparities Based on Socioeconomic Inequities: Implications for Urban Health Care

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Health Disparities Based on Socioeconomic Inequities: Implications for Urban Health Care S PECIAL T HEME A RTICLE Health Disparities Based on Socioeconomic Inequities: Implications for Urban Health Care Kevin Fiscella, MD, MPH, and David R. Williams, PhD, MPH ABSTRACT Health is unevenly distributed across socioeconomic sta- explanations for these socioeconomic-based disparities are tus. Persons of lower income, education, or occupational addressed, including reverse causality (e.g., being poor status experience worse health and die earlier than do causes lower socioeconomic status) and confounding by their better-off counterparts. This article discusses these genetic factors. The article underscores social causation as disparities in the context of urban medical practice. The the primary explanation for health disparities and high- article begins with a discussion of the complex relation- lights the cumulative effects of social disadvantage across ship among socioeconomic status, race, and health in the stages of the life cycle and across environments (e.g., fetal, United States. It highlights the effects of institutional, family, educational, occupational, and neighborhood). individual, and internalized racism on the health of Afri- The article concludes with a discussion of the implica- can Americans, including the insidious consequences of tions of health disparities for the practice of urban med- residential segregation and concentrated poverty. Next, icine, including the role that concentration of disadvan- the article reviews health disparities based on socioeco- tage plays among patients and practice sites and the need nomic status across the life cycle, beginning in fetal health for quality improvement to mitigate these disparities. and ending with disparities among the elderly. Potential Acad Med. 2004;79:1139–1147. ifferences in socioeconomic status, whether mea- ship. We conclude by discussing the implications of these sured by income, educational achievement, or disparities for the provision of health care to urban, low- occupation, are associated with large disparities in income, and minority patients. Studies for this review were health status.1 This association persists across the identified through selected Medline searches, bibliographic D2,3 life cycle and across measures of health, including health searches of key articles, and the authors’ knowledge of the status,4 morbidity,5 and mortality.6 Although effects are literature. The size of the literature on health disparities largest for those living in poverty, gradients of disparity are precluded a complete, systematic literature search. seen across the socioeconomic spectrum.7 This article discusses health disparities based on socioeco- nomic status in the context of urban health care. We begin THE INTERRELATION OF RACE,SOCIOECONOMIC STATUS, by discussing the relationships among race, socioeconomic AND HEALTH status, and health. We trace disparities in health based on socioeconomic status throughout the course of an individu- Race, socioeconomic status, and health have historically al’s life and review potential explanations for this relation- been inextricably intertwined in the United States. Unlike most countries, however, the United States collects national health data primarily by race and not by socioeconomic Dr. Fiscella is associate professor, Departments of Family Medicine and status.8 African Americans have experienced varying levels Community Preventive Medicine, University of Rochester School of Medicine of social, economic, and political exclusion that have re- Dr. Williams and Dentistry, New York. is professor, Department of Soci- sulted in poorer health since their arrival on this continent as ology, University of Michigan, Institute for Social Research, Ann Arbor. slaves several hundred years ago.9 Historically, slavery in the Correspondence should be addressed to Dr. Fiscella, 1381 South Avenue, Rochester, NY 14620; telephone: (585) 506-9484 ext. 106; e-mail: United States was rationalized on the basis of racism—an ͗[email protected]͘. ideology of oppression based on a belief in the inherent racial A CADEMIC M EDICINE,VOL. 79, NO . 12/DECEMBER 2004 1139 S OCIOECONOMIC I NEQUITY AND H EALTH, CONTINUED biological inferiority of one race and the superiority of ities in health potentially begin in utero because the health another.10 The construct of race, however, is socially derived of the fetus is so closely linked to the health of the mother. with limited biological basis.11 A mother’s low socioeconomic status is associated with To this day, as a legacy of this oppression, African Amer- multiple risk factors for adverse birth outcomes, including icans experience dramatically worse health across the age unplanned and unwanted pregnancy,27 single and/or adoles- spectrum, including higher adult and infant mortality.12,13 cent motherhood,27 smoking,28 urogenital tract infections,29 They have significantly higher mortality rates from cardio- chronic illness in the mother, and inadequate prenatal vascular and cerebrovascular disease, most cancers, diabetes, care.30 Not surprisingly, a mother’s low socioeconomic status, HIV, unintentional injuries, pregnancy, sudden infant death and to some extent the low socioeconomic status of the syndrome, and homicide than do whites.14 These health father, are associated with low birth weight31and infant disparities have been rationalized on the basis of genetic mortality.32 “differences” despite evidence that genetics does not contrib- ute significantly to these disparities.15,16 Racial differences in socioeconomic status, not genetics, are the most important Child Health 6 cause of these health disparities. 33 Racism perpetuates these health disparities by operating at Socioeconomic disparities continue into childhood. Chil- dren of low socioeconomic status have greater risks of death three distinct levels: institutionalized policies and practices 34 35 36 that maintain racial disadvantage, individual racial discrim- from infectious disease, sudden infant death, accidents, and child abuse.37 They have higher rates of exposure to lead ination and biased treatment, and internalized cognitive 38 39 processes.17 Each reinforces the others. Institutionalized rac- poisoning and household smoke. They have higher rates of asthma,40 developmental delay and learning disabilities,41 ism, manifested through long-standing racial inequities in 42 43 employment, housing, education, health care, income, conduct disturbances, and avoidable hospitalizations. They more often reside in families with marital conflict44 and wealth, and criminal justice, is reinforced through racist 45 18 are more often exposed to intimate-partner and community beliefs. Individual racism, including unconscious bias, is 45 manifested through discrimination in housing, banking and violence. Low socioeconomic status and overcrowding are associated with infectious disease including tuberculosis34 employment, racial profiling by police, harsher sentencing for 46 minority defendants, lower educational expectations for mi- and Helicobacter pylori infection. By their preteen years, 19 children of low socioeconomic status report lower health nority students, and unequal medical treatment. Racial 2 stereotypes contribute to voting patterns and public policies status and more risk behaviors. that, in turn, reinforce institutionalized racism. Internalized racism refers to introjection of racial stereotypes by the Adolescent Health minority group members. Internalized racism may contribute to self doubts, lower school performance, depressive symp- Low socioeconomic status affects adolescents as well. Low toms, substance abuse, dropouts, and other risk behav- 20–22 socioeconomic adolescents report worse health; they have iors. higher rates of pregnancy,47 sexually transmitted disease,48 Residential segregation, a product of long-standing insti- 49 50 23 depression, obesity, and suicide. They are more likely to tutional and individual racism, represents a fundamental be sexually abused,51 drop out of high school,52 or be killed.53 cause of racial disparities in health because it perpetuates Satisfaction with health, better family involvement, better racial disparities in poverty, education, and economic oppor- 24 problem solving, more physical activity, better home safety, tunity that, in turn, drive disparities in health. The social having higher school achievement, and being in the best and spatial marginalization associated with segregation rein- health profiles are all positively related to parental socioeco- forces substandard housing, underfunded public schools, em- nomic status during adolescence.54 ployment disadvantages, exposure to crime, environmental hazards, and loss of hope, thus powerfully concentrating disadvantage.25 Adult Health HEALTH DISPARITIES ACROSS THE LIFE CYCLE By adulthood, health disparities related to socioeconomic status are striking. Compared with persons who have a Fetal and Neonatal Health college education, those with less than a high school educa- tion have life expectancies that are six years shorter.6 People Health disparities resulting from socioeconomic status begin with low socioeconomic status experience higher rates of early in life, but have potential for lasting effects.26 Dispar- death across the spectrum of causes.55 They experience 1140 A CADEMIC M EDICINE,VOL. 79, NO . 12/DECEMBER 2004 S OCIOECONOMIC I NEQUITY AND H EALTH, CONTINUED premature chronic morbidity and disability including the onset Genetic Confounding of hypertension at an earlier age,56 diabetes,57 cardiovascular disease,58
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